Transcript Comorbidity - The University of Sydney

Physical & Mental Disorder
Comorbidity in Substance
Users
© 2009 University of Sydney
Learning outcomes
• To be able to describe the common medical
conditions and common mental disorders
amongst those with substance use disorders
• To be able to assess common medical
conditions relevant to substance use disorders
• To be able to assess common mental disorders
relevant to substance use disorders
• To be able to initiate management of both
physical and mental disorder comorbidity
General principles
• Physical and mental disorders are
common in individuals with substance
use disorders
• Assessment and management are
more difficult in the presence of such
comorbidity
Comorbidity: Quick history
• 1970 Feinstein first described as
“any additional coexisting ailment”
• 1990’s
• term first used for mental or
physical disorder and substance
use disorders.
Common physical
comorbidity
• Liver disease:
– Alcohol
– Hepatitis C
• Interferon not possible if unstable
substance use or psychiatric conditions
– Obesity (fatty liver) exacerbated by
alcohol and weight gain related to
antipsychotics
– or other conditions (e.g.) infections: local,
systemic
• Poor nutrition
Common physical comorbidity
• Late presentation for unrelated
conditions
• Poor treatment adherence for other
conditions (e.g. diabetes)
– Preoccupation with substance use
– Disorganised e.g. for appointments
– Limited finances/unemployment
Common mental disorder
comorbidity
• 1 in 5 individuals with a substance use
disorder also have an affective disorder;
• 1 in 3 individuals with a substance use
disorder also have an anxiety disorder;
Teesson, Slade & Mills, 2009, ANZJP, in press
• Individuals with cannabis dependence are
twice as likely to experience psychotic
symptoms.
Mental Disorder Comorbidity in
Australia: adult females
anxiety
affective
3.9
12.6
2.5
1.6
0.8
0.2
substance use
1.7
Teesson, Slade & Mills, 2009, ANZJP, in press;
National Survey of Mental Health and Wellbeing (NSMHW), ABS, 2007
Mental Disorder Comorbidity in
Australia: adult males
anxiety
substance use
4.3
6.7
1.3
0.9
0.6
2.0
affective
1.9
Teesson, Slade & Mills, 2009, ANZJP, in press;
National Survey of Mental Health and Wellbeing (NSMHW), ABS, 2007
How common is trauma exposure
& PTSD among people with SUDs
in Australia?
100
80
60
40
20
0
93
83
73
91
89
75
57
33
29
6
Trauma
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PTSD
Mills et al., 2006, Am J Psychiatry, 163: 651-658.
Reprinted with permission from the American Journal of Psychiatry (copyright 2006).
American Psychiatry Association
Mechanisms of co-morbidity:
mental disorders
• Substance use may cause mental disorders,
through a variety of neurobiological
mechanisms
• Substance use may trigger the onset of mental
disorder in susceptible individuals
• Persons with mental disorders may seek to
relieve their symptoms (or medication sideeffects) through psychoactive substance use
• Substance use can cause life difficulties which
can precipitate or worsen mental disorders
Assessment
• Screen all substance misuse patients
for psychiatric symptoms & physical
conditions
• Seek corroborative history
• Repeat substance use history when
patient not intoxicated or acutely unwell
• Repeat psychiatric history when patient
not intoxicated or withdrawing
Management principle
• Treatment of all conditions
should be considered, managed
and monitored
Initial Management
• Alcohol dependence:
– Management acute withdrawal - reducing regime
benzodiazepines (maximum 7 days)
– Engagement with programmes to maintain
abstinence: Cognitive Behaviour therapy, motivational
enhancement, AA, pharmacotherapy
(naltrexone/acamprosate).
• Opiate dependence
– Manage withdrawal - symptomatic, reducing doses of
long-acting opiate or maintenance
• Cannabis dependence
– Cognitive behaviour therapy, motivational
enhancement.
– Education about interaction of psychosis and
cannabis use
• Treat physical and psychosocial complications of
substance misuse
Barriers to treatment
Patients with substance misuse may have:
• Poor family/social support
• Poor nutrition and living circumstances
• Encountered real or perceived prejudice by
health care staff
• Difficulties with compliance:
– Preoccupation with substance misuse
– Disorganisation/intoxication
– Limited finances/unemployment
Further management
• Engage in therapeutic
relationship, set specific goals,
and follow-up regularly
• Re-evaluate need for treatment
of comorbid conditions and treat
as usual if symptoms remain
Alcohol: Further
management
• Physical complications
• Psychiatric complications
– Depression & Anxiety
• anxiety/agitation in withdrawal
– Psychosis
• Hallucinations
Physical complications of
alcohol dependence
•
Alcoholic liver disease
• Acute fatty
infiltration
• Alcoholic hepatitis
• Cirrhosis
•
Brain injury
• Subdural
haematomas
• Frontal dementia
• Wernicke’s/Korsakof
f’s
• Cerebellar
dysfunction
•
Poor nutrition
• Vitamin B1
• Vitamin B12
(neuropathy)
•
•
Gastritis
Delirium Tremens
(Alcohol withdrawal
syndrome)
• Considerable
morbidity untreated
• May present as
acute psychosis with
confusion
• Grand mal seizures
possible
Relationship between
alcohol and depression
• Depression is a risk factor for drinking
as well as a complication of alcohol
misuse
• Social complications of alcoholism
– Unemployment & relationship difficulties
may precipitate or exacerbate depression
• Comorbidity predicts a poor treatment
response
Alcohol and depression
• Symptoms of depression hard to
distinguish from complications of
alcohol misuse
– e.g. poor energy, disrupted sleep, loss of
weight, social isolation
• Symptoms of intermittent alcohol
withdrawal may mimic anxiety
disorders
• Depressive symptoms and suicidal
ideation must be regularly reassessed,
particularly when patient no longer
intoxicated
Management principles
where patient continues to
use alcohol
• Alcohol dependence:
– Motivational interviewing to encourage reduction in
alcohol or abstinence
• Depression:
– Education about relationship of alcohol and
depression
– Use of antidepressants
• Little evidence that antidepressants reduce alcohol
intake
• Antidepressants do help with symptoms of depression,
but on-going alcohol use remains a perpetuating
factor for depression
• Avoid tricyclic antidepressants (overdose risk)
• SSRIs have most evidence of efficacy
– Cognitive Behavioural Interventions
Alcohol and psychosis
• Withdrawal: Delirium tremens with
prominent visual hallucinations
• Alcoholic hallucinosis: Auditory
hallucinations not in context of
withdrawal (rare)
Alcohol and hallucinations
• Alcohol withdrawal
–
–
–
–
–
In setting of having recently stopped or cut down
usually visual hallucinations – fleeting, early
with clouded sensorium (i.e. DTs)
Usually resolves within the week
DTs potentially life-threatening
• Alcoholic hallucinosis
–
–
–
–
–
Uncommon
Auditory or visual hallucinations (usually auditory)
with clear sensorium
May occur in days to weeks after abstinence
Lasts hours to weeks
Drugs: Further management
• Physical complications
• Psychiatric complications
– Depression & Anxiety
• anxiety/agitation in withdrawal
– PTSD
– Psychosis
Medical complications of
injecting drug use
• Local: abscesses, cellulitis, venous
thrombosis
• Systemic: infected thrombi may affect
any organ e.g. kidney, brain, heart
(endocarditis)
• Blood borne viruses: Hepatitis C,
Hepatitis B, HIV
Management of PTSD and
Substance Use Disorder
• PTSD symptoms independent from drug
disorder
• Intervention should address both PTSD and
SUDs concurrently
• Traditionally exposure therapy was considered
inappropriate for those with SUDs
– The emotions experienced may be overwhelming and
could lead to more substance use
– Cognitive impairment associated with SUD could
impair the patient’s ability to do imaginal tasks
• Growing evidence for effectiveness of exposure
therapy
Illicit substance use in those
with psychosis
• In order of decreasing prevalence:
–
–
–
–
–
Cannabis
Amphetamines
LSD
Heroin
Tranquillisers
Management of druginduced psychosis
• Supervised withdrawal from drugs
– E.g. inpatient detoxification, in a
psychiatry ward if prominent psychiatric
symptoms
• Antipsychotic medication often not
required long-term (e.g. amphetamine
psychosis)
• Relapse prevention:
– Feedback on psychotic episode
Relationship between
cannabis and psychosis
• May cause psychosis in intoxication (e.g.
paranoid ideas)
• Higher rate of use in those who later go on
to develop schizophrenia - ? causal link
• Use worsens outcome in psychotic
disorders and may precipitate relapse
• Some may use for perceived relief of
positive symptoms/anxiety
• Also associated with: amotivational
syndrome, anxiety (mostly in withdrawal)
and depression
Relative risk of developing
schizophrenia with use of
cannabis: Swedish conscript
study
7
6
5
4
3
2
1
0
No use
1-10 times
11-50 times
50+ times
Risk of diagnosis 2.4 times higher in those who tried cannabis before 18 years.
Dose response which decreased but persisted after adjustment for psych history.
Hall, Degenhardt, & Teesson, 2004, Drug and Alcohol Review, 23: 433-443
Cannabis & Psychosis
• Communicate the risk while honestly
acknowledging the uncertainties that
remain
– people with psychosis or a first degree
relative with psychosis should avoid using
cannabis
– one in seven people who use cannabis
report unpleasant, psychotic-like
symptoms; avoid use
– discouraging young people from using
cannabis daily or near daily
Relationship between
stimulants and psychosis
• A common cause of psychosis in
young people
• History of stimulant use
• Rapid recovery in hospital, often
without specific treatment
• Earlier intervention may prevent
progression of symptoms
Relationship between
heroin and psychosis
• Higher relative risk of heroin use in those
with psychosis compared to general
population
• Psychosocial complications have most
impact:
– Already vulnerable patients may resort to
crime or sex work to maintain habit (prevent
withdrawals)
– Heroin use will add to disorganisation, poor
social support, and stigmatisation, further
affecting access to care and compliance
Case Study 1:
Alcohol and depression
Kate is 42 years old
• Presents to ED after haematemesis
• 1-2 bottles of wine daily for 4 years
• Over the last 6 months she has
become increasingly depressed - poor
sleep, loss of weight, reduced
enjoyment and social isolation.
• She admits to feeling increasingly
suicidal over the past 2 weeks.
Case Study 1: Questions
• What is the relationship between
alcohol misuse and depression?
• What medical complications should
you screen for?
• How does one manage comorbid
depression and alcohol dependence?
Case Study 1: Answers
• Depression may be a contributing factor to
the alcohol misuse, or may be caused or
exacerbated by alcohol dependence
• Kate needs assessment of her liver status, to
exclude cirrhosis with portal hypertension.
• Depression often lessens once the person
stops drinking. Where it is safe to do so, you
can wait a month before commencing antidepressants.
– Where treatment is required an SSRI with
lesser potential to provoke anxiety can be
useful, e.g. citalopram or sertraline.
Case Study 2: John
John is 24 years old
• Two previous admissions with
?schizophrenia.
• Now admitted to a psychiatric unit
– Suffering from prominent auditory hallucinations
and paranoid delusions.
– The day after admission he is noted to be suffering
from opiate withdrawal (yawning, sweating, muscle
cramps, diarrhoea)
• Admits to injecting heroin daily for the past
month. He also uses marijuana, which he
believes helps with the side-effects of his
psychiatric medication.
Case study 2: Questions
• What is the relationship between
psychosis and substance misuse?
• What medical conditions should you
screen for?
• How does one manage comorbid
substance misuse and psychosis, in
the short and long term?
Case Study 2: Answers
• Relationship between psychosis and substance
misuse?
– cannabis and heroin may both exacerbate and relieve
psychosis
– Drug induced psychosis (does he have schizophrenia?)
• Medical conditions to exclude?
– BBV, sepsis
– Chest infections after cannabis
• How to manage comorbid substance misuse and
psychosis?
– Encourage treatment be with psychiatry and addiction
teams. Minimise drug use. Assertive case management
to increase compliance with therapy.
Contributors
Associate Professor Kate Conigrave
Royal Prince Alfred Hospital & University of Sydney
Dr Glenys Dore
Macquarie Hospital, Northern Sydney Health
Dr Joanne Ferguson
Rozelle & Concord Hospitals
Professor Paul Haber
Royal Prince Alfred Hospital & University of Sydney
Dr Kezia Lange
Royal Prince Alfred Hospital
Professor Maree Teesson
National Drug and Alcohol Research Centre, UNSW
All images used with permission, where applicable