Treating Co-Occurring Treating Co-Occurring Disorders Across Disorders Across

the Life Spanthe Life Span

Sheila B. Blume, M.D.Sheila B. Blume, M.D.

Women Across the Life Span: Women Across the Life Span: A National Conference on Women, Addiction and RecoveryA National Conference on Women, Addiction and Recovery

July 12, 2004July 12, 2004

DEFINITIONS OF DEFINITIONS OF “DUAL DIAGNOSIS”“DUAL DIAGNOSIS”

1.1. SUBSTANCE DISORDER + PHYSICAL ILLNESSSUBSTANCE DISORDER + PHYSICAL ILLNESS

2.2. ALCOHOL DISORDER + OTHER DRUG DISORDERALCOHOL DISORDER + OTHER DRUG DISORDER

3.3. SUBSTANCE DISORDER + PSYCHIATRIC DISORDERSUBSTANCE DISORDER + PSYCHIATRIC DISORDER

AXIS I ONLYAXIS I ONLY

AXIS I AND ASPDAXIS I AND ASPD

AXIS I AND AXIS IIAXIS I AND AXIS II

ALCOHOLISM AS A SYMPTOM

““Alcohol addiction is a symptom rather than a disease… Alcohol addiction is a symptom rather than a disease…

There is always an underlying personality disorder There is always an underlying personality disorder

evidenced by obvious maladjustment, neurotic character evidenced by obvious maladjustment, neurotic character

traits, emotional immaturity, or infantilism.”traits, emotional immaturity, or infantilism.”

Source: R.P. Knight, 1937Source: R.P. Knight, 1937

DSM I - 1952

ALCOHOL ADDICTION COULD NOT BE ALCOHOL ADDICTION COULD NOT BE

DIAGNOSED IF AN “UNDERLYING DIAGNOSED IF AN “UNDERLYING

DIAGNOSIS” IS PRESENTDIAGNOSIS” IS PRESENT

POSSIBLE RELATIONSHIPS IN DUAL DIAGNOSIS

1.1. AddictionAddiction -------------------- > Mental Illness> Mental Illness

2.2. Mental Illness ----------Mental Illness ---------- > Addiction> Addiction

3.3. ------> Mental Illness (separate causes)------> Mental Illness (separate causes)------> Addiction ------> Addiction

4.4. ------> Mental Illness (common cause)------> Mental Illness (common cause)------> Addiction------> Addiction

5.5. Switch of Addictions Switch of Addictions

DUAL DIAGNOSIS:DUAL DIAGNOSIS: COMPLEX INTERRELATIONSHIPS

1. Substance use may help to alleviate symptoms of the psychiatric disorder

2. Substance use may help to alleviate side effects of therapeutic medications

3. Substance use may precipitate psychiatric illness or lead to biological changes that increase risk of mental disorder

4. All of the above take place

LONGITUDINAL STUDY, 2002

N= 736, 50% Female, mostly Caucasian, upstate NYFollowed from age 5 to late 20s, rated 5 times

Early SUDs predicted: SUDs Early MDD predicted: MDD, Alcohol Dep Early freq of TOBACCO use predicted: Alc Dep, SUDs Early heavier ALC use predicted: MDD, Alc Dep, SUDs Early MARUJUANA use predicted: MDD, Alc Dep, SUDs Early Illicit DRUG use predicted: MDD, Alc Dep, SUDs BOYS > GIRLS: SUDs only Income, parent education: + Alc Dep, - MDD Source: Brook et al. Arch Gen Psych 59:1039-1044, 2002

Early Substance Abuse Increases Likelihood of Developing Psychiatric Disorders in Late Twenties

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Substances Abused in Childhood, Adolescence, and/or Early Twenties

Longitudinal study participants who abused tobacco, alcohol, marijuana, and other illicit substances in earlier years were more likely to have diagnoses of major depressive disorder (MDD), alcohol dependence, or substance use disorders (SUDs) in their late 20s.

DUAL DIAGNOSIS THROUGHOUT THE LIFESPAN

  ADOLESCENCE:•       ADHD Anxiety disorders•       Conduct disorders Eating disorders•       Depression Gambling disorders•       PTSD

ADULTHOOD:•       All of the above•       Psychoses (schizophrenia, organic, postpartum, etc.)•       ASPD•       Personality disorders (incl. Borderline PD) GERIATRIC:•       All of the above•       Chronic organic syndromes of later life

Lifetime prevalence of comorbid Lifetime prevalence of comorbid mental and addictive mental and addictive disorders in the United States, disorders in the United States, combined community and combined community and institutional institutional five-site five-site Epidemiologic Catchrnent Epidemiologic Catchrnent Area data, standardized to the Area data, standardized to the U.S. U.S. PopulationPopulation

Comorbidity, 72%

Lifetime Prevalence of Cormorbid Mental and Addictive Disorders in the U.S.

12-MONTH CO-OCCURRENCE OF 12-MONTH CO-OCCURRENCE OF ADDICTIVE AND MENTAL DISORDERSADDICTIVE AND MENTAL DISORDERS

AGES 15-54AGES 15-54If Psychiatric Dx.If Psychiatric Dx.

Any AddictionAny Addiction Also Addiction Also Addiction

Major DepressionMajor Depression 23%23% 18%18%DysthymiaDysthymia 2% 2% 19%19%ManiaMania 2% 2% 37%37%Any AffectiveAny Affective 25%25% 18%18%

General Anxiety DisorderGeneral Anxiety Disorder 8% 8% 21%21%Panic DisorderPanic Disorder 5% 5% 18%18%PTSDPTSD 8% 8% 18%18%Social PhobiaSocial Phobia 17%17% 17%17%Simple PhobiaSimple Phobia 15%15% 14%14%AgoraphobiaAgoraphobia 8% 8% 18%18%Any AnxietyAny Anxiety 36%36% 15%15%

Any Mental DisorderAny Mental Disorder 43%43% 1515%%

Source: Kessler et al, National Comorbidity Study, American Journal of Orthopsychiatry 66:17-31, 1996Source: Kessler et al, National Comorbidity Study, American Journal of Orthopsychiatry 66:17-31, 1996

CO-OCCURRING DISORDERS, U.S.NHSDA Survey (2001, gen. population, ages 12 and older)

Alcohol/other drug, abuse/dependence: 16.6 million Alcohol only: 11 million Other drug (s) only: 3.2 million

Both alcohol and drug: 2.4 million

NCS Data (1990s, ages 15-54)

42.7% with 12-month addictive disorder had at least one 12-month mental disorder

14.7% with a 12-month mental disorder had at least one 12-month addictive disorder.

CO-OCCURRING DISORDERS, Cont.ECA Data (1980s, 18 and older)

47% with schizophrenia also had a substance use disorder (more than 4 times as likely as the general population).

61% with bi-polar disorder also had a substance use disorder (more than 5 times as likely as the general population).

Source: SAMHSA Report to Congress on Co-occurring Disorders, 2001Source: SAMHSA Report to Congress on Co-occurring Disorders, 2001

CO-OCCURRING DISORDERS:CO-OCCURRING DISORDERS:GENDER DIFFERENCES

NCS Data (1990s, ages 15-54)NCS Data (1990s, ages 15-54)% with lifetime addictive disorder who had at least one % with lifetime addictive disorder who had at least one

mental disorder:mental disorder: Males:Males: 57%57% Females:Females: 72%72%

ECA data (1980s, 18 and older)ECA data (1980s, 18 and older)% with lifetime addictive disorder who had at least one % with lifetime addictive disorder who had at least one

mental disorder:mental disorder: Males:Males: 44%44% Females:Females: 65%65%

PERSONALITY DISORDERS AND SUBSTANCE USE DISORDERS: NESARC 2000-2001

12–month prevalence If A/D, PD If PD, A/DAny Alcohol Dis. 8.5% 28.6% 16.4%Alcohol Abuse 4.7% 20.0% 6.2%Alcohol Dep. 3.8% 40.0% 10.2%Any Drug Dis. 2.0% 47.7% 6.5%Drug Abuse 1.4% 38.0% 3.5%Drug Dep. 0.6% 70.0% 2.9%

Any Personality Dis. 14.8%Obs-comp 7.9%Paranoid 4.4%ASPD 3.6%

Source: Grant BF et al. Arch General Psych 61:361-368, 2004

UNDERSTANDING RATES OF COMORBIDITY

To understand the meanings of statistics in this area and To understand the meanings of statistics in this area and compare the findings of various studies consider the following:compare the findings of various studies consider the following:

Note that lifetime Note that lifetime prevalenceprevalence differs from 6- or 12–month differs from 6- or 12–month prevalence and lifetime riskprevalence and lifetime risk

Note the Note the age rangeage range included in the study (e.g. the ECA study included in the study (e.g. the ECA study differs from the NCS)differs from the NCS)

Note the Note the range ofrange of diagnosesdiagnoses included in the study: included in the study:

Selected Axis I (mood and anxiety disorders)Selected Axis I (mood and anxiety disorders) Axis I, plus ASPD only from Axis IIAxis I, plus ASPD only from Axis II Axis I and Axis IIAxis I and Axis II Does it include eating disorders? Pathological gambling?Does it include eating disorders? Pathological gambling?

Lifetime Prevalence of Key Diagnoses:Lifetime Prevalence of Key Diagnoses:Comparison of Individuals with Alcohol Abuse Comparison of Individuals with Alcohol Abuse

or Dependence to Total ECA population or Dependence to Total ECA population (5-site ECA data, weighted to U.S. population, in percent)(5-site ECA data, weighted to U.S. population, in percent)

TOTAL Those with Alcohol Population Abuse and/or

Dependence Diagnosis Men Women Men Women Drug abuse and/or 7 5 19 31 dependenceAntisocial personality 4 0.81 15 10Phobic Disorder 9 16 13 31Major Depression 3 7 5 19Panic Disorder 1 2 2 7Somatization 0.02 0.2 0.07 0.87Mania 0.3 0.4 1 4_________________________________________________________Source: Helzer, Journal of Studies on Alcohol, vol. 49, pp. 219-24, 1988

Lifetime and Current Prevalence of Lifetime and Current Prevalence of Psychopathology Among Hospitalized Alcoholics*Psychopathology Among Hospitalized Alcoholics*

______________________________________________________________________________________________________________________________________________________________________________MenMen WomenWomen TotalTotal(N=231),%(N=231),% (N=90),% (N=90),% (N=321),%(N=321),%

________________________________________________________________________________________________________________________________________________________

No additional psychopathology No additional psychopathology 2525 2020 2323

Antisocial personality**Antisocial personality** 4949 2020 4141

Substance AbuseSubstance Abuse 45(8)***45(8)*** 38(13)38(13) 43(9)43(9)

DepressionDepression 32(18)32(18) 52(38)52(38) 38(23)38(23)

Obsessive-compulsive disorderObsessive-compulsive disorder 12(4)12(4) 13(7)13(7) 12(5)12(5)

Panic disorderPanic disorder 8(5)8(5) 14(9)14(9) 10(6)10(6)

ManiaMania 5(2)5(2) 3(1)3(1) 4(2)4(2)

SomatizationSomatization 1(1)1(1) 2(2)2(2) 1(1)1(1)

SchizophreniaSchizophrenia 2(2)2(2) 3(1)3(1) 2(2)2(2)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________** Diagnoses are without exclusion criteriaDiagnoses are without exclusion criteria**** Diagnosis of antisocial personality was modified to exclude two items that are related to abuseDiagnosis of antisocial personality was modified to exclude two items that are related to abuse****** Percentages in parentheses indicate current diagnosisPercentages in parentheses indicate current diagnosis

Source: Hesselbrock, Archives of General Psychiatry, vol. 42, pp. 1060-66, 1986Source: Hesselbrock, Archives of General Psychiatry, vol. 42, pp. 1060-66, 1986

PSYCHIATRIC COMORBIDITY IN OPIATE DEPENDENTS (N=716)

Lifetime Prevalence %Lifetime Prevalence % One Month Prevalence %One Month Prevalence %DiagnosisDiagnosis MaleMale FemaleFemale MaleMale FemaleFemale

Any Axis IAny Axis I 15.815.8 33.433.4 5.0 5.0 11.211.2Affective DisorderAffective Disorder:: 11.411.4 27.527.5 2.1 2.1 5.3 5.3 Major Dep.Major Dep. 8.7 8.7 23.723.7 1.3 1.3 5.3 5.3 DysthymiaDysthymia 2.4 2.4 4.4 4.4 BipolarBipolar 0.8 0.8 0.0 0.0 0.8 0.8 0.0 0.0

Anxiety DisorderAnxiety Disorder:: 6.1 6.1 10.710.7 3.4 3.4 6.8 6.8 Panic DisorderPanic Disorder 2.1 2.1 1.8 1.8 0.3 0.3 0.9 0.9 GADGAD 0.3 0.3 0.0 0.0 0.3 0.3 0.0 0.0 OCDOCD 0.5 0.5 0.0 0.0 0.5 0.5 0.0 0.0 Simple PhobiaSimple Phobia 1.9 1.9 5.3 5.3 1.9 1.9 3.6 3.6 Social PhobiaSocial Phobia 1.9 1.9 3.6 3.6 0.8 0.8 2.7 2.7 AgoraphobiaAgoraphobia 0.0 0.0 0.6 0.6 0.0 0.0 0.3 0.3

Eating DisorderEating Disorder 0.0 0.0 1.5 1.5 0.0 0.0 0.0 0.0SchizophreniaSchizophrenia 0.0 0.0 0.3 0.3 0.0 0.0 0.3 0.3

Source: Brooner et al, Archive of General Psychiatry 54:71-80, 1997Source: Brooner et al, Archive of General Psychiatry 54:71-80, 1997

PRIMARY DISORDERPRIMARY DISORDER- earlier onset- earlier onset- onset during prolonged remission- onset during prolonged remission

(3 to 6 months)(3 to 6 months)

SECONDARY DISORDERSECONDARY DISORDER- later onset- later onset- relapse following primary disorder during - relapse following primary disorder during prolonged remissionprolonged remission

Disorders: Primary and Secondary

WHICH CAME FIRST?WHICH CAME FIRST?(Major Depression/Alcoholism)

AlcoholismAlcoholism DepressionDepression PrimaryPrimary Primary Primary

PopulationPopulationMenMen WomenWomen MenMen Women Women

Research volunteersResearch volunteers 62%62% 40% 40% 38%38% 60%60%

InpatientsInpatients 59%59% 35% 35% 41%41% 65%65%

General populationGeneral population 78%78% 34% 34% 22%22% 66%66%

Sources:Sources: ECA Helzer & Pryzbeck, 1985ECA Helzer & Pryzbeck, 1985Hesselbrock, 1985Hesselbrock, 1985Roy, 1991Roy, 1991

Meta-analysis of Eight Longitudinal Studies(U.S., Canada, Scotland) 2-10 Years

For MEN and WOMEN:For MEN and WOMEN:

DepressionDepression PredictsPredicts DepressionDepressionAlcohol IntakeAlcohol Intake PredictsPredicts Alcohol IntakeAlcohol Intake

For MEN:For MEN:

Alcohol IntakeAlcohol Intake PredictsPredicts DepressionDepression

For WOMEN:For WOMEN:

Alcohol IntakeAlcohol Intake PredictsPredicts DepressionDepression(stronger effect)(stronger effect)over short intervalsover short intervals

DepressionDepression PredictsPredicts Alcohol IntakeAlcohol Intakeover long intervalsover long intervals

Source: Hartka et al, 1989 (submitted to British Journal of Addiction)Source: Hartka et al, 1989 (submitted to British Journal of Addiction)

PRIMARY VERSUS SECONDARY DEPRESSION PRIMARY VERSUS SECONDARY DEPRESSION IN ADDICTIVE ADOLESCENTSIN ADDICTIVE ADOLESCENTS

BoysBoys GirlsGirlsN=26N=26 N=25N=25

Alcohol/Drug PrimaryAlcohol/Drug Primary 60%60% 28%28%

Depression PrimaryDepression Primary 30%30% 40%40%

Same TimeSame Time 10%10% 32%32%

Source: Deykin et al, American Journal of Psychiatry 149:1341-1347, 1992Source: Deykin et al, American Journal of Psychiatry 149:1341-1347, 1992

WHICH CAME FIRST?WHICH CAME FIRST?NATIONAL COMORBIDITY STUDYNATIONAL COMORBIDITY STUDY

AGES 15-54AGES 15-54

WOMENWOMEN MEN MEN Add 1Add 1stst Ment 1Ment 1stst Add 1Add 1stst Ment Ment 11stst

Any Affective 31%Any Affective 31% 59% 59% 50% 50% 40% 40%

Any Anxiety 13%Any Anxiety 13% 85%85% 20% 20% 74% 74%

Antisocial 6%Antisocial 6% 40%40% 7%7% 89% 89%

Any Mental 11%Any Mental 11% 85%85% 14% 14% 82% 82%

Source: Kessler et al, National Comorbidity Study, American Journal of Orthopsychiatry 66:17-31, 1996Source: Kessler et al, National Comorbidity Study, American Journal of Orthopsychiatry 66:17-31, 1996

PRIMARY PSYCHIATRIC DIAGNOSIS IN COCAINE AND ALCOHOL DEPENDENT PATIENTS

Total with Co-occurring Disorders (including ASPD):Total with Co-occurring Disorders (including ASPD):

Men:Men: 56%56%Women:Women: 68%68%

Primary Diagnosis:Primary Diagnosis: Men (50) Women (50)Men (50) Women (50)

TotalTotal PrimaryPrimary TotalTotal PrimaryPrimaryMajor Depression 18 4 Major Depression 18 4 20 10 20 10BipolarBipolar 3 3 1 1 5 2 5 2Panic DisorderPanic Disorder 5 5 1 1 9 8 9 8Social PhobiaSocial Phobia 7 7 7 7 5 5 5 5PTSDPTSD 11 11 8 23 18 8 23 18

Source: NIDA Notes Vol 12 No.4, 1997, work of Kathleen Brady MD and colleagues at Med University of South Carolina.Source: NIDA Notes Vol 12 No.4, 1997, work of Kathleen Brady MD and colleagues at Med University of South Carolina.

COGA SAMPLECOGA SAMPLE

All AlcoholicAll Alcoholic 11° Alcohol° Alcohol No PsychNo Psych

Women Women Dependent WomenDependent Women DiagnosisDiagnosis

ANOREXIAANOREXIA 1.4%1.4% 1.26%1.26% 0.34%0.34%BULIMIABULIMIA 6.2%6.2% 3.46%3.46% 0.6%0.6%

- Eating Disorders Correlate With ASPD- Eating Disorders Correlate With ASPD- Eating Disorders Correlate With Major Depression- Eating Disorders Correlate With Major Depression

WomenWomen Women Women WomenWomenAmphet/CocaineAmphet/Cocaine CannabisCannabis OpiateOpiate

ANOREXIAANOREXIA 2.3%2.3% 2.0%2.0% 2.5%2.5%BULIMIABULIMIA 8.2%8.2% 8.4%8.4% 7.5%7.5%

Source: Schuckit, 1997, Addiction 92(10)Source: Schuckit, 1997, Addiction 92(10)

PATHOLOGICAL GAMBLING IN CHEMICALLY DEPENDENT ADULTS

SOUTH OAKS HOSPITAL LIFETIME

N = 458 ADULTS Problems 10% Path Gamb 9% Total 19%

N=100 ADOLESCENTS Problems 14% Path Gamb 14% Total 28%

YALE ADDICTION CLINIC

N=198 COCAINE DEPEND CURRENT PATH GAMB Males 19.0% Females 5.5%

309.81 POST TRAUMATIC STRESS DISORDER

A. Traumatic Events (intense event, response)A. Traumatic Events (intense event, response)

B. Event Re-experienced (1 or more)B. Event Re-experienced (1 or more) (1) recurrent memories/intrusive thoughts(1) recurrent memories/intrusive thoughts (2) recurrent dreams(2) recurrent dreams (3) acting or feeling as if recurring(3) acting or feeling as if recurring (including during intoxication)(including during intoxication) (4) distress at related cues(4) distress at related cues (5) physiological reaction to related cues(5) physiological reaction to related cues

309.81 POST TRAUMATIC STRESS DISORDER

C. Persistent Avoidance/Numbering (3 or more)C. Persistent Avoidance/Numbering (3 or more)

(1) thoughts(1) thoughts

(2) activities(2) activities

(3) memory gaps(3) memory gaps

(4) diminished interest in activities(4) diminished interest in activities

(5) restricted affects(5) restricted affects

(6) sense of shortened future (6) sense of shortened future

D. Persistent Increased Arousal (2 or more)

(1) sleep

(2) anger

(3) concentration

(4) hypervigilance

(5) startle

E. More then 1 Month, Significant Distress, Impairment

309.81 POST TRAUMATIC STRESS DISORDER

REVIEW OF PTSD AND SUBSTANCE USE DISORDERS

– Higher rates of exposure to trauma in women/menHigher rates of exposure to trauma in women/men

– Higher rates of exposure in chemically dependent Higher rates of exposure in chemically dependent

women/general pop. (30-60% vs. 10%)women/general pop. (30-60% vs. 10%)

– Higher rates of PTSD in women/men (general)Higher rates of PTSD in women/men (general)

– Higher rates of PTSD in chemically dependent Higher rates of PTSD in chemically dependent

women/chemically dependent menwomen/chemically dependent men

– Higher rates of chemical dependency in PTSD 40-50%Higher rates of chemical dependency in PTSD 40-50%

– Higher rates of PTSD in cocaine, opiates than marijuana, Higher rates of PTSD in cocaine, opiates than marijuana,

alcoholalcohol

Source: Najavits, 1997, American Journal Addictions, 6(4):273-281Source: Najavits, 1997, American Journal Addictions, 6(4):273-281

PTSD IN ADOLESCENTS WITH SUBSTANCE USE DISORDERS

– Dual diagnosis more prevalent/adults

– Dual diagnosis more prevalent girls/boys

PTSDPTSD BOYSBOYS GIRLSGIRLS TOTALTOTAL

LifetimeLifetime 24.3%24.3% 45.3%45.3% 29.6%29.6%

4 weeks4 weeks 12.2%12.2% 40.0%40.0% 19.2%19.2%

PTSD 1PTSD 1ºº 28%28% 59%59%

(N= 222 boys; 75 girls)

Source: Deykin & Buka, 1997, A.J. Psych 154:752-757

DIFFERENTIAL DIAGNOSIS

1.1. Substance ToxicitySubstance Toxicity– Acute (e.g. hallucinations)Acute (e.g. hallucinations)– Long term (e.g. organic brain syndrome)Long term (e.g. organic brain syndrome)

2.2. Substance Withdrawal Substance Withdrawal (e.g. anxiety)(e.g. anxiety)

3.3. Comorbid Physical Disorder Comorbid Physical Disorder (e.g. ammonia delirium)(e.g. ammonia delirium)

4.4. Comorbid Psychiatric DisorderComorbid Psychiatric Disorder– primaryprimary– secondarysecondary

DIAGNOSIS: SUBSTANCE-INDUCED MOOD OR ANXIETY DISORDER

Use these diagnoses when the prominent mood or anxiety symptoms:

have their onset during or just after intoxication or withdrawal

are in excess of those usually seen require independent clinical attention are most likely due to the substance

e.g. Alcohol-induced Mood disorder with depressive features, onset during intoxication

TREATMENT SETTINGS

Inpatient SecureInpatient Secure Inpatient OpenInpatient Open Partial HospitalPartial Hospital Halfway House; ResidenceHalfway House; Residence Outpatient (including methadone)Outpatient (including methadone) Ancillary – social, vocationalAncillary – social, vocational Self-help – in Self-help – in allall settings settings

NON-PHARMACOLOGICAL TREATMENT

PsychotherapiesPsychotherapies

Behavior TherapiesBehavior Therapies

Relaxation TrainingRelaxation Training

PsychoeducationPsychoeducation

PRINCIPLES OF MEDICATIONS TREATMENT

1.1. Addiction PotentialAddiction Potential– benzodiazepinesbenzodiazepines– sedatives/hypnoticssedatives/hypnotics– opiatesopiates– StimulantsStimulants

2.2. Danger of Interaction with AlcoholDanger of Interaction with Alcohol– MAOIMAOI– Sedating antidepressantsSedating antidepressants

BENZODIAZEPINE USE: REAL WORLD 1) V.A. 129 M. H. Clin: 128,029 OPs Tx for Depr: 1 yr. 36% filled Rx for BZ (30% of those with SUDs)  78% 90 day supply or over (82% of 65+) 61% 180 day supply or over 2) New Hampshire Medicaid: 9,884 pts; 18-64 y/o; 5 yrs.   BZ in + SUD BZ in - SUD MDD 66%* 49% Bipolar 75% 58% Schizophrenia 63% 54% Other psych disord. 48%* 40%* more fast acting/high potency BZs Sources: Valenstein et al Am Jour Psych 161:654-661, 2004 Clark et al Jour Clin Psych 65:151-155, 2004   

BZ USE/ABUSE IN DUAL DIAGNOSIS PATIENTS

 ·     6 year longitudinal study:·      N = 203 patients (74% male) Outpatients·      Severe Mental Disorder (Schz/Schzaffective 75%; Bipolar 25%) ·      in State C.M.H. System·      All had Substance Use Disorder

PATIENTS WITH BZ PRESCRIPTION: 

• 43% of patients had prescription for BZ during study period• Higher symptom scores• Lower quality of life scores• 15% developed BZ abuse (vs. 6% of patients without BZ Rx)

  Source: Brunette, MF et al. Psych Services 54:1395-1401, 2003 

ARE PEOPLE RECEIVING HELP? 2002 (SAMHSA REPORT, 2004) 1) 8% of adult population (or 18 million) have SMI*2) Of those with SMI 23% SUD3) Of non-SMI 8% SUD 4) Of the 4 million Dually Diagnosed persons, for the last year:

52% No treatment34% MH treatment only

2% SUD treatment only12% Both MH and SUD Ttreatment

5) More women (49%) MH Treatment > men(26%) 6) More Treatment age 26-49, Metrop (MH,SUD) *SMI = Serious mental illness: Past 12 mo. DSM-IV Diagnosis + functional impairment Source: SAMHSA Report 6/23/04: Adults with Co-Occurring SMI and SUD. (available on-line)

CONCLUSIONS:CONCLUSIONS:

1. Co-occurring disorders are common in the general population, and even more so in clinical populations in SUD treatment

2. They are more common in women than men (men have more ASPD and pathological gambling)

3. They differ in prevalence through the lifespan

4. To understand statistics, look for: -- Age range of population studied

-- Diagnoses included (Axis I only? Does Axis I include Pathological Gambling, Bulimia? Axis I plus ASPD? Axis II? other SUDs?)

CONCLUSIONS:5. There are complex relationships between comorbid

diagnoses

6. Each patient should be evaluated for co-occurring physical, psychiatric and other substance diagnoses

7. Use diagnosis of Substance-induced mood or anxiety disorder when onset is during intoxication or withdrawal

8. The distinction between primary versus secondary diagnosis can be useful; a time line can help distinguish these

9. Primary diagnoses are more likely to need independent treatment and vigorous follow-up, although both may need this

CONCLUSIONS (cont.):

10. Consider non-pharmacological treatments as well as medications for comorbid disorders

11. Choose medications that do not have abuse potential whenever possible

12. Alert/remind/train patient and family to be aware of early signs of possible recurrence of psychiatric disorder

13. Outcome best if both disorders are diagnosed and treated simultaneously in coordinated manner. Communication is a key factor in success.