Treating Dually Diagnosed Patients

A number of years ago, a recovering alcoholic was referred for treatment of depression. He had been sober for about a year but was depressed and afraid that it would precipitate a relapse. He was doing well in many ways, being steadily employed and attending weekly meetings at two different Alcoholics Anonymous (AA) groups. He thought that antidepressant medication might help but had noticed that most members of one AA group were opposed to taking medication, while the other group accepted its use. He wanted to continue in each group but was concerned that one would ostracize him if he took medication. After some discussion, we decided to begin antidepressant medication and simply not mention it in the one group. His depression resolved over the next several months, he continued to participate in both groups, and he remained sober until he left treatment about two years later. He continued in AA but discontinued medication after a period of remission from depression.

Then there was the patient with alcohol dependence who was drinking heavily and had signs and symptoms of major depression but no history of depression prior to the development of alcohol dependence or during periods of sobriety. He had been prescribed an antidepressant in hopes it would treat the depression and alcoholism but it was not helping. He was admitted for inpatient treatment where his depressive symptoms began to remit as he was detoxified. The antidepressant was stopped, and the patient did well with counseling and participation in AA.

These two anecdotes illustrate some of the issues that emerge when treating people with psychiatric symptoms and substance-use disorders. On the one hand are patients who need both psychiatric and substance-abuse treatment over an extended period of time. On the other hand are people whose psychiatric symptoms are substance-induced and will remit with abstinence. Implicit in these two vignettes are issues of attitudinal and informational barriers to use of psychiatric treatment (especially medication), differential diagnosis, and the benefits of combining psychiatric and substance-abuse treatment for some patients.

Attitudinal and informational barriers were common in the early 1970s when patients were typically diagnosed as having either a substance-use or psychiatric disorder and then assigned to a treatment where only one disorder was addressed. However, as the number of psychiatrically trained clinicians in substance-abuse treatment expanded, the prevalence of comorbidity was noted by authors such as Khantzian (1985) and documented by other studies (Kessler et al., 1997; Regier et al., 1990). At about the same time, guidelines were developed for differentiating substance-induced from nonsubstance-induced disorders; these were formalized in DSM-IV.

A key feature of the DSM guidelines is the relationship between psychiatric symptoms and the drug(s) of abuse. In the first vignette, the guidelines indicate that the patient needed antidepressant and substance-abuse treatment. In the second vignette, the guidelines indicate that the depression was substance-induced, and, thus, treatment should focus mainly on that problem. Other cases are not so simple: for example, when the history is unclear or not available, when the psychiatric disorder begins after substance use, or when substance use magnifies a pre-existing psychiatric disorder.

Studies combining medication and/or psychotherapy for people with substance-use disorders have addressed patients with varying types of substance-use and other psychiatric disorders. Many studies used random assignment to a psychiatric treatment plus a substance-focused treatment or to a substance-focused treatment alone.

One of the first studies in a methadone (Dolaphine) maintenance program randomly assigned 35 patients with mild/moderate depressive symptoms at treatment admission to 12 weeks of doxepin (Sinequan) or placebo. Doxepin patients had more improvement in depression and a suggestion of a decrease in substance use (Woody et al., 1975). A later study by Nunes et al. (1998) randomized 137 methadone maintenance patients who had been chronically depressed for an average of six months, in spite of receiving adequate methadone doses and regular counseling, to a 12-week course of imipramine (Tofranil) or placebo. Results showed that depression improved in the imipramine group, with a trend toward less drug use as compared to placebo. No serious adverse effects attributable to medication were seen in either study, although side effects accounted for nine (12%) early dropouts in the imipramine group and only three (5%) placebo patients. Two psychotherapy studies examined the efficacy of psychotherapy when combined with methadone maintenance and drug counseling (Woody et al., 1995, 1983). These studies found that patients with high levels of psychiatric symptoms--mainly anxiety and depression--showed decreased substance use and improvement in other areas of adjustment if they received additional psychotherapy.

Mason et al. (1996) randomly assigned 71 patients with alcohol dependence and depression (sober for a median of eight days) to a six-month course of desipramine (Norpramin) or placebo plus encouragement to attend counseling and AA. Desipramine patients had less depression and a longer time to relapse than those on placebo, although most patients in each group relapsed by six months. In another study, McGrath et al. (1996) randomized 69 actively alcoholic outpatients to 12 weeks of imipramine or placebo plus weekly counseling. All patients had onset of depression prior to the alcohol dependence or during periods of remission. Imipramine was associated with more improvement in depression than placebo with no clear effect on alcohol use, although imipramine patients whose mood improved showed more decrease in alcohol consumption. Cornelius et al. (1997) randomized 51 severely depressed alcoholics to a 12-week course of fluoxetine (Prozac) or placebo. There was a strong treatment effect, with fluoxetine patients having significantly more improvement in depression and less alcohol use than placebo patients. In one of the few pharmacotherapy studies of anxious alcoholics, Kranzler et al. (1994) randomized 61 detoxified anxious alcoholics to weekly relapse prevention plus buspirone (BuSpar) or placebo. At 12 weeks, buspirone patients had less anxiety and a slower return to heavy alcohol use than placebo patients. No serious adverse events attributable to medication were reported in these studies, although there were more dropouts due to medication side effects in the McGrath et al. study (1996).

Regarding bipolar disorders (BDs) and comorbid substance-use disorders, Brady et al. (1995) treated nine acutely manic patients with substance-use disorders using divalproex (Depakote) and found good improvement in mania, no adverse effects and a decrease in substance use. In one of the few random assignment studies with patients with BD, Geller et al. (1998) randomly assigned 46 adolescents with BD and substance-use disorders (mainly marijuana and alcohol dependence) to psychosocial treatment plus lithium (Eskalith, Lithobid) or lithium placebo. Lithium patients had more improvement in BD and substance use than those who received placebo.

Studies of schizophrenia have routinely used medication and focused mainly on treatment delivery models. These studies found that delivering treatment in the same location and using the same staff for both the schizophrenia and the substance-use disorder provided the best results (Hellerstein et al., 2001).

For attention-deficit/hyperactivity disorder (ADHD), a pilot study of bupropion (Wellbutrin) plus psychosocial treatment in 13 adolescents with ADHD, substance-abuse disorder and conduct disorder suggested that bupropion is safe and effective (Riggs et al., 1998). A single-blind study of bupropion for 11 adults with cocaine dependence showed that both ADHD and cocaine use decreased at 12-week follow-up (Levin et al., 2002). These findings were similar to their single-blind study of sustained-release methylphenidate (Concerta) (Levin et al., 1998).

As in the case of medication studies in psychiatric patients who are not abusing substances, not all results have been positive. However, findings from the studies summarized here are consistent with the idea that medication and psychotherapy or counseling can be combined for patients with substance-use and other psychiatric disorders with additional benefits and few adverse events. These studies suggest that patients who have one or more independent psychiatric disorders in addition to their substance-abuse disorder(s) are those most likely to benefit from combined therapy and that the most likely result is a reduction in psychiatric symptoms, not in substance use. However, reductions in both are seen in some studies. These findings are consistent with clinical experience and common sense--patients with substance-use and additional psychiatric disorders do best if both disorders are treated. Furthermore, substance-use and other psychiatric disorders are on different tracks, with each having a negative influence on the other. All the studies discussed here delivered parallel, integrated treatment. This model is also consistent with common sense and other research findings that are not reviewed here, but that have become increasingly difficult to implement in the age of carveout reimbursement models.

References:

References

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