Transcript CO-OCCURRING DISORDERS - Women, Children, & Families

Treating Co-Occurring
Disorders Across
the Life Span
Sheila B. Blume, M.D.
Women Across the Life Span:
A National Conference on Women, Addiction and Recovery
July 12, 2004
DEFINITIONS OF
“DUAL DIAGNOSIS”
1.
SUBSTANCE DISORDER + PHYSICAL ILLNESS
2.
ALCOHOL DISORDER + OTHER DRUG DISORDER
3.
SUBSTANCE DISORDER + PSYCHIATRIC DISORDER
AXIS I ONLY
AXIS I AND ASPD
AXIS I AND AXIS II
ALCOHOLISM AS A SYMPTOM
“Alcohol addiction is a symptom rather than a disease…
There is always an underlying personality disorder
evidenced by obvious maladjustment, neurotic character
traits, emotional immaturity, or infantilism.”
Source: R.P. Knight, 1937
DSM I
-
1952
ALCOHOL ADDICTION COULD NOT BE
DIAGNOSED IF AN “UNDERLYING
DIAGNOSIS” IS PRESENT
POSSIBLE RELATIONSHIPS IN
DUAL DIAGNOSIS
1. Addiction
----------
> Mental Illness
2. Mental Illness
----------
> Addiction
3. ------> Mental Illness (separate causes)
------> Addiction
4. ------> Mental Illness (common cause)
------> Addiction
5. Switch of Addictions
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 NY
Followed from age 5 to late 20s, rated 5 times

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Early SUDs predicted:
Early MDD predicted:
Early freq of TOBACCO use predicted:
Early heavier ALC use predicted:
Early MARUJUANA use predicted:
Early Illicit DRUG use predicted:
BOYS > GIRLS:
Income, parent education:
SUDs
MDD, Alcohol Dep
Alc Dep, SUDs
MDD, Alc Dep, SUDs
MDD, Alc Dep, SUDs
MDD, Alc Dep, SUDs
SUDs only
+ Alc Dep, - MDD
Source: Brook et al. Arch Gen Psych 59:1039-1044, 2002
Increased Likelihood of Psychiatric
Disorders in Late Twenties
Early Substance Abuse Increases Likelihood of
Developing Psychiatric Disorders in Late Twenties
80
70
60
50
MDD
Alcohol
Depenence
SUDs
40
30
20
10
0
Tobacco
Alcohol
Marijuana
Other Illicit
Drugs
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
•
Conduct disorders
•
Depression
•
PTSD
 Anxiety disorders
 Eating disorders
 Gambling disorders
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 Cormorbid Mental and
Addictive Disorders in the U.S.
Lifetime prevalence of comorbid
mental and addictive
disorders in the United States,
combined community and
institutional five-site
Epidemiologic Catchrnent
Area data, standardized to the
U.S. Population
Comorbidity, 72%
12-MONTH CO-OCCURRENCE OF
ADDICTIVE AND MENTAL DISORDERS
AGES 15-54
Any Addiction
If Psychiatric Dx.
Also Addiction
Major Depression
Dysthymia
Mania
Any Affective
23%
2%
2%
25%
18%
19%
37%
18%
General Anxiety Disorder
Panic Disorder
PTSD
Social Phobia
Simple Phobia
Agoraphobia
Any Anxiety
8%
5%
8%
17%
15%
8%
36%
21%
18%
18%
17%
14%
18%
15%
Any Mental Disorder
43%
15%
Source: 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:
Alcohol only:
Other drug (s) only:
Both alcohol and drug:
16.6 million
11 million
3.2 million
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, 2001
CO-OCCURRING DISORDERS:
GENDER DIFFERENCES
NCS Data (1990s, ages 15-54)
% with lifetime addictive disorder who had at least one
mental disorder:
Males:
57%
Females: 72%
ECA data (1980s, 18 and older)
% with lifetime addictive disorder who had at least one
mental disorder:
Males: 44%
Females: 65%
PERSONALITY DISORDERS AND SUBSTANCE
USE DISORDERS: NESARC 2000-2001
12–month prevalence
Any Alcohol Dis.
8.5%
Alcohol Abuse
4.7%
Alcohol Dep.
3.8%
Any Drug Dis.
2.0%
Drug Abuse
1.4%
Drug Dep.
0.6%
If A/D, PD
28.6%
20.0%
40.0%
47.7%
38.0%
70.0%
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
If PD, A/D
16.4%
6.2%
10.2%
6.5%
3.5%
2.9%
UNDERSTANDING RATES OF COMORBIDITY
To understand the meanings of statistics in this area and
compare the findings of various studies consider the following:

Note that lifetime prevalence differs from 6- or 12–month
prevalence and lifetime risk

Note the age range included in the study (e.g. the ECA study
differs from the NCS)

Note the range of diagnoses included in the study:




Selected Axis I (mood and anxiety disorders)
Axis I, plus ASPD only from Axis II
Axis I and Axis II
Does it include eating disorders? Pathological gambling?
Lifetime Prevalence of Key Diagnoses:
Comparison of Individuals with Alcohol Abuse
or Dependence to Total ECA population
(5-site ECA data, weighted to U.S. population, in percent)
TOTAL
Population
Those with Alcohol
Abuse and/or
Dependence
Men
Women
19
31
Diagnosis
Men
Women
Drug abuse and/or
7
5
dependence
Antisocial personality
4
0.81
15
10
Phobic Disorder
9
16
13
31
Major Depression
3
7
5
19
Panic Disorder
1
2
2
7
Somatization
0.02
0.2
0.07
0.87
Mania
0.3
0.4
1
4
_________________________________________________________
Source: Helzer, Journal of Studies on Alcohol, vol. 49, pp. 219-24, 1988
Lifetime and Current Prevalence of
Psychopathology Among Hospitalized Alcoholics*
_______________________________________________________________________________________
Men
Women
Total
(N=231),%
(N=90),%
(N=321),%
____________________________________________________________________________
No additional psychopathology
25
20
23
Antisocial personality**
49
20
41
Substance Abuse
45(8)***
38(13)
43(9)
Depression
32(18)
52(38)
38(23)
Obsessive-compulsive disorder
12(4)
13(7)
12(5)
Panic disorder
8(5)
14(9)
10(6)
Mania
5(2)
3(1)
4(2)
Somatization
1(1)
2(2)
1(1)
Schizophrenia
2(2)
3(1)
2(2)
___________________________________________________________________________________________________________________________
*
Diagnoses are without exclusion criteria
**
Diagnosis of antisocial personality was modified to exclude two items that are related to abuse
***
Percentages in parentheses indicate current diagnosis
Source: Hesselbrock, Archives of General Psychiatry, vol. 42, pp. 1060-66, 1986
PSYCHIATRIC COMORBIDITY IN
OPIATE DEPENDENTS (N=716)
Diagnosis
Lifetime Prevalence %
Male
Female
One Month Prevalence %
Male
Female
Any Axis I
Affective Disorder:
Major Dep.
Dysthymia
Bipolar
15.8
11.4
8.7
2.4
0.8
33.4
27.5
23.7
4.4
0.0
5.0
2.1
1.3
11.2
5.3
5.3
0.8
0.0
Anxiety Disorder:
Panic Disorder
GAD
OCD
Simple Phobia
Social Phobia
Agoraphobia
6.1
2.1
0.3
0.5
1.9
1.9
0.0
10.7
1.8
0.0
0.0
5.3
3.6
0.6
3.4
0.3
0.3
0.5
1.9
0.8
0.0
6.8
0.9
0.0
0.0
3.6
2.7
0.3
Eating Disorder
Schizophrenia
0.0
0.0
1.5
0.3
0.0
0.0
0.0
0.3
Source: Brooner et al, Archive of General Psychiatry 54:71-80, 1997
Disorders: Primary and Secondary
PRIMARY DISORDER
- earlier onset
- onset during prolonged remission
(3 to 6 months)
SECONDARY DISORDER
- later onset
- relapse following primary disorder during
prolonged remission
WHICH CAME FIRST?
(Major Depression/Alcoholism)
Alcoholism
Primary
Depression
Primary
Population
Men
Women
Men
Women
Research volunteers
62%
40%
38%
60%
Inpatients
59%
35%
41%
65%
General population
78%
34%
22%
66%
Sources: ECA Helzer & Pryzbeck, 1985
Hesselbrock, 1985
Roy, 1991
Meta-analysis of Eight Longitudinal Studies
(U.S., Canada, Scotland) 2-10 Years
For MEN and WOMEN:
Depression
Alcohol Intake
Predicts
Predicts
Depression
Alcohol Intake
Predicts
Depression
Alcohol Intake
Predicts
Depression
(stronger effect)
over short intervals
Depression
Predicts
Alcohol Intake
over long intervals
For MEN:
Alcohol Intake
For WOMEN:
Source: Hartka et al, 1989 (submitted to British Journal of Addiction)
PRIMARY VERSUS SECONDARY DEPRESSION
IN ADDICTIVE ADOLESCENTS
Boys
Girls
N=26
N=25
Alcohol/Drug Primary
60%
28%
Depression Primary
30%
40%
Same Time
10%
32%
Source: Deykin et al, American Journal of Psychiatry 149:1341-1347, 1992
WHICH CAME FIRST?
NATIONAL COMORBIDITY STUDY
AGES 15-54
WOMEN
Add 1st
Ment 1st
MEN
Add 1st
Ment 1st
Any Affective
31%
59%
50%
40%
Any Anxiety
13%
85%
20%
74%
6%
40%
7%
89%
11%
85%
14%
82%
Antisocial
Any Mental
Source: 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):
Men:
Women:
56%
68%
Primary Diagnosis:
Major Depression
Bipolar
Panic Disorder
Social Phobia
PTSD
Men (50)
Total
Primary
18
4
3
1
5
1
7
7
11
8
Women (50)
Total
Primary
20
10
5
2
9
8
5
5
23
18
Source: NIDA Notes Vol 12 No.4, 1997, work of Kathleen Brady MD and colleagues at Med University of South Carolina.
COGA SAMPLE
All Alcoholic
Women
ANOREXIA
BULIMIA
1° Alcohol
No Psych
Dependent Women Diagnosis
1.4%
6.2%
1.26%
3.46%
0.34%
0.6%
- Eating Disorders Correlate With ASPD
- Eating Disorders Correlate With Major Depression
Women
Amphet/Cocaine
ANOREXIA
BULIMIA
2.3%
8.2%
Source: Schuckit, 1997, Addiction 92(10)
Women
Cannabis
2.0%
8.4%
Women
Opiate
2.5%
7.5%
PATHOLOGICAL GAMBLING IN
CHEMICALLY DEPENDENT ADULTS
SOUTH OAKS HOSPITAL
LIFETIME
N = 458 ADULTS
Problems
Path Gamb
Total
10%
9%
19%
N=100 ADOLESCENTS
Problems
Path Gamb
Total
14%
14%
28%
YALE ADDICTION CLINIC
N=198 COCAINE DEPEND
CURRENT PATH GAMB
Males
Females
19.0%
5.5%
309.81 POST TRAUMATIC
STRESS DISORDER
A. Traumatic Events (intense event, response)
B. Event Re-experienced (1 or more)
(1) recurrent memories/intrusive thoughts
(2) recurrent dreams
(3) acting or feeling as if recurring
(including during intoxication)
(4) distress at related cues
(5) physiological reaction to related cues
309.81 POST TRAUMATIC
STRESS DISORDER
C. Persistent Avoidance/Numbering (3 or more)
(1) thoughts
(2) activities
(3) memory gaps
(4) diminished interest in activities
(5) restricted affects
(6) sense of shortened future
309.81 POST TRAUMATIC
STRESS DISORDER
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
REVIEW OF PTSD AND SUBSTANCE USE
DISORDERS
–
Higher rates of exposure to trauma in women/men
–
Higher rates of exposure in chemically dependent
women/general pop. (30-60% vs. 10%)
–
Higher rates of PTSD in women/men (general)
–
Higher rates of PTSD in chemically dependent
women/chemically dependent men
–
Higher rates of chemical dependency in PTSD 40-50%
–
Higher rates of PTSD in cocaine, opiates than marijuana,
alcohol
Source: 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
PTSD
BOYS
GIRLS
TOTAL
Lifetime
24.3%
45.3%
29.6%
4 weeks
12.2%
40.0%
19.2%
PTSD 1º
28%
59%
(N= 222 boys; 75 girls)
Source: Deykin & Buka, 1997, A.J. Psych 154:752-757
DIFFERENTIAL DIAGNOSIS
1.
Substance Toxicity
–
–
Acute (e.g. hallucinations)
Long term (e.g. organic brain syndrome)
2.
Substance Withdrawal (e.g. anxiety)
3.
Comorbid Physical Disorder (e.g. ammonia delirium)
4.
Comorbid Psychiatric Disorder
–
–
primary
secondary
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 Secure
Inpatient Open
Partial Hospital
Halfway House; Residence
Outpatient (including methadone)
Ancillary – social, vocational
Self-help – in all settings
NON-PHARMACOLOGICAL TREATMENT

Psychotherapies

Behavior Therapies

Relaxation Training

Psychoeducation
PRINCIPLES OF MEDICATIONS TREATMENT
Addiction Potential
1.
–
–
–
–
benzodiazepines
sedatives/hypnotics
opiates
Stimulants
Danger of Interaction with Alcohol
2.
–
–
MAOI
Sedating 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%
61%
90 day supply or over
180 day supply or over
(82% of 65+)
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%*
* more fast acting/high potency BZs
40%
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% SUD
3) Of non-SMI
8% SUD
4) Of the 4 million Dually Diagnosed persons, for the last year:
52% No treatment
34% MH treatment only
2% SUD treatment only
12% 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:
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.