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Comorbid Substance Use & Anxiety

How common is comorbid substance use and anxiety?

AnxietyAnxiety disorders occur in 18 to 28 percent of the United States population, [1] and within that subgroup, there is a 33 to 45 percent 12-month prevalence rate for a comorbid substance use disorder (SUD).[2] To break it down, the lifetime prevalence of comorbid alcohol dependence is between 30 and 35 percent, while the prevalence of drug abuse and dependence is between 25 and 30 percent.[3] The National Epidemiologic Survey on Alcohol and Related Conditions reports that as an individual’s number of comorbidities increases, so does their disability, while their quality of life significantly decreases.[4] In most cases, anxiety disorders precede SUDs.[5]

Self-medicating anxiety symptoms with substance use.

Individuals who experience high levels of anxiety interpret physiological sensations that are commonly experienced during an attack as harmful, leading them to lose control or die.[6] Many self-medicates with substance abuse. They use emotional avoidance strategies to deal with the symptoms of anxiety and are likely to use substances to help them avoid situations.6 Therefore, Baillie and colleagues state that anxiety and SUDs should be co-targets of an intervention.[7] This idea has been supported with beginnings of work with individuals who abuse cocaine, alcohol, and heroin.[8]

What should the treatment for this anxiety and substance use comorbidity be?

AnxietyRegarding treatment, Schatzberg proposed the conceptualization of the stages of SUD treatment, beginning with the acute phase, or first several weeks to months.[9] This phase includes detoxification, if needed; initiation of goals of sobriety; and establishing treatment tasks for both the SUD and anxiety.9 Other psychosocial treatment elements include motivational interviewing and cognitive-behavioral therapy (CBT).[10] According to Schatzberg, during the early weeks of the acute phase, withdrawal anxiety is common with most drugs of abuse.9 Therefore, clonidine and benzodiazepines are treatments for opiate and alcohol withdrawal symptoms, including anxiety.9 The continuation phase, months four through nine, and the maintenance phase, one year and more, target ongoing sobriety and treatment of anxiety.9

Medication management may also be necessary for treatment. SSRIs are the first-line medicines for anxiety disorders, as they help patients with anxiety embrace psychosocial treatments.[11] They are well-tolerated and do not have the potential for abuse. As individuals with anxiety have a high rate of drug and alcohol relapse, Still and colleagues believe that aggressive concurrent treatment is best, as anxiety and SUDs are likely to perpetuate each other.[12]



[1] Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication [published correction appears in Arch Gen Psychiatry. 2005;62:709]. Arch Gen Psychiatry. 2005;62:617-627.

[2] Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807-816.

[3] Simon NM. Generalized anxiety disorder and psychiatric comorbidities such as depression, bipolar disorder, and substance abuse. J Clin Psychiatry. 2009;70(suppl 2):10-14.

[4] Alegría AA, Hasin DS, Nunes EV, et al. Comorbidity of generalized anxiety disorder and substance use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2010;71:1187-1195.

[5] Kushner MG, Krueger RF, Frye B, Peterson J. Epidemiological perspectives on co-occurring anxiety disorder and substance use disorder. In: Stewart SH, Conrod PJ, eds. Anxiety and Substance Use Disorders: The Vicious Cycle of Comorbidity. New York: Springer; 2008:3-17.

[6] Still, E.L. and Hulvershorn, L. (2011, Sept. 6). Anxiety Disorders With Comorbid Substance Abuse: Understanding the Link and Strategies for Treatment. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/anxiety/content/article/10168/1942971

[7] Baillie AJ, Stapinski L, Crome E, et al. Some new directions for research on psychological interventions for comorbid anxiety and substance use disorders. Drug Alcohol Rev. 2010;29:518-524.

[8] Lejuez CW, Zvolensky MJ, Daughters SB, et al. Anxiety sensitivity: a unique predictor of dropout among inner-city heroin and crack/cocaine users in residential substance use treatment. Behav Res Ther. 2008;46:811-818.

[9] Schatzberg AF. Achieving remission and favorable outcomes in patients with depression/anxiety and substance use disorders. CNS Spectr. 2008;13(4 suppl 6):10-12.

[10] McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33:511-525.

[11] Howland RH, Rush AJ, Wisniewski SR, et al. Concurrent anxiety and substance use disorders among outpatients with major depression: clinical features and effect on treatment outcome. Drug Alcohol Depend. 2009;99:248-260.

[12] Compton WM 3rd, Cottler LB, Jacobs JL, et al. The role of psychiatric disorders in predicting drug dependence treatment outcomes. Am J Psychiatry. 2003;160:890-895. anxiety.

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