CONCURRENT PSYCHIATRIC

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CONCURRENT PSYCHIATRIC SUBSTANCE USE DISORDERS
PHM 462 November 11, 2004
Beth Sproule, Pharm.D.
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Learning Objectives

• At the completion of this class, students will
  be able to 
• Consider the clinical implications of concurrent
  psychiatric and substance use disorders. 
• Identify and describe the unique drug-related
  problems encountered by patients with concurrent
  psychiatric and substance use disorders.

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Case Study

• Harry is a 35 year old man with a 10 year
  history of schizophrenia admitted for acute
  decompensation. He reported having low energy and
  the onset of hearing voices 2 weeks prior to
  admission. A long-time cocaine user, he reported
  increasing his use of cocaine on the weekends for
  the last few weeks.

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Case Study

• The psychiatric diagnosis is clear. What is the
  likely substance use disorder?
• How common do you think this is?

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Epidemiology
Population with Comorbid SUD
Major Depression 27
Bipolar Disorder 56
Schizophrenia 47
Anxiety Disorders 24
General Population 17
Regier et.al. JAMA 1990264(19)2511-2518.
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Epidemiology
Population Any Psych Disorder Mood Disorder Anxiety Disorder Schizo-phrenia
Alcohol Use Disorder 37 13 19 4
Drug Use Disorder 53 26 28 7
General Population 23 8 15 2
Regier et.al. JAMA 1990264(19)2511-2518.
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Case Study

• The onset of increased cocaine use coincided
  with hearing the voices what may that suggest
  with respect to the relationship between the
  disorders? How could the cocaine have affected
  the psychotic illness?

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Possible Relationships

• The psychiatric disorder is induced by the
  substance use disorder.
• Examples
• psychosis from cocaine intoxication
• anxiety from benzodiazepine withdrawal
• anxiety from high doses of caffeine
• Mania from amphetamine intoxication

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DSM-IVSubstance-Induced Psychosis
Substance Intoxication Withdrawal
Alcohol ? ?
Amphetamines ?
Cannabis ?
Cocaine ?
Hallucinogens ?
Inhalants ?
Opioids ?
Phencyclidine ?
Sed/Hyp ? ?
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DSM-IV Substance-Induced Persisting Disorders

• Substance-Induced Persisting Dementia
• alcohol, inhalants, sedative/hypnotics
• Substance-Induced Persisting Amnestic Disorder
• alcohol, sedative/hypnotics
• Hallucinogen Persisting Perception Disorder
• AKA Flashbacks

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DSM-IVSubstance-Induced Disorders

• Evidence from history or examination that
  suggests a substance-induced disorder
• symptoms developed during or within 1 month of
  substance intoxication or withdrawal
• presence of features atypical of psychiatric
  disorder (e.g., first manic episode after age 45)
• substance-specific effects consistent with the
  disturbance

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DSM-IVSubstance-Induced Disorders

• Evidence that suggests that the disturbance is
  better accounted for by non-substance-induced
  disorder
• symptoms precede the onset of substance use
• symptoms persist for a period of time (e.g.,
  about a month) after the cessation of acute
  withdrawal or severe intoxication
• symptoms are in excess of what would be expected
• family history

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Possible Relationships

• The substance use disorder is causally dependent
  on the psychiatric disorder (i.e., functionally
  linked, self-medication).
• Example
• Panic disorder leads to dependence on
  benzodiazepines

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Possible Relationships

• The psychiatric disorder and the substance use
  disorder have common risk factors.
• Example
• Personality disorders leading to substance abuse

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Possible Relationships

• The psychiatric disorder and the substance use
  disorder are independent of each other.
• Example
• a simple phobia in an alcohol abuser

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Case Study

• Albert is a 45 year old single male, employed in
  the service industry, although his job is in
  jeopardy due to absenteeism. His chief complaints
  are of anxiety, depression, insomnia, and stress
  related to his girlfriend threatening to leave.
  He describes symptoms of fatigue, difficulty
  concentrating and weight loss. Upon questioning
  it is determined that he has been drinking
  heavily (1.5 litres of wine daily) for 20 years.
  He says he was treated with benzodiazepines in
  the past for depression. He has had a brief
  inpatient stay in a psychiatric unit for
  stress. Albert refused to undergo acute alcohol
  withdrawal treatment. Instead a program of
  gradual withdrawal was agreed upon, with a target
  of 10 reduction weekly. Three weeks later Albert
  is still drinking the same amount. He says that
  although he wants to reduce his drinking he has
  been unable to due to his persistent feelings of
  low mood and anxiety.

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Case Study

• What is the likely substance use disorder?
• What is the likely psychiatric disorder?

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DSM-IV Substance Dependence
? 3 criteria leading to significant
impairment/distress

• Tolerance
• Withdrawal
• More or longer than intended
• Unable to cut down or control use

• Great deal of time spent around substance use
• Important activities given up
• Use continues despite link to physical or
  psychological problem

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DSM-IV Major Depressive Episode

• ? 5 symptoms for 2 weeks
• from previous functioning
• depressed mood
• loss of interest/pleasure
• ?? appetite
• ?? sleep
• psychomotor agitation
• fatigue

and represents a change
must include 1 of these

• worthlessness
• ? concentration
• thoughts of death

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Case Study

• Does this patient require pharmacotherapy?
• What DRPs would you anticipate in this patient?

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Pharmacotherapy for Depression Alcohol
Dependence

• TCAs - conflicting evidence whether both
  depressive symptoms and drinking respond
• SSRIs
• Fluoxetine shown to reduce depressive symptoms
  and alcohol consumption
• Sertraline reduced drinking in
  alcohol-dependent patients without lifetime
  depression reduced drinking in depressed,
  adolescent alcoholics
• Combinations naltrexone SSRI

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Drug-Related Problems in a Comorbid Population

• Drug interactions
• Medication compliance
• Abuse/addiction potential of psychotherapeutic
  agent

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Drug Interactions

• Combining prescribed psychotherapeutic drugs
  with
• Alcohol
• Street drugs
• Nicotine
• OTC psychotropic drugs

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Weiss RD et.al., Medication compliance among
patients with bipolar disorder and substance use
disorder. J Clin Psychiatry 199859172-174.
Compliance

• n44, 55 female, age 37 ? 9 years
• gt 2/3 level of compliance
• lithium 67, VA 73, CBZ 67, SSRIs 85
• Reasons for non-compliance
• side-effects, no need, wanted to use
  drugs/alcohol, hassle, forgot
• may take higher doses than prescribed

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Abuse of Psychiatric Medications

• anticholinergic agents
• benzodiazepines

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Question

• Antipsychotic and antidepressant medications are
  not usually subject to abuse because
• a) they are more strictly controlled than
• other drugs
• b) in general, they do not produce euphoria
• and may have unpleasant side-effects
• c) they are generally not prescribed on a
• long-term basis
• d) they are only available orally

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Question

• Antipsychotic and antidepressant medications are
  not usually subject to abuse because
• a) they are more strictly controlled than
• other drugs
• b) in general, they do not produce euphoria
• and may have unpleasant side-effects
• c) they are generally not prescribed on a
• long-term basis
• d) they are only available orally

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Anticholinergic Agents

• Examples
• benztropine (Cogentin)
• procyclidine (Kemadrin)
• trihexyphenidyl (Artane)
• dimenhydrinate (Gravol)
• tricyclic antidepressants
• abuse potential limited by relative mildness of
  euphoric effect and unpleasant side-effects

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Benzodiazepines

• Relatively low abuse liability compared to
  barbiturates, alcohol, opioids, stimulants
• low inherent harmfulness and ease of availability
  increase potential for abuse
• low dose versus high dose abuse or dependence