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Orchestrated treatment for youth: sound pharmacotherapy and psychotherapy will benefit young people with co-occurring disorders.

In the treatment of addictions, addressing co-occurring disorders is becoming the norm. A holistic view of patient complaints has to include both psychiatry and psychotherapy in conjunction with both traditional and non-traditional forms of recovery counseling.

In the assessment and treatment of co-occurring disorders, there can be a delicate balance in the interactions of the treatment disciplines. Therapists may be resistant to the use of drug therapies, as they do not want their patients to become reliant on medications and to disregard much-needed therapy. Some physicians may not see emotional difficulties as part of the process of healing, but as symptoms to be alleviated through medication. Learning to practice smart pharmacotherapy and smart psychosocial therapy requires an orchestrated, integrated effort, rather than parallel, singular efforts. It is truly a dance, and for the choreography to benefit the patient, the two disciplines must have equal footing.

This article will attempt to provide the reader with a thorough understanding of the interactions between the two disciplines, using co-occurring substance use and anxiety disorders as the context.

Smart pharmatotherapy

Anxiety disorders as a whole are the most common mental illness, with a lifetime prevalence of 29 percent. (1), (2) Recent studies indicate that approximately 6 percent of adolescents have severe anxiety disorders, based on symptom rating and level of disability. However, there is a large disparity between those who meet criteria for any anxiety disorder and those who seek treatment. (3) This places affected youth at two to three times greater risk for substance abuse disorders. (4)


The most prevalent anxiety disorders are generalized anxiety disorder, social anxiety, panic disorder (with/without agoraphobia), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), phobic disorders, and separation antety. (2), (5), (6), (7), (8)

In substance abuse treatment settings, the reporting of anxiety as an ongoing symptom appears to be increasing in the adolescent population. The prevalence of comorbid anxiety in those with substance abuse has been reported to be 20 to 50 percent, (9) with an even larger proportion of patients reporting anxiety symptoms that do not meet criteria for any disorder.

A confounding issue is the development of anxiety symptoms while intoxicated or as part of a withdrawal syndrome. Stimulants tend to create anxiety states during intoxication, whereas sedatives, alcohol and opiates tend to produce similar symptoms during withdrawal. Marijuana often is reported to relieve anxiety initially; however, it can induce heightened anxiety states as well as panic attacks with ongoing use.

The question of how best to treat these youths with comorbid illness will become an increasingly pressing one. One of the first assessments should explore whether the individual meets criteria for a distinct anxiety disorder separate from the effects of substance abuse. Detailed history should be obtained from patient and parent in an attempt to delineate the course of illness. It is also imperative to determine the level of disability that the symptoms caused, and to account for variations in development of social skills as well as coping mechanisms to deal with unpleasant affective states. (3), (4)

The primary treatment for anxiety dis-orders consists of medication and therapy, either alone or in combination. First-line treatment includes cognitive-behavioral therapy (CBT) and psychosocial supports, as well as selective serotonin reuptake inhibitors (SSRIs). Additional medication recommendations are tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), atypical antipsychotics, and beta-blockers. (9) Benzodiazepines should be avoided in the young population if at all possible.

The choice as to which medication to use is not entirely arbitrary. Many studies support the use of sertraline for social anxiety, generalized anxiety disorder and PTSD, showing significant improvement vis-a-vis use of placebo. (10), (11), (12) There is also evidence that use of a beta-blocker leads to significantly reduced symptoms?

A proposed alternative medication strategy accounts for the symptoms of each patient and, ultimately, the side effect profile of each medication. For patients with physical symptoms of anxiety, use of a low-dose beta-blocker scheduled throughout the day can bring significant symptomatic relief, which then allows for ongoing treatment with therapy. (9) In those patients who have significant depressive symptoms, an SSRI/ serotonin-norepinephrine reuptake inhibitor (SNRI) should be the primary choice. Within this group, fluoxetine, sertraline and venlafaxine tend to be more activating, which can be useful for those with more neuro-vegetative signs of depression. Citalopram, escitalopram and paroxetine tend to be a bit more sedating, which can benefit those in a somewhat more agitated state.


Remeron can be quite useful for those who have poor sleep and/or poor appetite. The addition of an atypical antipsychotic can be particularly helpful in those who have perseverative thought processes, dissociative episodes, mood instability, body image distortions, or intrusive thoughts/flashbacks. The decision to use TCAs should be made very carefully, since overdose on this class of medications can be lethal. Providers should be careful in the amount of medication prescribed, and avoid this class altogether in patients known to have a history of medication overuse or overdose.

Not all anxiety is pathologic, however. Jumping immediately to pharmacotherapy, particularly in a population accustomed to utilizing a substance (prescribed or otherwise) to cope with negative affects, risks ongoing substance-seeking behavior. If possible, consider therapy as an initial course of treatment, and avoid as-needed medications, which serve to reinforce the behavior of seeking substances to decrease tension and/or discomfort.

Smart psychotherapy

Science has taken a firm hold in the field of addiction treatment. This is a welcome ally as we move forward from a time when the reality of addictions psychotherapy was our best guess and an AA schedule. The advent and availability of brain scanning is becoming a tool for many of us. Consumers of our services are coming to us increasingly more educated on evidence-based practices. To remain relevant, we as practitioners are doing our utmost to stay current.

The effect of data-driven research has taken a dominating hold on the addiction field. We have substantially increased our ability to measure our successes and our effectiveness as treatment providers. Pharmacotherapy, CBT and Dialectical Behavior Therapy (DBT) have come to be expected features of many treatment programs, and the practitioner who isn't at least minimally trained in these models can easily become inconsequential in a managed care-driven environment. This constitutes a paradigm shift that was much-needed for us, and the fruits of this are becoming apparent in the outcomes of treatment.

Paradigm shifts in any culture, including the culture of a profession, will also tend to have a rubber band effect. In the case of addiction treatment, there has been a move away from the art of psychotherapy, to create space for the science of psychotherapy. When treating adolescents, the practitioner must develop a style that encompasses both art and science in order to be successful. Today's practitioner must be current and creative. He/she must be safe and adventurous, and must know how to work across disciplines.

As previously stated, complaints of anxiety are incredibly common among adolescent addiction patients. An unbalanced approach to psychotherapy would make paramount the aim of treating and alleviating these symptoms through teaching specific coping skills and providing a referral for medication. Of course, many of the adolescents we treat have a propensity to seek medication already, so this can be in alliance with a primary substance use disorder.


A therapist has to remember that anxiety is not the enemy of treatment--it can also be an ally. (13) Anxiety can be highly motivating when reframed appropriately by a therapist. Working through it can be the key to the development of self-worth and self-esteem--issues that no medication can currently claim to increase. These internal, core experiences are still the practice realm of therapists, and it can be through anxiety that we help our patients gain access.


When working closely with our patients, it is important to properly assess the anxiety. (14) The therapist and psychiatrist have to work together to make the distinction between anxiety that can be the key to psychotherapy and anxiety that is crippling a person from engaging in psychotherapy. Once a person is through the initial detoxification, and some basic coping skills are taught, it becomes more apparent what is being observed.

Severe anxiety disorders will create difficulty for the patient in addressing underlying psychological and relational issues. A patient who consistently dissociates or has panic attacks in session might need to be medicated for the anxiety. A patient who is reporting anxiety but does not appear distressed, or to be unable to continue to work in therapy, might not be in desperate need of a pharmacological intervention, or might only need a medication that assists in decreasing the physical symptom base of the anxiety without affecting the mental state (15) Tapping into the resolution of anxiety for use as a motivating factor in therapy can be an essential tool in the long-term healing of a co-occurring anxiety disorder.

Once the anxiety is accurately identified and assessed to be at a manageable level, we continue to have at our disposal methods of further addressing the underlying causes. In some cases this can be the difference between a long-term reliance on the hope that a patient will remain medication-compliant or the resolution of anxiety caused by psychological issues.

For teens, family dynamics can be the cause of anxiety. In this case, an adolescent may initially present as anxious, respond to the structure of residential treatment with a decrease in anxiety, and proceed to re-create the social environment that caused the anxiety. While pharmacology might provide relief in these situations, it might prevent a change in relational dynamics for the adolescent and sentence the person to continue this pattern for years following treatment.

When a psychotherapist works from the dual paradigm of a scientist and an artist, he/she is not limited in these cases. The therapist will be open to the use of alternative methods of re-creating relational dynamics in the therapy setting. Psychodrama can be a powerful tool of awareness and healing, as can the relationship that occurs between an adolescent and a horse in the equine therapy setting. (16) Process groups that focus on the relational dynamics of the milieu can also engage resistant adolescents and provide them with the developmentally appropriate context to sort out their own patterns and difficulties, resulting in a decrease in perceived anxiety.

Exposure therapies also can be effective in aiding adolescents. For example, bulimic teens should be exposed to food challenges that can be enormous sources of anxiety during the process of their treatment. CBT is not the be-all, end-all of professional psychotherapy. (13)

All of these alternative approaches to anxiety treatment share a commonality. They address the problem of anxiety as related to the emotion of fear. As they address the fear of teens they increase self-efficacy, self-confidence and self-esteem. These core traits provide the adolescent with the opportunity to heal from what may be emotional turmoil and a developmental interruption (caused by drugs and/or relational factors) in emotional management. They provide teens with the opportunity to learn how to cope with the difficult times they will occasionally have in the future while also fostering interdependence, and new core beliefs in the adolescent that manifest in increased resilience.


Substance use disorders can manifest symptoms consistent with a myriad of mental health disorders, including anxiety disorders. True anxiety disorders can prevent teens or adults from engaging in psychotherapy and counseling, thus preventing resolution of the substance use disorder and leaving patients feeling defeated and hopeless. (17) Psychiatric and psychotherapeutic care of these patients requires these two disciplines to value each other's strengths and to learn to work hand in hand with their mutual patients so that intelligent, informed treatment can be implemented.

Knowing when to medicate, how to medicate, and how much to medicate can be a daunting task with addiction patients because of the complex relationships between co-occurring disorders and the perception of these disorders by both patients and professionals. Integrative approaches are the most effective at providing accurate diagnosis and creative yet safe treatment options, fostering success.


(1.) Kessler RC, Ruscio AM, Shear K, et al. Epidemiology of anxiety disorders. Curr Top Behav Neurosci 2010;2:21-35.

(2.) Kessler RC, Chiu WT, Demler 0, et al. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry 2005 Jun;62:617-27.

(3.) Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2011 Jan;50:32-45.

(4.) Brady K. Clinical challenges: anxiety and substance abuse. Program and abstracts of the 154th annual meeting of the American Psychiatric Association, May 5-10, 2001, New Orleans.

(5.) Callen J, Stanley M. Anxiety disorders in later life: differentiated diagnosis and treatment strategies. Psychiatric Times 2008;25.

(6.) Barker P. Psychiatric and Mental Health Nursing: The Craft of Caring. London: Hodder Arnold; 2003.

(7.) Post-Traumatic Stress Disorder and the Family. Veterans Affairs Canada; 2006. Available at

(8.) Allgulander C, Dahl AA, Austin C, et al. Efficacy of sertraline in a 12-week trial for generalized anxiety disorder. Am J Psychiatry 2004 Sep:161:1642-9.

(9.) American Psychiatric Association. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington, Va.: American Psychiatric Publishing; 2006.

(10.) Brawman-Mintzer 0, Knapp RG, Rynn M, et al. Sertraline treatment for generalized anxiety disorder: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry 2006 Jun;67:874-81.

(11.) Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double - blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry 2001 May;58:485-92.

(12.) Pollack MH, Rapaport MH, Clary CM, et al. Sertraline treatment of panic disorder: response in patients at risk for poor outcome. J Clin Psychiatry 2000 Dec;61:922-7.

(13.) Yalom ID. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. New York City: HarperCollins; 2002.

(14.) Barbour A. Caring for Patients A Critique of the Medical Model. Palo Alto, Calif: Stanford University Press; 1995.

(15.) Miller NS. Treating Coexisting Psychiatric and Addictive Disorders. Center City, Minn.: Hazelden Publishing; 1994.

(16.) Dayton T. The Living Stage: A Step-by-Step Guide to Psychodrama, Sociometry and Experiential Group 'therapy. Deerfield Beach, Fla.: Health Communications Inc.; 2005.

(17.) Daley D, Moss H. Dual Disorders Counseling Clients With Chemical Dependency and Mental Illness (3rd edition). Center City, Minn.: Hazelden Publishing; 2002.

BY KANSAS CAFFERTY, LAADC, MCA, MFTI, AND VALEH KARIMKHANI, DO Kansas Cafferty, LAADC, MCA, MFTI, is Program Director for the Newport Academy Intensive Outpatient Program in Orange, Calif. ( and Program Therapist for its residential program. He serves on the Adolescent Specialty Leadership Committee for NAADAC, The Association for Addiction Professionals. His e-mail address is Valeh Karimkhani, DO, is Medical Director at Newport Academy and provides direct psychiatric care in its residential and intensive outpatient programs. She is board-certified in addiction medicine and is Chief of Psychiatric Service at the chemical dependency and recovery unit at Hoag Hospital in Newport Beach.
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Author:Cafferty, Kansas; Karimkhani, Valeh
Publication:Addiction Professional
Date:Jul 1, 2011
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