Annotated bibliography: Comorbidity

Annotated bibliography

Bonevski, B., Regan, T., Paul, C., Baker, A. L., & Bisquera, A. (2014). Associations between alcohol, smoking, socioeconomic status and comorbidities: evidence from the 45 and Up Study. Drug and Alcohol Review, 33(2), 169-176.

This study aimed to examine if there were any links between mental illness and low socioeconomic status (SES) and concurrent tobacco and alcohol consumption. Data was obtained from the 45 and Up Study of 267153 adults aged over 45 in New South Wales, who completed a survey assessing alcohol, smoking, psychological distress, treatment for anxiety or depression and a range of SES factors. The research found strong links between low SES, treatment for anxiety or depression, psychological distress and concurrent tobacco smoking and alcohol misuse. It recommended a move away from the silo approach of addressing tobacco, alcohol and mental health, as it has proved ineffective in reducing the high smoking rates among people experiencing mental illness or seeking help for alcohol and other drug problems. It suggested a comprehensive and holistic approach was needed in treating these people. It also recommended more research to explore the potential for the community service sectors to provide treatment for people with multiple health and social concerns.

Brière, F. N., Rohde, P., Seeley, J. R., Klein, D., & Lewinsohn, P. M. (2014). Comorbidity between major depression and alcohol use disorder from adolescence to adulthood. Comprehensive Psychiatry, 55(3), 526-533.

The aim of this study was to examine the development of comorbidity between alcohol use disorder (AUD) and major depressive disorder (MDD). It focussed on the relationship between the disorders at different time periods in adolescence and young adulthood. Participants were interviewed at ages 16, 17, 24 and 30. There were 861 participants who were predominantly white and equally split between male and female. Comorbidity was found to be low in adolescence but increased in adulthood, with most individuals with one disorder having the other. The exception was women with MDD. Adolescents with AUD were at increased risk of developing MDD and young adults with MDD were more likely to develop AUD. People diagnosed with comorbidity of MDD and AUD had an increased risk of alcohol dependence, suicide attempts and life dissatisfaction than those diagnosed with either MDD or AUD. Lifetime rates of comorbid MDD and AUD were higher than in previous studies and the report recommended screening for the other disorder at regular intervals when an individual presented with either MDD or AUD.

Carter, M., Fisher, C., & Isaac, M. (2013). Recovery from comorbidity: depression or anxiety with alcohol misuse—a systematic and integrative supradisciplinary review and critical appraisal. SAGE Open, 3(4), 2158244013512133.

Comorbidity of mood and anxiety disorders with alcohol misuse is not unusual. The study conducted a systematic literature review across different disciplines and research methodologies. Inconsistencies were found in definitions and measurements in the literature reviewed. Little evidence was found to support treatment plans. Competing paradigms in mental illness and addiction pose a barrier to progress and consumers frequently fall between the gaps. Clinicians feel undertrained and may be judgmental or unrecognise comorbidity, particularly in high risk populations. It suggested a consideration of different combinations of comorbidity and other factors such as social support, housing and employment which are crucial to recovery. It also recommended a need to build on the limited evidence and generalisation that was available.

Debell, F., Fear, N. T., Head, M., Batt-Rawden, S., Greenberg, N., Wessely, S., & Goodwin, L. (2014). A systematic review of the comorbidity between PTSD and alcohol misuse. Social Psychiatry and Psychiatric Epidemiology, 49(9), 1401-1425.

This systematic review was performed to ascertain the prevalence of comorbidity of post-traumatic stress disorder (PTSD) and alcohol misuse and any associations between the conditions. The literature reviewed was limited to that published between 2007 and July 2012.   A total of 42 papers were included in the review, after reviewing 620 abstracts. The incidence of PTSD comorbid to alcohol misuse ranged from 2 to 63% and alcohol abuse comorbid to PTSD 9.8 to 61.3%, with most of the prevalence rates being greater than 10%. These results indicated a strong association between the disorders. Significant evidence was found for association between alcohol misuse and numbing symptoms and hyperarousal. The evidence from the review supports the need for screening comorbidity in individuals who are known to have PTSD or alcohol misuse.

Gorka, S. M., MacNamara, A., Aase, D. M., Proescher, E., Greenstein, J. E., Walters, R., … & Digangi, J. A. (2016). Impact of alcohol use disorder comorbidity on defensive reactivity to errors in veterans with posttraumatic stress disorder. Psychology of Addictive Behaviors, 30(7), 733.

Evidence suggests that people who suffer from both PTSD and alcohol use disorder (AUD) have a heightened defence reactivity. This then maintains both their drinking behaviours and their anxiety or hyperarousal symptoms. Few studies however, have established whether people with PTSD and AUD have greater defence reactivity than those with PTSD without AUD. The aim of this study was to test this hypothesis. Error–related negativity (ERN) was measured, which is increased in anxious individuals and is thought to reflect defence reactivity to errors. Participants consisted of 66 male military veterans who were split into three groups:

  1. Controls with no PTSD or AUD
  2. Those with PTSD and no AUD
  3. Those with both PTSD and AUD

Those from the third group exhibited heightened ERN, whereas those in the first and second groups did not. This suggests that PTSD with AUD is a unique subtype of PTSD, with the comorbidity of AUD enhancing the defence reactivity in people with PTSD. The limitations in the study include the group size and demographics.

Leventhal, A. M., & Zvolensky, M. J. (2015). Anxiety, depression, and cigarette smoking: A transdiagnostic vulnerability framework to understanding emotion–smoking comorbidity. Psychological Bulletin, 141(1), 176.

The research on comorbidity between emotional disorders and cigarette smoking has centred on the symptoms of anxiety and depression rather than clinical and theoretical advancement. The researchers who performed this study hypothesized that emotional vulnerabilities or behavioural traits, which reflect maladaptive emotional responses link various depressive and anxiety disorders to smoking. They did a literature review on three emotional vulnerabilities implicated in smoking:

  1. Anhedonia (Anh.)
  2. Anxiety sensitivity (AS): fear of anxiety related sensations
  3. Distress tolerance (DT): ability to withstand distressing situations

They concluded that the three collectively form a foundation for multiple emotional disorders; amplify the anticipated and actual affect enhancing properties of smoking; promote progression towards the smoking pathway and therefore are promising targets for smoking intervention. They used the information collected to propose a model linking emotional psychopathology to smoking:

  • Anh. amplifies smoking’s actual and expected pleasurable effects
  • AS increases smoking’s anxiety reducing effects
  • Low DT increases smoking’s distress reducing effects.

Together these factors reinforce smoking for individuals suffering from emotional disorders, which increases their risk of smoking initiation, progression, maintenance, not stopping, avoidance and relapse. They conclude that the results can be used for clinical and scientific implications that can be expanded to other comorbidities.

Riga, D., Schmitz, L. J., Van Der Harst, J. E., Van Mourik, Y., Hoogendijk, W. J., Smit, A. B., … & Spijker, S. (2014). A sustained depressive state promotes a guanfacine reversible susceptibility to alcohol seeking in rats. Neuropsychopharmacology, 39(5), 1115-1124.

The reported rates of comorbidity between AUD and MDD are high, but preclinical models studying how primary depression affects secondary AUD are lacking. This results in inadequate testing of drug treatment. The authors combined social defeat-induced persistent stress (SDPS) with operant self-administration (SA) concepts to assess causality between the disorders. They used guanfacine, a drug used to reduce cravings in humans against SDPS-induced change of operant alcohol SA. They socially defeated and isolated rats for at least 9 weeks, during which time they assessed depressive symptomology. The rats were then exposed to 5 months of operant SA concept, studying acquisition, motivation, extinction and cue-induced reinstatement of alcohol seek. Then at 6 months they measured the effects of the drug on motivation and relapse. The SDPS rats demonstrated significant changes to social and cognitive behaviour several months after defeat and increased motivation to obtain alcohol. Guanfacine reduced the effects on motivation caused by SDPS. The authors state that their model mimics the symptomology of a sustained depressive state and resultant vulnerability to alcohol abuse and that SDPS is strongly associated with alcohol intake and relapse. They argue that the study indicated that guanfacine has potential as a new treatment for patients with MDD and AUD comorbidity, as it is effective in reducing the sensitivity to alcohol and alcohol-induced stimuli. The limitation to this study is that it was performed on rats so may not translate to humans.

Scott, C. K., Dennis, M. L., & Lurigio, A. J. (2015). Comorbidity among female detainees in drug treatment: an exploration of internalizing and externalizing disorders. Psychiatric Rehabilitation Journal, 38(1), 35.

This study examined the incidence and comorbidity of major psychiatric disorders in female prisoners who were participating in drug treatment programs in a large American prison. The Needs Inventory was used, which includes a large mixture of methods to capture demographics, psychological problems, substance use and drug treatment histories and their criminal thinking tendencies. Two hundred and fifty-three women participated in the study, who were then split into three groups: those with substance use disorders (SUD) but no psychiatric disorders (24%); those with one psychiatric disorder (34%) and those with both internalising and externalising comorbidities (42%). Over 75% of the participants had comorbid psychiatric disorders and SUD, which are linked to lower self-esteem, increased drug use severity and levels of criminal thinking. The authors concluded that female prisoners in drug treatment programs need interventions focussing on both criminal and psychiatric recidivism, both whilst in prison and in the post-release phase. Limitations in the study are that it is a female only study and results may differ in a male population, and it was limited to those in drug treatment.

Emmerik‐van Oortmerssen, K., Glind, G., Koeter, M. W., Allsop, S., Auriacombe, M., Barta, C., … & Casas, M. (2014). Psychiatric comorbidity in treatment‐seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study. Addiction, 109(2), 262-272.

Previous studies have indicated the attention deficit hyperactive disorder (ADHD) is highly comorbid with SUD, and that both ADHD and SUD are associated with other comorbid conditions including mental health disorders. The studies show that the disorders both independently and together increase the risk of comorbidity with psychiatric disorders. The objective of the study was to examine comorbidity patterns in adults seeking treatment for SUD, with or without ADHD. Different subtypes of ADHD and comorbidity patterns were examined, along with differences in gender and primary substance of abuse. They focussed on MDD, current (hypo)manic episode (HME), antisocial personality disorder (ASPD) and borderline personality disorder (BPD). They screened 3558 people from 47 centres in 10 countries, with a final group of 1205 participants. They found that MDD, BPD, ASPD and HME were all more prevalent in participants with ADHD than those without. Both BPD and MDD had increased comorbidity when alcohol was the primary substance of abuse as opposed to drugs. Comorbidity differed between ADHD subtypes with increased MDD in the inattentive and combined subtypes, increased HME and APSD in the hyperactive/impulsive and combined subtypes and increased BPD in all subtypes. The incidence of at least one comorbid disorder was 75% in those with ADHD, compared to 37% in those without. They concluded that treatment-seeking SUD patients with ADHD are at a very high risk of developing psychiatric disorders. The limitations of the study include the data collected was all self-reported and standardised measurement tools were not used between the different centres.

All the articles except the first one are Open Access and can be read by clicking on their titles. The top one is available from our library database to all staff and volunteers at Healthy Options Australia.


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