Affective Disorders and Substance Abuse Comorbidity

Report
Depression and Recovery
or
“The fingers of the hand”
Omar S. Manejwala, M.D.
William J. Farley Center
Williamsburg, VA
www.farleycenter.com
Overview
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CONTEXT
Specific Depressive Disorders
Suicide
Neurobiology of Depression
Prevalence of Dual Diagnosis
Diagnostic Difficulties
Barriers to Recovery in Dual Diagnosis
Treatment Principles: Medications, Therapy, 12step approaches
2
Source?
“But this does not mean that we disregard human
health measures. God has abundantly supplied
this world with fine doctors, psychologists, and
practitioners of various kinds. Do not hesitate to
take your health problems to such persons. Most
of them give freely of themselves, that their
fellows may enjoy sound minds and bodies. Try to
remember that though God has wrought miracles
among us, we should never belittle a good doctor
or psychiatrist.
Their services are often indispensable in treating
a newcomer and in following his case afterward.”
3
“Alcoholics Anonymous” p133
“But this does not mean that we disregard human
health measures. God has abundantly supplied
this world with fine doctors, psychologists, and
practitioners of various kinds. Do not hesitated to
take your health problems to such persons. Most
of them give freely of themselves, that their
fellows may enjoy sound minds and bodies. Try to
remember that though God has wrought miracles
among us, we should never belittle a good doctor
or psychiatrist.
Their services are often indispensable in treating
a newcomer and in following his case afterward.”
4
Source?
The AA member- medications and other
drugs” pamphlet
“
"...A.A. members and many of their physicians have
described situations in which depressed patients have
been told by A.A.'s to throw away the pills, only to have
depression return with all its difficulties, sometimes
resulting in suicide.
We have heard, too, from schizophrenics, manic
depressives, epileptics, and others requiring medication
that well-meaning A.A. friends often discourage them from
taking prescribed medication.
Unfortunately, by following a layman's advice, the
sufferers find that their conditions can return with all their
previous intensity”
5
“The AA member- medications and
other drugs” pamphlet
"It becomes clear that just as it is wrong to
enable or support any alcoholic to become
re-addicted to any drug, it's equally wrong
to deprive any alcoholic of medication
which can alleviate or control other
disabling physical and/or emotional
problems."
6
Narcotics Anonymous Fellowship
Services states…
"The question of prescription medication should
be decided between the member, their doctor,
and the member's Higher Power.
Our pamphlet "In Times Of Illness" and our
10th Tradition, make this abundantly clear.
We strongly recommend telling our doctors about
our history so that when prescription medication
is absolutely necessary they can prescribe it
knowing that we are recovering addicts."
7
AA grapevine October 1956
• “One with the Angels” m.p.g. Boston, MA
• In July of 1950, while attending the Cleveland
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Convention and not having had a drink for many
months, I became psychotic. I lost contact with
reality. I lost my sanity, in the clinical sense.
For ten months I was treated in a Maryland
hospital. The illness required electric shock
treatments and intensive psycho-therapy.
On one occasion, just before discharge, I asked
my doctor how he related my alcoholism to my
psychosis. He showed how the fingers of the hand
are distinct, separate and still connected. Thus
closely are alcoholism and mental disease kin.
8
State of the evidence
• Recent meta-analysis (Nunes & Levin) of depression
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treatment in patients with substance use disorders
300 trials between 1973-2003
Only 44 were placebo controlled
Only 14 met inclusion criteria for rigor (randomized, etc)
8 studies focused on EtOH
In 4 of those studies, patients were drinking at the time
of the study
The only clear findings were that antidepressants
worked better for depression if patients were sober and
they didn’t improve abstinence rates
9
Overview
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Context
SPECIFIC DEPRESSIVE DISORDERS
Suicide
Neurobiology of Depression
Prevalence of Dual Diagnosis
Diagnostic Difficulties
Barriers to Recovery in Dual Diagnosis
Treatment Principles: Medications, Therapy, 12step approaches
11
Some “depressive” disorders
commonly seen
• Major Depressive disorder
• Dysthymia
• Premenstrual dysphoric disorder
• Bipolar disorder (Type I, II, mixed)
• Bereavement
• Depressed mood is a symptom, NOT
an illness
12
Symptoms of major depressive
disorder
• Depressed mood*
• Loss of interest/ pleasure in activities
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(including sex)
Weight loss, weight gain (>5%/month)
or appetite change
Sleep disturbance
Fatigue/loss of energy
Psychomotor agitation/retardation
Worthlessness/excessive or inappropriate
guilt
Poor concentration (its not always ADD!)
Recurrent thoughts of death/suicide
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Exclusionary/Other Criteria for Diagnosis
of Major Depressive Disorder
• Not better accounted for by:
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Bereavement
Substance induced mood disorder
Dysphoria of some psychotic states
Certain medical illnesses (e.g.
hypothyroidism)
Also there can never have been a history of a
manic episode.
Durational Criteria
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Bipolar disorder (manic-depression)
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Elevated, expansive or irritable moods
Inflated self-esteem/grandiosity
Decreased need for sleep (as opposed to insomnia)
Flight of ideas
Distractibility, poor concentration (its not always
ADD!)
Increase in goal directed activity or psychomotor
agitation
Excessive involvement in behaviors with a high-risk
for painful consequences.
• Probably more common in our chronic relapse
population. 56.1% of bipolar patients had a SUD in
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the ECA study (flawed)
Medical Illnesses commonly associated
with depression comorbidity:
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Epilepsy
Huntington’s disease
Infections (HIV, neurosyphillis)
Migraines
MS
Narcolepsy
Cancer
Wilson’s disease
Parkinson’s Disease
Cushing’s disease
Menses-related
Post-partum
Parathyroid disorders and thyroid disorders
SLE
Immune/inflammatory disorders
Certain medications
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Overview
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Context
Specific Depressive Disorders
SUICIDE
Neurobiology of Depression
Prevalence of Dual Diagnosis
Diagnostic Difficulties
Barriers to Recovery in Dual Diagnosis
Treatment Principles: Medications, Therapy, 12step approaches
17
Suicide
• People with an EtOH use disorder 20x
more likely to complete suicide than
general population.
• Between 18% and 66% of suicide victims
have alcohol in their blood at the time of
death (Roizen 1988; Welte et al. 1988,
Collier et al. 1986, Berkelman et al.
1985).
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Suicide Risk Factors
• Previous suicide attempts
• History of mental disorders, particularly
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depression
History of alcohol and substance abuse
Family history of suicide
Family history of child maltreatment
Feelings of hopelessness
Impulsive or aggressive tendencies
Barriers to accessing mental health
treatment
Loss (relational, social, work, or financial)
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Suicide Risk Factors
• Physical illness
• Easy access to lethal methods
• Unwillingness to seek help because of the
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stigma attached to mental health and
substance use disorders or suicidal
thoughts
Cultural and religious beliefs—for instance,
the belief that suicide is a noble resolution
of a personal dilemma
Local epidemics of suicide
Isolation, a feeling of being cut off from
other people
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Suicide—contact with GP
• Among suicide completers, 80% had
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contact with a physician in the 6 months
prior
Majority of suicide completers are under
the care of a physician at the time of their
death
• Among suicide attempters the picture is
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comparable
1/3 of suicide attempters contacted their
physician the week prior to the attempt.
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Suicide Protective factors
• Effective clinical care for mental, physical,
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and substance abuse disorders
Easy access to a variety of clinical
interventions and support for help seeking
Family and community support
Support from ongoing medical and mental
health care relationships
Skills in problem solving, conflict
resolution, and nonviolent handling of
disputes
Cultural and religious beliefs that
discourage suicide and support selfpreservation instincts
22
Overview
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Context
Specific Depressive Disorders
Suicide
NEUROBIOLOGY OF DEPRESSION
Prevalence of Dual Diagnosis
Diagnostic Difficulties
Barriers to Recovery in Dual Diagnosis
Treatment Principles: Medications, Therapy, 12step approaches
23
Neurobiology of Depression
“Chemical Imbalance” hypothesis postulates that reduced levels of brain
serotonin or norepinephrine leads to depression.
100
80
60
Serotonin
40
Norepinephrine
20
0
Depressed Depressed
Not
Depressed
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Mood regulatory neural networks
Biological vulnerability
Gender
FH
Gene polymorphism
Temperament
Pre-natal insults
Exogenous Stressors
homeostasis
Mood Regulatory
Circuits
Trauma
Abuse
Life events
Medical illness
Depressive Episode
Adapted from H. Mayburg, MD
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Neural Network hypothesis
• In this paradigm, disruption of the regulatory
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network causes inability to respond to
endogenous and exogenous stress.
This network regulates homeostatic responses
in:
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Affect
Cognitive process
Psychomotor activity
Circadian rhythm
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Opening up the Mood Regulating
Circuits Box
Biological vulnerability
Gender
FH
Gene polymorphism
Temperament
Pre-natal insults
Exogenous Stressors
homeostasis
Mood Regulatory
Circuits
Trauma
Abuse
Life events
Medical illness
Depressive Episode
Adapted from H. Mayburg, MD
27
The neural network model cont’d
Cognitive Processing
attention – memory - action
CBT
EmotionCognition
Integration
Salience
self-reference
reinforcement
DBS
Meds
PF9/46, PM6, Par40, hc,
aCg24b,
mCg24c, pCg
mF9/10
rCg24a
oF11
cd-vst, thal
amg
mb-sn
Mood
State
sgCg25
a-ins, hth, bstem
Autonomic Responses
arousal – vegetative – circadian
29
Adapted from Helen Mayburg, MD
Kindling
• Alcoholism and bipolar disorder may be
related d/t the concept of neuronal
sensitization
• Subsequent episodes of illness are often
more frequent and more intense
• Similar to epilepsy in this regard
• Use of antikindling agents may be
beneficial in this population
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31
Overview
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Context
Specific Depressive Disorders
Suicide
Neurobiology of Depression
PREVALENCE OF DUAL DIAGNOSIS
Diagnostic Difficulties
Barriers to Recovery in Dual Diagnosis
Treatment Principles: Medications, Therapy, 12step approaches
32
Prevalence of SUD in psychiatric
treatment settings
• The “flip side”
– 30% of depressive d/o patients and 50% of Bipolar
patients in inpatient settings meet criteria for a SUD
– In VA studies the rates have been as high as 64%
lifetime SUD prevalence and 29% SUD in the last 30
days!
– This not only argues for a high incidence of SUD in
these conditions, but a clear association of substance
use with decompensation, since these were
inpatients.
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Affective/SUD comorbidities by
substance of abuse
• Bipolar d/o is more common among
cocaine dependent patients than
alcoholics
• The prevalence of depressive d/o among
treatment seeking alcoholics ranges from
15-67% depending on the study
• 98% of patients presenting for substance
abuse treatment report the symptom of
depression
34
What conclusions about prevalence
can be drawn?
• Data are conflicting d/t failure to exclude
substance induced illnesses, study design,
etc.
• All affective disorders are common in SUD
patients, and Bipolar d/o has the highest
rate of SUD of any psychiatric illness
• Depression and dysthymia are more
common in opiate dep and alcohol dep.
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Overview
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Context
Specific Depressive Disorders
Suicide
Neurobiology of Depression
Prevalence of Dual Diagnosis
DIAGNOSTIC DIFFICULTIES
Barriers to Recovery in Dual Diagnosis
Treatment Principles: Medications, Therapy, 12step approaches
36
Distinguishing SUD from DD
• Mood instability and depression are among the
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most common symptoms reported in people with
substance use disorders
People with substance use disorders who don’t
experience mood symptoms are in the minority
Depressed mood is almost universal in early
recovery, especially during detoxification
Protracted withdrawal states can have affective
lability that is difficult to distinguish from a
primary mood disorder.
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Comorbidity of Affective and SUD
• ECA: 32% of Affective d/o pts had SUD
• Among those with MDD:
– 16.5% had alcohol use disorder
– 18% had drug use disorder
• Among those with Bipolar disorder:
– 56.1% had substance use disorder
• In both the ECA and the NCS, Bipolar d/o
was the axis I condition most likely to also
have a SUD comorbidity.
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Diagnostic Difficulties
• Diagnostic difficulties at the interface of
SUD and Affective disorders are reflected
in varying prevalence rates across studies
• In some cases of “true” affective disorder,
substance use predates onset of affective
symptoms i.e. “which came first” may not
help you distinguish.
39
Diagnostic Difficulties
• Periods of abstinence, while extremely
helpful in clarifying diagnosis are…
– Often inaccurately reported
– Sometimes never present or too short to be
useful
– Often characterized by the dysphoria of
untreated alcoholism / addiction
– Occasionally characterized by exposure to
prescription medications that further
complicate diagnostic clarity e.g.
sedative/hypnotics, opiates, stimulants
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Diagnostic Difficulties
• For example, a recent study of 207 cocaine
addicts using the DIS (diagnostic interview
schedule) found…
– Current rate of affective illness 17%
– Lifetime prevalence of affective illness 28%
– 65% of subjects reported that drug use onset
preceded affective illness onset
– The primary problem with all these studies is that
they simply haven’t been done rigorously in
recovering populations
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Diagnostic Confusion
• Stimulant and alcohol intoxication can
produce symptoms indistinguishable from
mania or hypomania
• Withdrawal from these agents is
frequently indistinguishable from
depression and dysthymia
• Withdrawal from CNS depressants can
produce anxiety and agitation
• PAWS
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Some problems with diagnosis
• Substances induce
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• Psychiatric disorders
overlap
symptoms
“The best wayoften
to
clarify
with each other
• Multiple
psychiatric
diagnosis is
through
comorbidities can be
e.g.a
depression
observation common,
during
and anxiety disorders.
• Many psychiatric
period of abstinence”
disorders are cyclic and
psychiatric symptoms
Withdrawal mimics
psychiatric disorders
Protracted withdrawal
states not-well defined
and mimic primary
psychiatric conditions
Clean time vs. Dry Time
Substances can cause OR
exacerbate psychiatric
syndromes.
•
timing of dx difficult
Initial onset of a “true”
psychiatric disorder can
be precipitated by
substance intoxication or
withdrawal.
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Diagnostic Confusion
• Mania is generally easier to diagnose than
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depression in people with a SUD
Manic symptoms induced by substance use tend
to resolve in days; depressive symptoms can
take weeks or in some cases, months
Methamphetamine and hallucinogens can be the
exception to this rule, as substance-induced
mania with these agents can persist for weeks.
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Dorus et al 1987
• 171 inpatients in
80
•
60
% depressed
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EtOH-treatment
National prevalence
estimate for current
MDD is 5%
ETOHics are at a
higher risk for MDD
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Alcoholic
Inpatients
General
population
50
40
30
20
10
0
day 1
Day 28
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When to diagnose?
• Diagnosing too early can lead to overtreatment
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and mismatching and possibly poorer
outcomes.
Overtreatment can undermine the person’s
sense that AA/NA is the primary treatment of
their alcoholism / addiction
Diagnosing too late can lead to higher risk of
relapse, poorer outcomes, and suicide.
What clinical features predict comorbidity rather
than substance-induced affective d/o?
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Differentiating Illnesses
• Affective symptoms that predate onset of
substance use d/o
• Affective symptoms during extended
periods of abstinence
• Strong family h/o affective d/o
• Positive h/o response to affective d/o
treatment
“hedging your bets”
47
Differentiating Illnesses…”hedging
your bets”
• Chronic relapser despite multiple treatment
attempts
• Frequently affective illnesses in this
population are excluded owing to rigid
application of diagnostic criteria
• Alcoholics and addicts with extensive
treatment exposure and multiple relapses
should be more carefully evaluated and
medication trials considered.
48
Differentiating Illnesses…
”The luxury of being a purist”
• We don’t have it.
• RCTs for antidepressants exclude current
or recent substance use or substance use
disorders.
• The dually diagnosed are heterogeneous
with respect to severity of substance use
disorder, substances used, periods of
abstinence, trauma history, type of
affective illness
49
Risks of overtreatment
“so just put everyone on an antidepressant?”
• NO!!!
• Integrating depression treatment with
recovery principles is extremely difficult.
• Prescribing without that integration is
dangerous and may lead to relapse
• Risks of ADRs, precipitating AD-induced
mania, etc.
• Terminal uniqueness…
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Overview
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Context
Specific Depressive Disorders
Suicide
Neurobiology of Depression
Prevalence of Dual Diagnosis
Diagnostic Difficulties
BARRIERS TO RECOVERY IN DD
Treatment Principles: Medications, Therapy, 12step approaches
51
Factors that interfere with recovery
in DD
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Increased level of social isolation
Low energy
Impaired concentration
Suicidality
Anxiety
• 12-step approaches are heavily socially driven
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Terminal Uniqueness
• “Terminal uniqueness” is a cognitive distortion
present substance use disorders.
• Confronting “terminal uniqueness” is frequently
essential in addiction tx.
• What to do with the dually diagnosed person
who really is different, in some respects?
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Homogenizing Disease in Recovery
“Terminal Uniqueness”
• Of course, everybody is both unique and
similar.
• The key issue is “uniqueness” with respect
to the disease process, or the requirement
to engage in behaviors or cognitive
processes that arrest the disease process.
• Contrasting the special issues in the
management of dual dx with the cognitive
distortion of terminal uniqueness can be
tough.
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The 12-step program member and
medications
• People are told they are not different, then find
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that they are (e.g. dual diagnosis vs. terminal
uniqueness)
They are told by peers and even sponsors to
discontinue medications or to seek multiple
medical opinions until they find the one that
states they can go without medications.
Peers within 12-step communities have
themselves been misdiagnosed as having
primary affective illness and therefore mistrust
doctors and their capacity to make the diagnosis.
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How we discuss medications with the
dually diagnosed:
• Remind the Dually Diagnosed that they are not
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unique with respect to their alcoholism, or the
specific treatments needed for that.
Caution the Dually Diagnosed against accepting
pseudomedical advice from recovering peers
Advise the Dually Diagnosed that all attempts to
discontinue or dose-adjust psychotropic
medications should be medically managed.
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Overview
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Context
Specific Depressive Disorders
Suicide
Neurobiology of Depression
Prevalence of Dual Diagnosis
Diagnostic Difficulties
Barriers to Recovery in Dual Diagnosis
TREATMENT PRINCIPLES
57
Classes of Medications
• SSRI
• TCA
• SNRI, “other” (Serzone, Effexor,
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Remeron, Wellbutrin, Cymbalta)
MAOi
Lithium
Atypicals (Seroquel, abilify,
geodon, zyprexa, risperdal)
Synthroid
Buspar
Strattera
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Issues we consider when
prescribing to recovering patients
• Patients with substance use disorders can
be more side-effect sensitive
• Sensitivity may be “primed” by substance
withdrawal cycles and side effects can
precipitate cravings and relapse
• Where possible “start low, go slow”
• Conflicting experience but many dually
diagnosed patients may require combined
therapy and higher target doses.
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Issues to consider in prescribing to
recovering patients
• “Off label” prescribing is common
– The problems of the FDA label, “psychotic
depression” etc.
• PRN indications should be clearly
explained
• Frequent reevaluation is necessary in the
first 18-24 months of recovery owing to
overlap of psychiatric illness and
protracted withdrawal states.
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Medication versus Therapy
• Those who have both SUD and Major Depressive
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Disorder should be offered both medication and
therapy if appropriate
Personal preference should be a guiding
principle
Because therapy can be distracting and difficult
in early recovery, when focus on AA is most
needed, meds can often be more effective.
Medication is certainly the option for severe
illness
61
Early Recovery and Therapy
• Intensive psychotherapy and exploration
of trauma can be extremely dangerous in
early recovery
• Particularly when sexual trauma or PTSD
is present, therapy should lean towards
supportive and 12-step facilitative
approaches until a resilient ego emerges.
• Remembering the therapeutic benefit of
AA / NA
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Types of Psychotherapy
• Brief psychodynamic
• Interpersonal therapy
• Cognitive Behavioral Therapy
• Marital Therapy (esp useful for wives with
MDD)
• Group Therapies
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Cognitive Behavioral Therapy
• “Feeling Good” David Burns, M.D.
• Aaron Beck
• Albert Ellis “Rational Emotive Therapy”
• Cognitions fuel emotional states and can
be modified
• Really quite effective particularly for the
mild-moderate varieties
64
Cognitive Behavioral Therapy and
12-step recovery
• CBT may be particularly well suited to Dually
diagnosed 12-step members.
Cognitive Therapy
12-step recovery
Behavioral
Change
Positive
Thinking
Depression interrupts the cycle
Hitting Bottom
Feeling Miserable
Feeling
Better
65
If Psychotherapy works, how can it be an illness?
A landmark study in 1991 by Martin et. al showed
that responders to venlafaxine had similar
changes in regional cerebral blood flow at 6
weeks as responders to psychotherapy
• Psychotherapy, if it works for these illnesses,
does so by modifying brain chemistry
66
Venlafaxine (right basal ganglia, right posterior temporal Psychotherapy (right basal ganglia, right posterior cingulate)
General Principles of Treatment
with Affective/SUD comorbidities
• “But doc I’m not an alcoholic/drug addict.
I was just medicating my
mania/depression”
• SUD are primary disorders. If patients
meet criteria for both disorders, both must
be treated.
• Why? Patient reports are typically
inaccurate when they report that they only
used or experienced consequences of use
during affective disturbances.
67
General Principles of Treatment
with Affective/SUD comorbidities
• Unless illnesses are severe, patients
should be able to participate in standard
addiction treatment
• Access to psychotherapy and medication
treatment is critical
• Avoid interruptions in treatment
• Educate patients on the dangers of
obtaining pseudomedical consultation
from recovering peers.
68
General Principles of Treatment
with Affective/SUD comorbidities
• Treating depression in these patients
definitely reduces depressive symptom
intensity and episode frequency and
improves quality of life.
• Treating depression in these patients
probably reduces risk of relapse
• For example, Cornelius et al 1997 found
that Prozac in depressed alcoholics
reduced depression and drinking
69
General Principles of Treatment
with Affective/SUD comorbidities
• Special attention must be paid to helping
patients with comorbid affective illness
integrate into 12-step approaches
• More intense primary addiction treatment
may be needed, and some studies suggest
initial treatment duration should be
longer.
70
Support Groups for Dual Dx
• Groups for patients with comorbid
substance use d/o and affective disorders
• May be most effective if separated into
unipolar and bipolar illness
• Should not be a replacement for addiction
treatment and recovery-enhancing
approaches
• Can be 12-step based, cognitive
behavioral, or other approach
71
What about Bipolar disorder?
• Lithium has been the mainstay of
treatment for decades
• Substance use disorder may predict poor
response to lithium
• Some practitioners will use multiple meds
or valproic acid derivatives to treat these
patients
73
What about Bipolar disorder?
• Patients with Bipolar/SUD comorbidity may:
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Have more mixed symptoms
Have more rapid cycling
Be more likely to be nonadherent with meds
Have greater rates of misdiagnosis
Misdiagnosis of bipolar disorder as unipolar depression
is particularly problematic because antidepressants
can precipitate manic episodes.
Symptoms of PAWS can predispose to poor bipolar
hygiene
74
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