Transcript Depression and Addiction

Brian Johnson M.D.
Assoc Prof Psychiatry and Anesthesia
SUNY Upstate Medical University
Member – Boston Psychoanalytic
Society
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I have never taken a pen or drank a soda at a
drug-sponsored event. I have not benefitted
personally from sponsorship by a drug
company; exceptResearch on shifts in the hypothalamicpituitary-adrenal system and depression
during and after alcohol withdrawal sponsored
by the Distilled Spirits Council of the United
States (Johnson 1986)
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Takes advantage of advances in both
neuroscience and psychoanalysis to formulate
testable hypotheses.
Like Freud’s original models of mental
functioning, neurology is the material base.
Contrast with cognitive-behavioral psychology
where the brain is a black box, outcomes are
counted.
Example – “Reward” versus “SEEKING”
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If depression is so disabling, why is it so
prevalent?
It must have some functional use.
What is an addiction?
Heroin
 Where is the line on drinking?
 What could the brain mechanism be in gambling?
 Internet? Exercise? TV watching?
Repeated harm from X
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Lifetime incidence of MDD – 13%
12 month prevalence – 5%
Lifetime MDD – Alcoholism 40% (8.5%)
Nicotine addiction 30%(20%)
Drug addiction 17% (2%)
Why?
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Women more MDD than men – 2/1
Men more addiction – 2/1
12,500 Amish, no addiction – 1/1 (Egeland &
Hostetter 1983)
Women tolerate emotional distress better
without resorting to drugs (Khantzian)
Could we be observing symptom constellations
with similar underpinning?
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PANIC (GRIEF) system-Insures contact
Babies cry when they are separated
In primitive conditions, crying babies starve or
are eaten
Is depression a protest shutoff?
S
E
P
A
R
A
T
I
O
N
ANXIETY
DEPRESSION
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Maternal deprivation a major risk factor for
both depression and addiction
(Heim…Nemeroff 2008)
Heim/Nemeroff depression model in rats
Separation for 15 minutes on days 2 – 14 leads
to more licking
Separation for 3 hours leads to ignoring, biting,
high CRF
Reversed by paroxetine and recurs off
paroxetine
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Obvious answer, give antidepressants?
(restore brain health)
Keller et al. study NEJM 2000
Response rate nefazodone 50%, CBT 50%,
combination 80%
Remission rate nefazodone 20%, CBT 20%,
combination 40%
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Childhood trauma subset: No added benefit of
nefazodone
Is there a subset of depressive illness (anaclitic)
that responds to psychotherapy and not
antidepressants?
(Lack of efficacy of antidepressants except for
severe depression)
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Addictive behavior has a transitional object
quality for teenagers leaving home
Wurmser’s “Addictive Search” (1974)
Idealization used as a defense against terror
Addictive splitting
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Wonderfully related/unrelated
Omnipotent power/helplessness
Independence/dependence
Rebellious separateness/not autonomous
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Changes in sleep induced by cocaine only
became worse over 17 days (Morgan 2006)
Hyperalgesia induced by opioid exposure
persisted for months in abstinent subjects
(Prosser 2008)
Drug dreams persisted for 5 years of abstinence
(Johnson 2001)
Anecdotal drug dreams for alcohol – 32 years,
nicotine – 50 years
Permanent changes – mood, sleep, paintolerance, desire?
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Alcohol, cocaine/methamphetamine, opioids –
each impair cortical functioning
Drug seeking becomes an automatic,
compulsive action mediated by NAC
Cognitively impaired patients most likely to
leave psychotherapy
Cognitive evaluation of patients central to any
evaluation (word-finding)
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Patients in alcohol WD: HRSD bifurcated after one
week (Johnson, Perry 1986)
110 patients followed for 1 year: dep equally likely –
independent or subst. induced depression
(Nunes…Hasin 2007)
“Depressed” patients started at McLean (Greenfield
1998): 20% sober if on antidepressants, none stayed
sober 4 months off antidepressants
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Repeat during early abstinence for diagnosis
Helps patients see what you are treating
Helps with lack of mood-altering effects
Helps patients see constellation of anxiety,
somatic and vegetative sxs
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ADHD – 62%
Amphetamines – 71%
Methylphenidate – 37%
Methylphenidate ER – 39%
Opioids – 35%
Bupropion - 0
Triangle – placebo,
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SSRIs and SNRIs inhibit at least one phase of
sexual functioning in 96% of women and 98%
of men; interest, erection/lubrication, orgasm
(Clayton 2006, 3114 subjects)
Mechanism of decreased libido – decreased
testosterone: dopamine/serotonin balance
Bupropion increases libido as side effect,
average patient loses 5 pounds
Trazodone is weight and sex neutral
Risk factors for completed suicide
 History of self harm
 Prior psychiatric treatment
 Current psychiatric treatment
 Benzo (Cooper 2006)
Risk factor for subjects over 65 (Voaklander 2008)
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Duloxetine 60
Imipramine 150
Trazodone 150
Propranolol 10
Paliperidone
Haloperidol 2
220
33
3
3
900
3
2640
396
40
40
10800
40
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Only 1/3 “bipolar” by psychiatrist admitted to
Dual Diagnosis Addiction Service met DSM-IV
criteria (Goldberg 2008)
Lithium #1
Lamotrigine #2
Avoid antidepressants – work, then provoke
rapid cycling
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Which is codeine 60 + acetaminophen 600?
A
C
B
D
E
F
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Outside A -----Ego-----Inside B
Sensation – Felt by all
Perception – Felt by some. Can be pointed out.
Requires input from memory
Affect – Specific to each person. Includes
relationship
Experience of patient – sensation (outside)
Understanding of physician - complex
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WHITE (2004) ADD. BEH. 29:1311-24
RATS IMPLANTED WITH MORPHINE
PELLET
INITIAL RESPONSE TO RADIANT HEAT;
ANALGESIA
BY DAY 4, CLEAR HYPERALGESIA (ON
MORPHINE!)
BIPHASIC RESPONSE TO OPIATES; RELIEF
FOLLOWED BY MORE PAIN; REPEATEDLY
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HAY-WHITE 2009 – CPT 31 CONTROL, 18-20
ON MORPHINE, METHADONE
METHADONE; 30 HOUR HALF LIFE; PEAK
AND TROUGH
COLD PRESSOR TEST: 65 SEC. CONTROLS,
15 SECONDS ON METHADONE
DURATION LESS THAN HALF AT PEAK
METHADONE LEVELS
Effect of Duration of Methadone Therapy on
Percent with Severe Chronic Pain
45
40
35
30
25
20
15
10
5
0
<7 mos
7-24 mos
>24 mos
1
2
3
4
5
6
Age Gender
Seconds
30 female
3
80
26 female
10
80
40 female
14
10
42 male
5
8
17 female
3 minutes
10
27 male
10
70
Repeated after detox
Pain Medication
hydrocodone
oxyc 240/day
illicit painkiller
oxyco 60/day
oxycodone
hydrocodone,
then methadone
3 minutes
20
1 week later
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Countertransference: Responsibility is
patient’s, not physician’s
Look for a specific cause with a specific
intervention
Don’t try to fix emotional or social problems
with medications – accept helplessness and
model it for the patient (“You have to live with
pain”)
Exercise/PT
NSAIDS
Acetaminophen
Low/usual-dose
tricyclics
Antidepressants
Anticonvulsants
Anxiety-reducing medications such as propranolol, clonidine
Topical aromatics
Topical diclofenac
Regional nerve block
Hot yoga
Massage
Acupuncture
Psychotherapy
Family Therapy
Group Psychotherapy
Detoxification
Naltrexone
Reiki
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Trazodone 200 – 600/day
Triad of ADHD, nicotine, depression makes
bupropion excellent
Avoid SSRIs because of sexual side effects
Tricyclics for refractory depressions
Include cost as a side effect
Addiction included as a side effect
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“For every problem there is a pill” mentality
“Racing thoughts” and “Constant worrying”
often have to do with living life on life’s terms
Usually anxiety does not require medication,
but difficult behavior may require meds to
allow treatment
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Antidepressants best, but have latency of onset
of action
Propranolol, clonidine - cut norepinephrine
Anticonvulsants: valproate, gabapentin
Antipsychotics: No reason to pay for second
generation
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“The AA Member and Medication” – AA
public policy
Go to doctors who understand addiction
Tell your doctor that you have an addiction
Sexuality is a central aspect of relatedness – don’t
disrupt it
 Medications can be categorized as dulling or
promoting relatedness
 Dull relatedness: Benzos, opioids, SSRI/SNRIs?
 Enhance relatedness: Antidepressants, ADHD
meds, antipsychotics – if psychotic
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Best understanding of depression and
addiction: symptoms of disruption of
relatedness
Addiction causes repeated harm (TV, exercise)
Treatments focus on promotion of relatedness:
psychotherapy, 12 Step programs
Many depressed patients respond to
relatedness alone
If prescribing medications, think about using
them to restore relatedness