There is substantial overlap between mood and substance use disorders and the concurrent presence of these disorders portends a higher disease burden and worse health outcomes. Despite this, concurrent mood and substance disorders are under-diagnosed and under-treated. Current gaps and future opportunities to improve models of care for the management of concurrent mood and substance use disorders in Canada was the focus of a session at the annual Canadian Psychiatric Association (CPA) conference in Vancouver on October 20th, 2023.
Current gaps and a call to action
Mood and substance use disorders (SUD) commonly co-exist. According to epidemiological evidence, the lifetime prevalence of mood and anxiety disorders among people with an SUD is 40% and 30%, respectively,1 with rates tending to be higher among women than men.2 On the other hand, about 20% of people with any mood or anxiety disorder have a lifetime risk of SUD.1
30-40% of individuals with SUD have a mood or anxiety disorder in their lifetime
Dr. Sidney Kennedy from the University of Toronto described similar findings in a Canadian real-world sample of adults attending an inpatient SUD program, where 46% of patients had a physician confirmed diagnosis of a concurrent depressive or anxiety disorder. In addition to gender differences, there may also be age differences in the prevalence of mood and anxiety disorders among adults with SUD. In Dr. Kennedy’s cohort, younger adults were more likely than older adults to have multiple concurrent mood or anxiety disorders. Whereas concurrent anxiety disorders were more prevalent in younger patients, concurrent depression was more prevalent in older adults with SUD.
There are gender and age-based differences in concurrent mood and substance use disorders
Despite their common co-occurrence, concurrent disorders tend to be under-diagnosed and undertreated, which likely reflects the silo approach to identifying and managing single disorders. Moreover, there is a wide variety of treatment philosophies and models of care for concurrent mood disorders and SUD, but there is a paucity of evidence on effective treatment approaches. This dearth of research has contributed to a lack of guidelines and standards of care. Dr. Kennedy remarked on the urgent need to address these knowledge and care gaps since people with concurrent disorders tend to have greater symptom severity and burden of disease, and higher relapse rates compared to individuals with single disorders.
Using measurement-based care to personalize management
Collecting real-world data on individuals receiving care for concurrent SUD and mood or anxiety disorders has the potential to improve treatment programs and offer a more personalized approach to disease management. James McKillop, PhD, from McMaster University in Hamilton, Ontario, described how a statistical methodology called latent profile analysis is being used to identify clinically distinct clusters of SUD and concurrent psychiatric disorders in addiction treatment settings. This approach combines routine assessments and data collection at the point of care with brief high-quality measures to automate the assessment of individuals presenting for addiction treatment. The aggregate data can then be used to help identify commonalities in symptom presentations or “clusters” (e.g., high or low SUD or alcohol use and high or low concurrent psychopathology) and guide a personalized treatment plan.
One of the key attributes of latent profile analysis is that it makes order from chaos. Patients present for treatment of SUD with widely variable clinical characteristics, some of which may be difficult to observe. Latent profile analysis integrates data from multiple sources including clinical intake forms, as well as laboratory and imaging tests. For example, the cluster of severe SUD or alcohol use and greater psychopathology tended to exhibit higher levels of craving and impulsivity, which may require a multifaceted approach that addresses these underlying mechanisms to optimize clinical outcomes. To date, this approach has been applied in two different clinical settings to help tailor programs and guide quality improvement efforts and resource allocation to best meet the needs of their catchment areas.
Latent profile analysis can help make order out of clinical heterogeneity
New models of care and future approaches to concurrent disorders
In early 2022, the Homewood Health Centre in Guelph, Ontario redesigned its care pathway to meet a recognized need for an enhanced approach to treating concurrent SUD, mood and anxiety disorders, which were highly prevalent in their inpatient mood and anxiety programs (MAP) and substance use (SU) programs. Thus, the centre launched a Mood, Anxiety and Concurrent Program (MACP) integrating the treatment of concurrent disorders with equal emphasis attributed to each single disorder. Shannon Remers, a Senior Manager of Research and Outcomes at Homewood Health, described the outcomes of the first 6 months of the MACP program implementation. Overall, there was a decrease in severity of depressive and anxiety symptoms, with many patients achieving reductions from moderate-to-severe scores at baseline to subthreshold scores at the end of the 9-week inpatient program. Patient satisfaction levels were higher in the concurrent MACP compared to the more siloed mood and anxiety (MAC) and SUD programs alone. Based on the MACP’s success, Homewood Health is now expanding the program and applying the learnings to other services across its continuum of care offerings.
Concurrent mood, anxiety and SUD programs demonstrate high levels of patient satisfaction and improved clinical outcomes
Dr. Christian Shütz from the University of British Columbia offered a perspective on emerging trends and future research opportunities to improve the management of concurrent mood and substance use disorders. He highlighted the increasing acknowledgment of the complexity of shared etiological factors for concurrent disorders, including considerable overlap between genetic, environmental, and biological risk factors. It is important for clinicians to recognize that concurrent disorders are the rule, not the exception, in order to overcome the current state of under-diagnosis and under-treatment. Transdiagnostic perspectives and measurement-based care will play increasingly important roles in quality improvement and research, and ultimately aid in the development of personalized care pathways that better meet the individual needs of patients with concurrent disorders.
Comprehensive characterization of individuals is critical for the implementation of personalized care pathways
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
