Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Less Severe
Mental Disorders
Richard Ries MD
rries@u.washington.edu
Harborview Medical Center
University of Washington
Seattle, Wa
TWO SYSTEMS
DOUBLE TROUBLE
MENTAL DISORDERS
Schizophrenia
Bi-polar
Schizoaffective
Major Depression
Borderline
Personality
Post Traumatic
Stress
Social Phobia
others
ADDICTION
DISORDERS
Alcohol
Abuse/Depen.
Cocaine/ Amphet
Opiates
Marijuana
Polysubstance
combinations
Prescription drugs
HH
2
Severity of
Psychiatric
Condition
1
4
Low
HL
LL
Low
High
Systems Problems
Different Lawscommitment/confid.
Different funding..audits etc
Different personnel
Different training
Different certification
Different sites
Different Norms
Less severe
mental disorder/
more severe
substance
abuse disorder
Less severe
mental disorder/
less severe
substance
abuse disorder
Low
severity
A four-quadrant
conceptual framework
to guide systems
integration and
resource allocation in
treating individuals
with co-occurring
disorders
(NASMHPD,NASADAD,
1998; NY State; Ries,
1993; SAMHSA Report
to Congress, 2002)
More severe
mental disorder/
more severe
substance
abuse disorder
More severe
mental disorder/
less severe
substance
abuse disorder
High
severity
Not intended to be
used to classify
individuals (SAMHSA,
2002), but ...
DOUBLE TROUBLE
Hall
Alterman
Solomon
Safer
Drake
Barbee
Lyons
Chen
77
85
86
87
89
89
89
92
Risk Factor
Cocaine use
Major Depression
Alcohol use
Separation or Divorce
NIMH/NIDA
Double Trouble:
RELATIONSHIP OF ALCOHOL & DRUG PROBLEMS
TO SEVERE SUICIDALITY (n=12,196)
ODDS adjusted
for age & gender
p < .001
Withdrawal
Acute
Protracted
Symptom Groups
Intoxication
Chronic Use
Depression
Anxiety
Psychosis
Mania
Rounsaville 90
Disorder
Respondents, % (SE)
Disorder
Respondents, % (SE)
Comorbidity of
Depression and Anxiety
Disorders
50% to 65% of panic disorder
patients have depression
67% of OCD
patients have
depression*
Panic
Disorder
HIGHLY
Depression COMMON Social
Anxiety
HIGHLY
Disorder
COMORBID
OCD
49% of social
anxiety disorder
patients have
panic disorder**
11% of social
anxiety disorder
patients have OCD**
Adapted with permission from American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 4th ed. 1994.
Dizziness
Chills or hot flushes
Feelings of unreality
Fear of losing
control or going
crazy
Fear of dying
Paresthesias
Choking feeling
Smothering or
shortness of breath
Chest pain or
discomfort
Abdominal distress
Somatic Symptoms In
Panic Disorder
Gastrointestinal
Symptoms
Chest Pain
SOMATIC
SYMPTOMS
Dizziness
Headache
Fatigue
Marital Discord
(past 2 weeks)
Markowitz et al. Arch Gen Psychiatry. 1989;46:984.
Use Of ER
(past year)
Financial
Dependence
(welfare or
disability)
DSM-IV Diagnostic
Criteria for PTSD
DSM-IV Diagnostic
Criteria for PTSD
Continued
Symptoms
appear in 3 symptom clusters: reexperiencing, avoidance/numbing,
hyperarousal
last for > 1 month
cause clinically significant distress or
impairment in functioning
DSM-IV Diagnostic
Criteria for PTSD
Hyperarousal
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th
ed. 1994.
Witness
Accident Threat w/
Weapon
1
2
Rape
SF-36
Score
Complaints Of Social
Anxiety Disorder
Stuttering
Palpitations
Butterflies
Beidel. J Clin Psychiatry. 1998;59(suppl 17):27.
Blushing
Sweating
Trembling
And Shaking
-5.0
Impairment**
(%)
-10.0
Wages
-15.0
-20.0
College
Graduation
Professional
Or
Management Positions
* LSAS score in controls = 25; ** Impairment (%) refers to percentage change in wages and percentage
point changes in probabilities of college graduation and having a technical, professional, or
managerial job.
Katzelnick et al. Presented at 37th Annual Meeting of the American College of Neuropsychopharmacology;
December 14-18, 1998; Los Croabas, Puerto Rico.
Therapy Plan
Bio
Psych
Social
Psych
Labs
Meds (anti-depressants,
etc.)
psychotherapy
education groups
process groups
Couples conf.
D/C planning
housing, etc.
CD
Labs
Meds (withdrawal, craving,
etc.)
Step work
Groups
AA Meetings
Intervention
Sober housing
DATA SYNTHESIS: For the HDS score, the pooled effect size from the random-effects model was
0.38 (95% confidence interval, 0.18-0.58). Heterogeneity of effect on HDS across studies was
significant (P <.02), and studies with low placebo response showed larger effects.
Moderator analysis suggested that diagnostic methods and concurrent psychosocial interventions
influenced outcome.
Studies with larger depression effect sizes (>0.5) demonstrated favorable effects of medication on
measures of quantity of substance use, but rates of sustained abstinence were low.
CONCLUSIONS: Antidepressant medication exerts a modest beneficial effect for
: Psychopharmacol Bull.
1998;34(1):117-21.
All 51 patients participated in a double-blind, parallel group study of fluoxetine versus placebo in depressed
alcoholics. The principal focus of this article is the one-third of the depressed alcoholics who also abused cocaine
and how the treatment response of those 17 patients compared with that of the 34 depressed alcoholics who did
not abuse cocaine.
During the study, no significant difference in treatment outcome was noted between the fluoxetine group
(N = 8) and the placebo group (N = 9) for cocaine use, alcohol use, or depressive symptoms. In addition,
no significant within-group improvement was noted for any of these outcome variables in either of the two
treatment groups.
Indeed, across the combined sample of 17 depressed alcoholic cocaine abusers, the mean Beck Depression
Inventory (BDI) score worsened slightly from 19 to 21 during the course of the study, and 71 percent of the
patients continued to complain of suicidal ideations at the end of the study.
The 17 cocaine-abusing depressed alcoholics showed a significantly worse outcome than the 34 non-cocaine
abusing depressed alcoholics on the 24-item Hamilton Rating Scale for Depression (HAM-D) and BDI depression
scales and on multiple measures of alcohol consumption. These findings suggest that comorbid cocaine
abuse acts as a robust predictor of poor outcome for the drinking and the depressive symptoms of
depressed alcoholics.
Depress Anxiety.
2001;14(4):255-62.
Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use
disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a
double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d
and increased to a target dose of 60 mg/d.
There was a significant effect of treatment group on social anxiety symptoms, where patients
treated with paroxetine improved more than those treated with placebo on both the
Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05).
On alcohol use, there was not a significant effect of treatment on quantity/frequency measures
of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo
patients were improvers on drinking, P < or = 0.05).
This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in
individuals with comorbid alcohol problems, and positive treatment effects can be seen in as
little as 8 weeks. Further study is warranted to investigate its utility in helping affected
individuals reduce alcohol use. Copyright 2001 Wiley-Liss, Inc.
Psychiatric outcomes:
Antidepressants only beat placebo by 20% anyway in
NON addicts
Study patients also get addiction rx
Maybe addiction rx is more anti-dep, anti anx than we
thinkviz Schuckit 80% -> 20%
This is poorly studiedmaybe better with 12 step
Sub Induced criteria are wrong
Addictions outcomes
Meds take focus off sobriety
Meds reinforce sobriety
Just dont work for this
The present study investigated whether simultaneous treatment of social phobia and alcoholism, compared
with treatment of alcoholism alone, improved alcohol use and social anxiety for clients with dual diagnoses
of social anxiety disorder and alcohol dependence.
METHODS: The design was a two-group, randomized clinical trial that used 12 weeks of individual
cognitive behavioral therapy for alcoholism only (n = 44) or concurrent treatment for both alcohol and social
anxiety problems (n = 49). Outcome data were collected at the end of 12 weeks of treatment and at 3
months after the end of treatment.
RESULTS: Results with intent-to-treat analyses showed that both groups improved on alcohol-related
outcomes and social anxiety after treatment.
Counter to the hypothesis, the group treated for both alcohol and social anxiety
problems had worse outcomes on three of the four alcohol use indices.
No treatment group effects were observed on social anxiety indices.
CONCLUSIONS: Implications for the staging of treatments for coexisting social phobia and alcoholism are
discussed, as well as ways that modality of treatments might impact outcomes.
treatment; at a followup 3 months later, seven (46%) still no longer met criteria
for PTSD
Additionally, there was a significant decrease in PTSD symptoms from intake to posttreatment,
which was maintained at the 3-month followup assessment.
Based on results from a diagnostic interview and results of urinalyses, six (35%) of the
women reported the use of illegal substances within 3 months from release from prison.
Measures of client satisfaction with treatment were high. Recidivism rate (return to prison) was
33% at a 3-month followup.
Outpt
Visits
Humphreys et al ..2001
Inpt days
Abstinence
Rates
12 Step
13.1
10.5
45.7
Cog Beh
17
17
36.2
Dual Screening:
CAGE Questions
Medications
2. Helpful Readings:
Differential Dx
12 step facilitation
Meds if indicated ( and I often use them)
Visits:
In most MHCs:
MD visit q 3 months
CM visit q 2 wksfocus on ADLs
Maybe dual dx group 1-2 hrs/wk
Limited expectations of recovery
Pschotherapy time ~ 0-2 hrs week
54%
40%
25%
20%
15%
20%
0%
Closed or Stopped
Services
Reorganized
Director in
No Information
Position Less Than Services, E-mail,
One Year
or Voicemail
SOURCE: Adapted by CESAR from the McLellan, A. T., Carise, D., and Kleber, J., Can the National Addiction Treatment Infrastructure Support the Publics
Demand for Quality Care? Journal of Substance Abuse Treatment 25(2):117-121, 2003. For more information, contact Dr. A. Thomas McLellan at
tmclellan@tresearch.org.
Medications: counselors
role
Compliance
Effectiveness
Side Effects.
Medications.potential
problems
Antipsychotics
METHODS: The study involved 262 patients. Patients with a history of substance
dependence within 1 month prior to entry were excluded.
RESULTS: Of this sample, 97 (37%) had a lifetime diagnosis of substance use disorder
(SUD); of these 74 (28% of the total) had a lifetime cannabis use disorder (CUD) and 54 (21%) had
a lifetime diagnosis of alcohol use disorder (AUD).
Those with CUD had a lower age of onset than those without.
Patients with SUD were more likely to be men.
Patients with SUD had more positive symptoms and fewer negative symptoms than
those without SUD, and they had a longer duration of untreated psychosis.
The 12-week response data indicated that 27% of patients with SUD were responders
compared to 35% of those without SUD.
Patients with AUD were less likely to respond to olanzapine than those without AUD.
DISCUSSION: These data suggest that first-episode patients are quite likely to have comorbid
substance use disorders, and that the presence of these disorders may negatively influence
response to antipsychotic medications, both typical and atypical antipsychotics, over the first 12
weeks of treatment.
Eur J Pharmacol.
2003 May
9;468(2):121-7.
OBJECTIVE: To examine the efficacy of atypical neuroleptics for decreasing craving and drug relapses
during protracted withdrawal in individuals dually diagnosed with schizophrenia and cocaine dependence.
METHOD: We conducted a 6-week, open-label pilot study comparing risperidone with typical neuroleptics
in a sample of withdrawn cocaine-dependent schizophrenia patients.
RESULTS: Preliminary results suggest that individuals treated with risperidone had significantly
less cue-elicited craving and substance abuse relapses at study completion. Further, they showed a
trend toward a greater reduction in negative and global symptoms of schizophrenia.
CONCLUSION: Atypical neuroleptics may help reduce craving and relapses in this population. Future
research should include more rigorous double-blind placebo-controlled studies with this class of
medications.
% Noncompliant
P < 0.05
RISPERDAL CONSTA
Injection Kit Components
Needle Pro Device
SmartSite
Access
Device
Aqueous
Diluent
Risperidone
Microspheres
Assembled
RISPERDAL CONSTA
Safety Needle
Risperidone +
9-hydroxyrisperidone (ng/mL)
Antipsychotic
Supplementation
6
Time (wk)
10
11
12
Amphet/Methamphetamines
Cocaine
Ecstacy
Hallucinogens ( strong THC too)
Other Rave Drugs
Alcohol WD and Hallucinosis
Anticonvulsants
Mania
Depression
Maintenance
Comments
New Depakote ER
Formulation
Gabapentin
Lamotrigine
Antidepressant activity in
several controlled trials
Topiramate
Valproate
Carbamzepine
Key:
comparator trials
Efficacy in two small or one large active comparator trial
Efficacy only in open trials and case series
Conflicting evidence of efficacy in available studies
Lack of efficacy demonstrated in randomized, controlled trials
ND No data presently available
Keck & McElroy, 2002
Mania
Depression
Maintenance
Comments
Zonisamide
ND
ND
Tiagabine
ND
ND
Levetiracetam
ND
ND
ND
Oxcarbazepine
Key:
ND
Am J Addict 2002
Spring;11(2):141-50
METHODS: For each calendar year from 1994 through 1998, data were drawn from
a database containing clinical and drug prescription information for every inpatient in
the adult civil facilities of the New York State Office of Mental Health.
RESULTS: In 1994 a total of 26.2 percent of inpatients diagnosed as having
schizophrenia received a mood stabilizer, compared with 43.4 percent in 1998. In
1994 lithium was the most commonly prescribed mood stabilizer, for 13.2 percent of
patients, followed by valproate, for 12.3 percent. In 1998 valproate was the most
commonly prescribed, for 35 percent of patients, followed by lithium, for 11.3
percent. On average, patients received valproate for about two-thirds of their
hospital stay, at a mean dose of 1,520 mg per day.
CONCLUSIONS: The adjunctive use of valproate nearly tripled from 1994 to
1998 among patients with a diagnosis of schizophrenia. Valproate has become
the most commonly prescribed mood stabilizer for this population, despite the
paucity of evidence in the literature for efficacy in this use. Controlled clinical trials
are needed to examine the adjunctive use of mood stabilizers, in particular
valproate, among patients with schizophrenia.
Divalproex sodium has been approved for use in treating bipolar disorder. Its
usefulness in schizophrenia has yet to be adequately assessed.
Compared with those who received no or delayed augmentation, the earlyaugmentation group required 44.8% fewer inpatient days from the initiation of
haloperidol treatment. Patient response to treatment was particularly noted in
suspiciousness, hallucinations, unusual thought content, and emotional withdrawal.
Early augmentation with valproate may reduce the length of inpatient stays
and provide substantially better therapeutic outcomes. It is, however,
premature to recommend changes in the standard clinical management of
schizophrenia on the basis of the data provided herein, in view of the small sample
and open-label nature of the report.
Effects on weight and outcome of long-term olanzapinetopiramate combination treatment in bipolar disorder .
Twenty-six Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition bipolar spectrum patients received olanzapine plus topiramate cotherapy for
treatment of their manic (n = 14), hypomanic (n = 6), depressive (n = 2), and mixed (n =
1) symptoms for 1 year. Three rapid cycling patients were also enrolled despite being
euthymic. Thirteen (50%) patients completed the 1-year follow-up.
By intent-to-treat, patients significantly improved from baseline in
Most patients gained weight during the first month of combined treatment (mean
weight gain 0.7 +/- 0.6 kg), but at the 12-month endpoint, the mean weight change
was -0.5 +/- 1.1 kg.
Alcohol-dependent outpatients with persisting insomnia were treated with either gabapentin or
trazodone. Patients were assessed at baseline and after 4-6 weeks on medication using the
Sleep Problems Questionnaire (SPQ). Of 55 cases initially treated, 9% dropped out due to
morning drowsiness. Of the remaining 50 cases, 34 were treated with gabapentin (mean dose
+/- SD = 888 +/- 418 mg) at bedtime and 16 were treated with trazodone (105 +/- 57 mg) at
bedtime.
Both groups improved significantly on the SPQ but the gabapentin group improved
significantly more than the trazodone group. Controlled studies are warranted to
replicate these findings.
In this study for thirty (30) patients with alcohol withdrawal syndrome, the
response to anticolvusant gabapentin was assessed. Thirty (30) patients
with median age of 57.0 years and median body weight of 79.1 kg were
treated with gabapentin 3 x 300 mg daily for up 30 days.
The preliminary findings of this study suggest that gabapentin is very
effective against tonic-clonic seizures in alcohol withdrawal
syndrome.
Gabapentin was safe and well tolerated. For twenty (20) patients no side
effect were observed.
METHOD: Lamotrigine was started at a dose of 25 mg/day (12.5 mg/day in those taking
valproic acid) and titrated to a maximum dose of 300 mg/day. The subjects consisted of 13
men and 17 women with cocaine dependence and bipolar I disorder (N = 22), bipolar II
disorder (N = 7), or bipolar disorder not otherwise specified (N = 1), with a mean +/- SD age of
35.4 +/- 7.2 years. Data were analyzed using the last observation carried forward on all
subjects who completed the baseline evaluation and at least 1 postbaseline assessment.
RESULTS: Significant improvement was observed in HAM-D, YMRS, and BPRS scores
(p < or =.02). Cravings also significantly decreased as measured by the CCQ (p <.001).
Dollar amount spent on drugs decreased nonsignificantly. Lamotrigine was well
tolerated, with no subjects discontinuing due to side effects.
CONCLUSION: Lamotrigine treatment was well tolerated in this sample and associated with
statistically significant improvement in mood and drug cravings but not drug use. The findings
suggest that larger controlled trials of lamotrigine are needed in this population.
Harm reduction:..opiates
Methadone
LAAM.
Suboxone
Buprenorphine
Withdrawal treatment
Methadone
Buprenorphine
Clonidine ++
Full Agonist
(Methadone)
80
70
Intrinsic Activity 60
Partial Agonist
(Buprenorphine)
50
40
30
20
10
Antagonist (Naloxone)
0
-10
-9
-8
-7
-6
-5
-4
No
Yes
Stop;
not dependent
on short-acting
opioids
Give buprenorphine
2-4 mg, observe 2+ hrs
Withdrawal symptoms
continue or return?
No
Yes
No
Yes
Repeat dose up to
maximum 8 mg for first day
Withdrawal symptoms
relieved?
Yes
Withdrawal symptoms
return?
No
Manage withdrawal
symptomatically
Opioid agonists
Relapse preventionAlcohol
Naltrexoneopiate system
% of Abstinent Patients
Sleep in recovering
Alc/Addicts
Anticonvulsants
Is there a role for PRN use in agitated Dual pts, such as 500 mg
valproate, 600 mg gabapentin etc??
Anticonvulsants in alcohol
withdrawal