5. Comorbid patients, especially after treatment, may have ambivalent feelings about taking prescribed drugs to feel better. Evidence suggests that benzodiazepines (BZS), often prescribed for anxiety disorders, may be contraindicated in comorbid patients because of their high potential for abuse. Ciraulo et al. (1988) have reviewed literature suggesting that alcoholics demonstrate a greater liability to BZ abuse than nonalcoholics. Jaffe and Ciraulo (1985) cautioned that, because of the potential for cross-dependence between BZs and alcohol, these agents should not be used in the longer term treatment of patients with a history of alcohol disorder. Woods et al. (1988) noted that sedative abusers may be especially prone to BZ abuse. These findings suggest that, if alternatives are available, BZs should not be used to treat psychiatric symptoms in comorbid patients. Evidence suggests that benzodiazepines (BZs), often prescribed for anxiety disorders, may be contraindicated in comorbid patients because of their high potential for abuse. Meyer (1986b) recommends that the ideal anxiolytic agent for alcoholic patients would be clinically effective, have a low abuse potential, and not potentiate the effects of alcohol. The usefulness of buspirone, a pharmacological agent that may meet these criteria, was supported in a study of 51 recently detoxified alcoholics who experienced generalized anxiety with depressive features (Tollefson et al. 1991). Compared with patients receiving placebo, patients receiving buspirone were better in terms of anxiety, global depressive symptoms, and number of days not using alcohol. Although this study needs to be replicated, it suggests that buspirone may be an effective treatment for such patients. Several other agents aimed at depression and anxiety have also been evaluated. A recent literature review indicates that tricyclic antidepressants (TCAs) improve persistent symptoms of depression in these comorbid patients (Merikangas and Gerlernter 1990). However, dosing TCAS in comorbid patients may raise special concerns: Studies suggest that TCA pharmacokinetic profiles may differ in alcoholic patients. Ciraulo et al. (1982) reported that blood levels of imipramine in response to a fixed drug dosage were lower in alcoholic than in nonalcoholic depressives. Monoamine oxidase inhibitors (MAOIs), another pharmacologic treatment for depression, may pose special risks in comorbid patients. Meyer (1986b) observed that MAOIS are not widely advocated for use in comorbid patients because of this group's increased risk for hypertensive crises and their failure to comply with important dietary, beverage, and medication restrictions. Initial clinical trials of MAOIS on depressed abstinent alcoholics produced a low improvement rate for depressive symptoms (Schottenfeld et al. 1989). Psychological treatments In addition to pharmacotherapy, effective psychological treatments such as behavior therapy are available for a range of psychiatric disorders (Bellack and Hersen 1990). Because the efficacy of such treatments is documented, especially for anxiety and depressive disorders, comorbid patients may benefit from them. Although few data directly address this possibility, the efficacy of standard behavioral treatments for anxiety seems limited by the presence of alcohol abuse (see Kushner et al. 1990). As with pharmacological interventions, it is important to establish the presence of stable anxiety or depression symptoms after withdrawal from alcohol before initiating psychotherapeutic treatment. More traditional psychotherapies may help some comorbid patients. Woody et al. (1984) reported that psychotherapy in addition to substance abuse counseling has an interactive effect on the outcome of patients with drug abuse disorders other than alcohol abuse, depending on the degree of psychopathology. Patients with low or high levels of psychopathology did not benefit from the added psychotherapy, but patients with medium levels of psychopathology improved the course of their drug use disorder with such psychotherapy. These results suggest that alcoholics with moderate levels of comorbid psychopathology may be good candidates for psychotherapy, regardless of symptoms or diagnosis. Woody et al. (1985) reported that patients with drug abuse disorders and ASPD did not benefit from psychotherapy unless they also had depression. Traditional Alcohol Treatments Comorbid patients with more severe psychiatric disorders, such as schizophrenia and bipolar disorder, may have a lowered capacity to comply with traditional alcoholism treatment regimens (Drake et al. 1990; Pristach and Smith 1990). This lowered capacity may be associated with their failure to benefit from traditional alcohol treatments. Studies examining the efficacy of structured, abstinence-oriented, interpersonally confronting approaches to treating alcoholism in these patients reveal high dropout rates and poor long-term outcomes (McLellan et al. 1981). Such findings suggest that standard therapeutic approaches to alcoholism treatment may be less effective for comorbid patients (Osher and Kofoed 1989). In particular, patients with schizophrenia are sensitive to the effects of stress, and interventions for alcohol abuse that fail to account for this fact may provoke symptom relapses or noncompliance with treatment (Mueser et al. in press). Hybrid Treatments The above discussion suggests that traditional psychiatric and substance abuse treatment strategies may be of limited use for many comorbid patients because they fail to address this population's unique needs. Recent innovations in treating comorbid alcohol abuse and psychiatric illness have designed integrated treatment programs for comorbid patients. Several integrated treatment models have been developed over the past 5 years (Drake et al. 1991; Kofoed et al. 1986; Levy and Mann 1988; Minkoff 1989; Sciacca 1991). Ridgely et al. (1991) summarized these common features of integrated psychiatric-alcoholism treatment programs: 1. client engagement and retention, 2. persuasion about the relevance of alcohol abuse to psychiatric disturbance, 3. assessment (distinguishing primary from secondary disorders), 4. concomitant treatment of both disorders, 5. training in relapse prevention in an aftercare setting. There are few controlled studies on the efficacy of hybrid programs, but they seem to offer an appropriate treatment model based on the current knowledge base. Barriers to Improved Treatment of Comorbid Patients Ridgely et al. (1990) reviewed organizational and financial barriers to the integrated treatment of chronic substance abusers with psychiatric disorders. They noted several limitations specific to a mental health system oriented to treating single rather than multiple disorders. One issue is that psychiatric patients with comorbid alcohol abuse are less likely to be referred for treatment of addictive disorders, and they receive less treatment than nonabusing peers (Solomon 1986; Solomon and Davis 1986). Anecdotal data indicate that comorbid patients can be caught in a therapeutic Catch-22, in which they cannot enter the mental health service system until they stop drinking and cannot enter substance abuse treatment until their psychiatric disorders are controlled. Psychiatric and alcohol abuse treatment services tend to be administered by separate agencies and provided by different staff members, a problem compounded by the lack of consulting professionals or professionals trained to treat both disorders (Sellman 1989). Studies suggest that specialized treatments for comorbid patients could circumvent many such problems (Lehman et al. 1989; Test et al. 1989). Comorbid patients with more severe psychiatric disorders, such as schizophrenia and bipolar disorder, may have a lowered capacity to comply with traditional alcoholism treatment regimens. An important first step in treatment includes identifying comorbid disorders-detecting psychiatric conditions for alcohol treatment patients and alcohol and other drug abuse or dependence among psychiatric patients and clarifying the source of psychiatric symptoms. An emphasis on hybrid programs aimed at treating comorbid patients would circumvent the difficulty of accessing treatment and give them access to more knowledgeable care providers. Summary Comorbidity is an important issue about which there are many unanswered questions. The literature reviewed here suggests that comorbidity is clinically and statistically significant. The frequency of co-occurring alcohol and psychiatric disorders goes beyond chance expectations, and comorbidity seems to affect the clinical course of both disorders adversely. Continued clinical and scholarly emphasis on comorbidity is clearly warranted. Important gaps in understanding comorbidity surround interrelated problems of assessment, comorbidity mechanisms, and treatment approaches. Valid and reliable assessment of alcohol problems in general, and comorbidity in particular, offers an important challenge to future researchers (Drake et al. 1990; Lehman et al. 1989). Related to the problem of assessment are unanswered questions about the mechanism(s) that link comorbid disorders. Understanding the interplay between alcohol consumption, psychiatric symptoms, and psychiatric diagnostic entities stands as an important goal in future comorbidity research. If research continues to support a bidirectional interaction (figure 4) between alcohol and psychiatric disorders, for example, assessment and treatment technologies may be most effective when they address comorbidity as a unique clinical entity rather than as two independent conditions. In this regard, hybrid programs that target the unique needs of these patients seem to be the best option for circumventing this group's problems in obtaining appropriate treatment. However, the efficacy of these hybrid treatment approaches, compared with traditional treatments for the separate comorbid disorders, is an important unanswered question. The introduction of qualitatively distinct psychiatric diagnostic categories in the early 1980s (DSM-III and DSM-III-R) offered important methodological advantages in studying comorbidity. By providing the methodology to address comorbidity separately for distinct diagnostic categories, this approach allows for more refined findings. For example, even within the broad. category of anxiety disorders, Kushner et al. (1990) suggested that comorbidity rates vary for specific anxiety diagnoses (phobias, obsessivecompulsive disorder, panic disorder). Such findings highlight the advantages to considering issues of comorbidity that involve various psychiatric diagnostic groups as conceptually related, yet in some respects unique research and clinical issues. It is also important that this methodology not obscure common comorbid processes. All mental disorders are associated with varying degrees of social, occupational, and personal disruptions; many include elements of dysphoria and distress. 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