co-occurring disorders | The Enlightenment & Simple Living Institute

I’ve been so busy with work and school, it is so good to finally have some time to write.

This week we studied co-occurring disorders. I was especially interested in the perspective presented on depression. Mainstream medicine appears to be in denial around the use of anti-depressants. Research consistently shows that antidepressants do not work any better than placebo. So why do we still use them? They get approved as drugs because they do have a statistically significant effect on depression. However, that effect is not clinically significant.

The difference between clinical significance and statistical significance can be described like this: Le’ts say that people start the study with depression reported as a 7.0 on a ten point scale with the most severe depression being 10. And at the end of the study they have improved to a 4.0. That’s great! They are feeling better. However, the placebo controls have also improved and they come in at a 4.1. For our example the 4.0 is statistically different than the 4.1. However the difference between placebo and anti-depressant is not clinically different. People just don’t say, “my depression is down to 4.0 from 4.1 and I feel the difference.”

Different ailments appear to have respond differently to placebo. Depression is highly responsive to placebo. Research from 1999 found the effects of placebo on depression to be 75%. However, these placebo effects on depression have been continuing to grow over the past couple decades, so that now we are finding certain antidepressants no better than placebo. Menopausal hot flashes also have a nice placebo response. And at least one third of the results of pain relief can be attributed to placebo effect alone.

Placebo, or context effect as I like to call it, has been extensively studied. We know some of the things that will increase the likelihood of a treatment being effective. These range from the color of the pill to patients perception’s of the health care practitioner. Placebo effect is really not much different than marketing.

The mental health practitioner doesn’t realize that when they listen attentively to their client, label them with a disorder name (e.g. “You have bipolar depression.”) and tell the client that there is a pill that will “stabilize their brain chemistry” they are actually marketing the treatment. They may also tell the client that the drug’s effects could “kick in” immediately, or they might occur slowly over a period of a couple months. This gives the client options on how to respond to their “placebo/antidepressant”. If the client then runs into someone that is on “their” antidepressant and they say it “saved their life”, they have additional context to boost the effectiveness of the treatment.

The word “placebo” has gotten a bad wrap, in the sense that only a fool would respond to placebo effect. That is one of the reasons I prefer “context effects” over “placebo”. Context matters and optimizing context to support healing seems like a good strategy, not a unethical strategy. Certain settings, particular colors, and personal biases make a difference in treatment effectiveness. Does optimizing context fall under the adage of “first do no harm” or does it harm someone to play into their natural tendencies to put faith in certain people, places and things?

REFERENCES
Kirsch, I., (2008). Challenging Received Wisdom: Antidepressants and the Placebo Effect. McGill Journal of Medicine, 11(2): 219-222.

Di Blasi, Z. & Kleijnen, J., (2003). CONTEXT EFFECTS: Powerful Therapies or Methodological Bias? Evaluation & The Health Professions, 26(2), 166-179 DOI: 10.1177/0163278703252254.

A co-occurring disorder (formerly referred to as dual diagnosis) is when someone has a mental health disorder at the same time as a substance use disorder (e.g. alcoholism, drug addiction). For instance, a person that abuses alcohol and is also schizophrenic would be said to have a co-occurring disorder.

Mental disorders that can co-occur with substances use disorders include: major depression, bipolar disorder, schizophrenia and other psychotic disorders, eating disorders (although I personally would class those as a substance use disorder), general anxiety disorder, post-traumatic stress disorder, personality disorders, attention-deficit/hyperactivity disorder, and pathological gambling disorder.

Fifty to 75 percent of people in treatment for a substance use disorder also have a co-occurring mental health disorder. And 20 to 50 percent of people that are treated for a mental health disorder also have a substance use disorder. My favorite statistic is that 60 percent of people with three or more disorders (identified by survey) never received any treatment. Although, people with a co-occurring disorder are more likely to seek treatment than people with just one problem.

Coming from an alternative health perspective the idea of diagnosing and labeling people with disease names seems weird to me and somewhat funny. People do not have diseases, they have a set of problems or issues that are interconnected and need to be considered as a whole.

The big thing in mainstream medicine is how we need to consider all disorders that co-occur when treating a person. A step in the right direction, but it still seems bizarre to me that anyone would think about reducing a person to specific sets of symptoms so they can label and treat each condition separately. This reductionist approach is supported by the medical practitioners, drug companies and insurance companies that seem to feel it is necessary to have this system in order to communicate with each other.

I also imagine that this reductionist approach may be due to the limitation of humans to handle complexity. It is simpler to label a disease and match it with a treatment than to understand what is happening with a person and create a unique treatment to address it. We see this same reductionist approach applied by herbalists as well. Often times a beginner or Western herbalist will just use a treatment that matches a disease name, unless they have training in a system that uses a constitutional approach (e.g. traditional Chinese medicine, etc.)

REFERENCES
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with Co-Occurring Disorders. (2013). Treatment Improvement Protocol (TIP) Series, No. 42 (DHHS Publication No. (SMA) 13-3992). Rockville, MD: Substance Abuse and Mental Health Services Administration (US).