Psychiatric Comorbidity in SUDs

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Psychiatric Comorbidity in SUDs

• The occurrence of psychiatric illness in an
  individual with a SUD
• In most settings, refers to occurrence of a
  diagnosable psychiatric disorder
• Comorbidity of SUDs and diagnosed psychiatric
  disorders is substantial
• SUD individuals with comorbid psychiatric illness
  are referred to as Dual Diagnosis

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Psychiatric Comorbidity in
NativeHawaiian Pacific Islanders Compared to
Other Populations Measurement Clinical Issues

• George Fein Ph.D.
• President and Senior Scientist,
• Neurobehavioral Research, Inc
• Victoria Di Sclafani Ph.D.
• John A. Burns School of Medicine,
• University of Hawaii at Manoa

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Myths Regarding Psychiatric Comorbidity and SUDs
Myth 1 It is very difficult for dual diagnosis
individuals to achieve abstinence. Myth 2 It
is very difficult for an abstinent individual to
maintain abstinence with a current psychiatric
diagnosis, especially if psychiatric medication
management is needed.
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Psychiatric Comorbidity

• We will present illustrative data from three
  studies of alcoholics
• 1. Long-Term (avg gt 6 yrs) Abstinent Alcoholics
• 2. Treatment Naïve Actively Drinking Alcohol
• Dependent Sample
• 3. Older Long-Term (avg gt 14 yrs) Abstinent
  Alcoholics
• Each group vs. its own age and gender
  comparable controls.

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Psychiatric DiagnosisLifetime and Current

• Long-term Abstinent Alcoholics
• minimum 6 months, average 6.3 years abstinence
• alcohol dependent sample 34-58 years old (n52)
• Age and gender comparable controls (n48)

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LTAA vs Controls
Lifetime psychiatric diagnoses do not militate
against achieving long-term abstinence in fact,
lifetime psychiatric diagnoses are the norm.
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LTAA vs Controls
Current psychiatric diagnoses (even those treated
with medication) do not militate against
maintaining long-term abstinence.
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Treatment Naïve Alcoholics vs Controls
Treatment Naïve Alcoholics do not evidence more
Lifetime diagnoses than Controls.
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Treatment Naïve Alcoholics vs Controls
There is no difference between Treatment Naïve
Alcoholics and Controls in current psychiatric
diagnoses.
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Older LTAA vs Controls
Older Long-Term Abstinent Alcoholics tend to have
somewhat more psychiatric morbidity than
Controls but less than seen in Middle-Aged
Alcoholics.
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Older LTAA vs Controls
Virtually no current psychiatric morbidity is
found in Older Abstinent Alcoholics.
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Tentative Conclusions

• Middle-aged LTAA have major psychiatric
  morbidity.
• Older LTAA have minimally more psychiatric
  morbidity than controls.
• Treatment naïve alcoholics have comparable
  psychiatric morbidity to controls.

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Sub-Diagnostic Psychiatric Comorbidity

• Most studies ignore psychiatric symptoms that do
  not meet criteria for a diagnosis.
• Subthreshold psychiatric disorder data (i.e., Sx
  LT the diagnostic threshold) are not presented,
  implying that Dx completely addresses the
  presence severity of psychiatric morbidity.
• Dx results in great loss of sensitivity,
  examining only tail of Sx distribution, leaving
  the bulk of the Sx distribution unexplored.

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Sub-Diagnostic Psychiatric
Comorbidity

• Currency of symptoms is usually not assessed
• unless diagnosis is met.
• Thus, diagnostic thinking is reflected even in
• the psychological measures we use.

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Mood Disorder Symptom Counts LTAA
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Mood Disorder Symptom Counts OAA
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Mood Disorder Symptom Counts TxN
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Anxiety Disorder Symptom Counts LTAA
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Anxiety Disorder Symptom Counts OAA
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Anxiety Disorder Symptom Counts TxN
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Externalizing Disorder Symptom Counts
LTAA
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Externalizing Disorder Symptom Counts
OAA
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Externalizing Disorder Symptom Counts TxN
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Sub-Diagnostic Psychiatric Comorbidity

• Psychological measures of attitudes, beliefs,
  reactions and thoughts also reflect psychiatric
  illness (e.g., depressive thinking, poor
  self-esteem, etc.)
• Such measures and scales are usually not part of
  an assessment of psychiatric comorbidity, but
  often represent the psychological substrate for
  illness (e.g., socialized thinking is
  antithetical to antisocial behaviors).

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Mood Psychological Measures LTAA
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Mood Psychological Measures OAA
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Mood Psychological Measures TxN
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Anxiety Psychological Measures LTAA
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Anxiety Psychological Measures OAA
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Anxiety Psychological Measures TxN
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Externalizing Psychological Measures LTAA
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Externalizing Psychological Measures OAA
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Externalizing Psychological Measures
TxN
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Conclusions

• Sub-diagnostic psychopathology carries the bulk
  of the difference between LTAA and NAC in
  psychiatric illness.
• Continuous measures of psychiatric illness yield
  a more accurate picture of psychiatric
  comorbidity than the limited view that is
  provided by using only symptomatology that meets
  criteria for a diagnosis.

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NRI Current Procedures c-Dis Follow Up
Questions

• In the last 12 months, have you had symptom?
• How old were you the first time you EVER had
  symptom?
• When you first felt/experienced this symptom,
  was it in the context of seeking/using/withdrawing
  from alcohol/drugs?
• What percent of the time that you had symptom
  was it in association with seeking/using/withdrawi
  ng from drugs or alcohol?

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• Older Abstinent Alcoholics (OAA)
• 49 men, 40 women
• age 60-85 years (mean 67.5 years)
• abstinent 6 mos 44 yrs (mean 14.8 yrs)
• Older Non-Alcoholic Controls (ONC)
• 24 men, 29 women
• age 60-85 years (mean 69.3 yrs)

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Diagnoses

• 51.7 of OAA vs. 30.2 of ONC had a lifetime
  psychiatric Dx (?2 5.40, p lt .02).
• 44.9 of OAA vs. 28.3 of ONC had a lifetime mood
  Dx (?2 3.21, p .07).
• No differences in anxiety and externalizing
  diagnoses ps gt 0.30
• Essentially NO current Diagnoses.
• 4.5 of OAA and 3.8 of ONC

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Symptoms and Psych Measures

• Total Psychiatric Sx 77 ? in OAA
• 50 ? Anxiety Sx in OAA vs. ONC
• 50 ? Mood Sx in OAA vs. ONC
• 250 ? Externalizing Sx in OAA vs. ONC
• Psychological Measures
• OAA vs. ONC ? ASI, no diff STAI- T or S
• OAA vs. ONC ? MMPI-Hy, no diff MMPI-D
• OAA vs. ONC ? MMPI pD, ? CPI Soc Scale

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Conclusions

• Psychiatric disorder is more prevalent in OAA
  than ONC.
• Psychiatric comorbidity is less in OAA compared
  with ONC compared to MAA vs. MNC.
• Largest effects in externalizing domain.
• Differences from middle-age study
• Cohort effects
• Selective survivorship
• Selection bias for participating is greater in
  older samples

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Sensation Seeking Scales
Scale Abstinent Alcoholics Abstinent Alcoholics Controls Controls Effect Size () Effect Size () Effect Size ()
Scale Male (n28) Female (n24) Male (n25) Female (n23) Group Sex Group x Sex
Disinhibition 4.36 1.393 3.04 1.756 3.68 1.574 3.13 1.180 1.0 9.2 1.7
Boredom Susceptibility 4.32 2.212 2.50 1.414 4.24 2.026 3.26 1.657 0.8 12.6 1.3
Thrill/ Adventure Seeking 7.39 2.470 5.46 2.570 6.12 2.774 5.22 2.907 2.0 6.8 1.0
Experience Seeking 5.04 1.527 5.00 1.103 4.76 1.640 5.30 1.396 0.0 0.8 1.0
Measures are reported as mean standard
deviation. Effect is significant p 0.05,
p 0.01, p 0.001.
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Conclusions

• The propensity towards sensation seeking
  normalizes with long-term abstinence.
• The measures are sensitive enough to detect
  gender differences within LTAA and NC.
• We see increased sensation seeking in treatment
  naïve actively drinking alcoholics (after
  removing items associated with substance use).

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Cognitive Function

• Rey-Osterrieth Complex Figure (copy, immediate,
  and 20 minute delayed), Trail Making Test A and
  B, Symbol Digit Modalities Test, American version
  of the Nelson Adult Reading Test, Short Category
  Test, Controlled Oral Word Association Test,
  Paced Auditory Serial Addition Test, Block Design
  Stroop Color and Word Test
• MicroCog (MC) Assessment of Cognitive Functioning
• Global Clinical Impairment Score (GCIS)
• 1 for each domain scoring 5-15th ile
• 2 for each domain scoring lt 5th ile
• Summed across 9 domains

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Cognitive Profiles
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Conclusions

• Very long-term abstinence resolves most
  neuro-cognitive deficits associated with
  alcoholism, except for the suggestion of
  lingering deficits in spatial processing.

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Cognitive Function in Older Long-Term Abstinent
Alcoholics

• 91 older (gt60 years of age) abstinent alcoholics
  in 3 subgroups
• OAA1 abstinence before age 50 (n39)
• OAA2 abstinence achieved 50-60 (n 26)
• OAA3 abstinence after 60 (n26)
• 39 older controls

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Results

• EAA were comparabe to controls, except those
  abstinent before 50 were worse than controls on
  auditory working memory
• EAA had larger craniums than controls
• effect was strongest for those who drank the
  longest and had shortest abstinence
• Such individuals also performed better cognitively

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Conclusions

• Older alcoholics who drank late into life, but
  with than six months abstinence can exhibit
  normal cognitive functioning.
• Selective survivorship and selection bias likely
  play a part in these findings.
• Cognitively healthier alcoholics, with more brain
  reserve capacity, may be more likely to live into
  their 60s 80s with relatively intact
  cognition, and to volunteer for studies such as
  ours.
• Our results do not imply that all elderly
  alcoholics with long-term abstinence will attain
  normal cognition

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Decision-Making

• Iowa Gambling Task (IGT)
• Task performance
• Voxel-based morphometry
• Balloon Analogue Risk Task
• Preliminary error-related negativity (ERN) data
  from treatment-naïve drinking alcoholics

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IGT
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ROI Restricted VBM Shows Amygdala Volume
Reductions

• The views on the right (B.) show the region
  of interest (ROI) to which the analysis was
  restricted the amygdala (blue) and the
  ventromedial prefrontal cortex (magenta). The
  views on the left (A.) show the SPM2 areas of
  significantly reduced gray matter (orange SPM2
  family wise error corrected plt 0.05), and the
  spatial uncertainty of that area (green).

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Conclusions

• Alcoholics can achieve long-term abstinence in
  spite of persistent deficits in decision- making.
• These deficits are associated with reduced gray
  matter in regions implicated in similar
  impairments in neurological samples.
• May result from long-term alcohol dependence, or
  may reflect a pre-existing factor that
  predisposes one to severe alcoholism.

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ERNs during the BART

• Brain activity during risk-assessment tasks can
  provide insights into the mechanisms underlying
  impaired behavior on these tasks.
• The feedback error-related negativity (F-ERN) is
  hypothesized to reflect the valence attached to
  the negative consequences of behavior.

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F-ERN during BART Task
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Results Conclusions

• Within treatment-naïve alcoholics, smaller F-ERN
  amplitudes were associated with a greater FHD of
  alcohol problems (r -0.567, p 0.007).
• Results suggest a possible link between the
  genetic vulnerability toward developing
  alcoholism and the brains response to the
  negative consequences of behavior.

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Region of Interest Analysis

• Most studies measure cortical gray matter volumes
  using masks from a common space, ignoring the
  variations in cortical folding between subjects.
• Our approach accounts for these variations.
• Middle-aged long-term abstinent alcoholics
• 48 NAC, 52 LTAA, 34.4 59.8 years old

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Volume Reductions in LTAA
Parietal ? 6.9, p 0.014 Lateral Parietal ?
7.4, p 0.006
Frontal ? 2.77, NS Primary Sensory ? 9.3, p
0.009
Occipital ? 6.2, p 0.015 Visual Assn ?
7.3, p 0.007 Ant Occipital ? 3.3, p 0.007
Limbic ? 0.9, NS Ant Cingulate ? 4.7, p
0.015
Temporal ? 1.9, NS
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Conclusions

• Reduced visual association and lateral parietal
  gray matter is consistent with reduced spatial
  processing scores in LTAA.
• Absence of reduced temporal lobe gray matter
  (which has been linked to alcohol-related damage)
  suggests recovery with abstinence, consistent
  with intact memory function in this sample.