Depression and Recovery or “The fingers of the hand” Omar S. Manejwala, M.D. William J. Farley Center Williamsburg, VA

Depression and RecoveryDepression and Recoveryoror

“The fingers of the hand”“The fingers of the hand”

Omar S. Manejwala, M.D.Omar S. Manejwala, M.D.

William J. Farley CenterWilliam J. Farley Center

Williamsburg, VAWilliamsburg, VA

www.farleycenter.comwww.farleycenter.com

22

OverviewOverview

• CONTEXTCONTEXT• Specific Depressive DisordersSpecific Depressive Disorders• SuicideSuicide• Neurobiology of DepressionNeurobiology of Depression• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis• Diagnostic DifficultiesDiagnostic Difficulties• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis• Treatment Principles: Medications, Treatment Principles: Medications,

Therapy, 12-step approachesTherapy, 12-step approaches

33

Source?Source?““But this does not mean that we disregard But this does not mean that we disregard human health measures. God has abundantly human health measures. God has abundantly supplied this world with fine doctors, supplied this world with fine doctors, psychologists, and practitioners of various psychologists, and practitioners of various kinds. Do not hesitate to take your health kinds. Do not hesitate to take your health problems to such persons. Most of them give problems to such persons. Most of them give freely of themselves, that their fellows may freely of themselves, that their fellows may enjoy sound minds and bodies. Try to enjoy sound minds and bodies. Try to remember that though God has wrought remember that though God has wrought miracles among us, we should never belittle a miracles among us, we should never belittle a good doctor or psychiatrist. good doctor or psychiatrist. Their services are often indispensable in Their services are often indispensable in treating a newcomer and in following his case treating a newcomer and in following his case afterward.”afterward.”

44

““Alcoholics Anonymous” Alcoholics Anonymous” p133p133““But this does not mean that we disregard But this does not mean that we disregard human health measures. God has abundantly human health measures. God has abundantly supplied this world with fine doctors, supplied this world with fine doctors, psychologists, and practitioners of various psychologists, and practitioners of various kinds. Do not hesitated to take your health kinds. Do not hesitated to take your health problems to such persons. Most of them give problems to such persons. Most of them give freely of themselves, that their fellows may freely of themselves, that their fellows may enjoy sound minds and bodies. Try to enjoy sound minds and bodies. Try to remember that though God has wrought remember that though God has wrought miracles among us, we should never belittle a miracles among us, we should never belittle a good doctor or psychiatrist. good doctor or psychiatrist. Their services are often indispensable in Their services are often indispensable in treating a newcomer and in following his case treating a newcomer and in following his case afterward.”afterward.”

55

Source?Source?

"...A.A. members and many of their physicians "...A.A. members and many of their physicians have described situations in which depressed have described situations in which depressed patients have been told by A.A.'s to throw away the patients have been told by A.A.'s to throw away the pills, only to have depression return with all its pills, only to have depression return with all its difficulties, sometimes resulting in suicide. difficulties, sometimes resulting in suicide.

We have heard, too, from schizophrenics, manic We have heard, too, from schizophrenics, manic

depressives, epileptics, and others requiring depressives, epileptics, and others requiring medication that well-meaning A.A. friends often medication that well-meaning A.A. friends often discourage them from taking prescribed discourage them from taking prescribed medication.medication.

Unfortunately, by following a layman's advice, the Unfortunately, by following a layman's advice, the sufferers find that their conditions can return with sufferers find that their conditions can return with all their previous intensity”all their previous intensity”

““The AA member- medications and The AA member- medications and other drugs” pamphletother drugs” pamphlet

66

““The AA member- medications The AA member- medications and other drugs” pamphletand other drugs” pamphlet

"It becomes clear that just as it is "It becomes clear that just as it is wrong to enable or support any wrong to enable or support any alcoholic to become re-addicted to alcoholic to become re-addicted to any drug, it's equally wrong to deprive any drug, it's equally wrong to deprive any alcoholic of medication which can any alcoholic of medication which can alleviate or control other disabling alleviate or control other disabling physical and/or emotional problems." physical and/or emotional problems."

77

Narcotics Anonymous Narcotics Anonymous Fellowship Services states…Fellowship Services states…

"The question of prescription medication "The question of prescription medication should be decided between the member, should be decided between the member, their doctor, and the member's Higher Power. their doctor, and the member's Higher Power.

Our pamphlet Our pamphlet "In Times Of Illness""In Times Of Illness" and our and our

10th Tradition10th Tradition, make this abundantly clear. , make this abundantly clear. We strongly recommend telling our doctors We strongly recommend telling our doctors

about our history so that when prescription about our history so that when prescription medication is absolutely necessary they can medication is absolutely necessary they can prescribe it knowing that we are recovering prescribe it knowing that we are recovering addicts."addicts."

88

AA grapevine October 1956AA grapevine October 1956

• ““One with the Angels” m.p.g. Boston, MAOne with the Angels” m.p.g. Boston, MA• In July of 1950, while attending the Cleveland In July of 1950, while attending the Cleveland

Convention and not having had a drink for many Convention and not having had a drink for many months, I became psychotic. I lost contact with months, I became psychotic. I lost contact with reality. I lost my sanity, in the clinical sense. reality. I lost my sanity, in the clinical sense.

• For ten months I was treated in a Maryland For ten months I was treated in a Maryland hospital. The illness required electric shock hospital. The illness required electric shock treatments and intensive psycho-therapy. treatments and intensive psycho-therapy.

• On one occasion, just before discharge, I asked On one occasion, just before discharge, I asked my doctor how he related my alcoholism to my my doctor how he related my alcoholism to my psychosis. psychosis. He showed how the fingers of the He showed how the fingers of the hand are distinct, separate and still connected. hand are distinct, separate and still connected. Thus closely are alcoholism and mental disease Thus closely are alcoholism and mental disease kin.kin.

99

State of the evidenceState of the evidence

• Recent meta-analysis (Nunes & Levin) of Recent meta-analysis (Nunes & Levin) of depression treatment in patients with substance depression treatment in patients with substance use disordersuse disorders

• 300 trials between 1973-2003300 trials between 1973-2003• Only 44 were placebo controlledOnly 44 were placebo controlled• Only 14 met inclusion criteria for rigor Only 14 met inclusion criteria for rigor

(randomized, etc)(randomized, etc)• 8 studies focused on EtOH8 studies focused on EtOH• In 4 of those studies, patients were drinking at the In 4 of those studies, patients were drinking at the

time of the studytime of the study• The only clear findings were that antidepressants The only clear findings were that antidepressants

worked better for depression if patients were sober worked better for depression if patients were sober and they didn’t improve abstinence ratesand they didn’t improve abstinence rates

1111

OverviewOverview

• ContextContext• SPECIFIC DEPRESSIVE DISORDERSSPECIFIC DEPRESSIVE DISORDERS• SuicideSuicide• Neurobiology of DepressionNeurobiology of Depression• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis• Diagnostic DifficultiesDiagnostic Difficulties• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis• Treatment Principles: Medications, Treatment Principles: Medications,


1212

Some “depressive” Some “depressive” disorders commonly seendisorders commonly seen

• Major Depressive disorderMajor Depressive disorder

• DysthymiaDysthymia

• Premenstrual dysphoric disorderPremenstrual dysphoric disorder

• Bipolar disorder (Type I, II, mixed)Bipolar disorder (Type I, II, mixed)

• BereavementBereavement

• Depressed mood is a symptom, Depressed mood is a symptom, NOT an illnessNOT an illness

1313

Symptoms of major Symptoms of major depressive disorderdepressive disorder

• Depressed mood*Depressed mood*

• Loss of interest/ pleasure in activities Loss of interest/ pleasure in activities (including sex)(including sex)

• Weight loss, weight gain (>5%/month) Weight loss, weight gain (>5%/month) or appetite changeor appetite change

• Sleep disturbanceSleep disturbance

• Fatigue/loss of energyFatigue/loss of energy

• Psychomotor agitation/retardationPsychomotor agitation/retardation

• Worthlessness/excessive or Worthlessness/excessive or inappropriate guiltinappropriate guilt

• Poor concentration (its not always Poor concentration (its not always ADD!)ADD!)

• Recurrent thoughts of death/suicideRecurrent thoughts of death/suicide

1414

Exclusionary/Other Criteria for Exclusionary/Other Criteria for Diagnosis of Major Depressive Diagnosis of Major Depressive

DisorderDisorder• Not better accounted for by:Not better accounted for by:

– BereavementBereavement– Substance induced mood disorderSubstance induced mood disorder– Dysphoria of some psychotic statesDysphoria of some psychotic states– Certain medical illnesses (e.g. Certain medical illnesses (e.g.

hypothyroidism)hypothyroidism)

Also there can never have been a history Also there can never have been a history of a manic episodeof a manic episode..

Durational CriteriaDurational Criteria

1515

Bipolar disorder (manic-Bipolar disorder (manic-depression)depression)• Elevated, expansive or irritable moodsElevated, expansive or irritable moods

• Inflated self-esteem/grandiosityInflated self-esteem/grandiosity

• Decreased need for sleep (as opposed to insomnia)Decreased need for sleep (as opposed to insomnia)

• Flight of ideasFlight of ideas

• Distractibility, poor concentration (its not always Distractibility, poor concentration (its not always ADD!)ADD!)

• Increase in goal directed activity or psychomotor Increase in goal directed activity or psychomotor agitationagitation

• Excessive involvement in behaviors with a high-Excessive involvement in behaviors with a high-risk for painful consequences.risk for painful consequences.

• Probably more common in our chronic relapse Probably more common in our chronic relapse population. 56.1% of bipolar patients had a SUD in population. 56.1% of bipolar patients had a SUD in the ECA study (flawed)the ECA study (flawed)

1616

Medical Illnesses commonly Medical Illnesses commonly associated with depression associated with depression comorbidity:comorbidity:

• EpilepsyEpilepsy

• Huntington’s diseaseHuntington’s disease

• Infections (HIV, neurosyphillis)Infections (HIV, neurosyphillis)

• MigrainesMigraines

• MSMS

• NarcolepsyNarcolepsy

• CancerCancer

• Wilson’s diseaseWilson’s disease

• Parkinson’s DiseaseParkinson’s Disease

• Cushing’s diseaseCushing’s disease

• Menses-relatedMenses-related

• Post-partumPost-partum

• Parathyroid disorders and thyroid disordersParathyroid disorders and thyroid disorders

• SLESLE

• Immune/inflammatory disordersImmune/inflammatory disorders

• Certain medicationsCertain medications

1717

OverviewOverview

• ContextContext• Specific Depressive DisordersSpecific Depressive Disorders• SUICIDESUICIDE• Neurobiology of DepressionNeurobiology of Depression• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis• Diagnostic DifficultiesDiagnostic Difficulties• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis• Treatment Principles: Medications, Treatment Principles: Medications,


1818

SuicideSuicide• People with an EtOH use disorder People with an EtOH use disorder

20x more likely to complete suicide 20x more likely to complete suicide than general population. than general population.

• Between 18% and 66% of suicide Between 18% and 66% of suicide victims have alcohol in their blood at victims have alcohol in their blood at the time of death (Roizen 1988; the time of death (Roizen 1988; Welte et al. 1988, Collier et al. 1986, Welte et al. 1988, Collier et al. 1986, Berkelman et al. 1985). Berkelman et al. 1985).

1919

Suicide Risk FactorsSuicide Risk Factors

• Previous suicide attempts Previous suicide attempts • History of mental disorders, History of mental disorders,

particularly depression particularly depression • History of alcohol and substance History of alcohol and substance

abuse abuse • Family history of suicide Family history of suicide • Family history of child maltreatment Family history of child maltreatment • Feelings of hopelessness Feelings of hopelessness • Impulsive or aggressive tendencies Impulsive or aggressive tendencies • Barriers to accessing mental health Barriers to accessing mental health

treatment treatment • Loss (relational, social, work, or Loss (relational, social, work, or

financial) financial)

2020

Suicide Risk FactorsSuicide Risk Factors

• Physical illness Physical illness • Easy access to lethal methods Easy access to lethal methods • Unwillingness to seek help because of Unwillingness to seek help because of

the stigma attached to mental health the stigma attached to mental health and substance use disorders or and substance use disorders or suicidal thoughts suicidal thoughts

• Cultural and religious beliefs—for Cultural and religious beliefs—for instance, the belief that suicide is a instance, the belief that suicide is a noble resolution of a personal noble resolution of a personal dilemma dilemma

• Local epidemics of suicide Local epidemics of suicide • Isolation, a feeling of being cut off Isolation, a feeling of being cut off

from other peoplefrom other people

2121

Suicide—contact with Suicide—contact with GPGP• Among suicide completers, 80% had Among suicide completers, 80% had

contact with a physician in the 6 contact with a physician in the 6 months priormonths prior

• Majority of suicide completers are Majority of suicide completers are under the care of a physician at the under the care of a physician at the time of their deathtime of their death

• Among suicide attempters the Among suicide attempters the picture is comparablepicture is comparable

• 1/3 of suicide attempters contacted 1/3 of suicide attempters contacted their physician the week prior to the their physician the week prior to the attempt.attempt.

2222

Suicide Protective Suicide Protective factorsfactors• Effective clinical care for mental, Effective clinical care for mental,

physical, and substance abuse disorders physical, and substance abuse disorders • Easy access to a variety of clinical Easy access to a variety of clinical

interventions and support for help interventions and support for help seeking seeking

• Family and community support Family and community support • Support from ongoing medical and Support from ongoing medical and

mental health care relationships mental health care relationships • Skills in problem solving, conflict Skills in problem solving, conflict

resolution, and nonviolent handling of resolution, and nonviolent handling of disputes disputes

• Cultural and religious beliefs that Cultural and religious beliefs that discourage suicide and support self-discourage suicide and support self-preservation instincts preservation instincts

2323

OverviewOverview

• ContextContext• Specific Depressive DisordersSpecific Depressive Disorders• SuicideSuicide• NEUROBIOLOGY OF DEPRESSIONNEUROBIOLOGY OF DEPRESSION• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis• Diagnostic DifficultiesDiagnostic Difficulties• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis• Treatment Principles: Medications, Treatment Principles: Medications,


2424

Neurobiology of DepressionNeurobiology of Depression

0

20

40

60

80

100

Depressed Depressed NotDepressed

Serotonin

Norepinephrine

“Chemical Imbalance” hypothesis postulates that reduced levels of brainserotonin or norepinephrine leads to depression.

2525

Mood regulatory neural Mood regulatory neural networksnetworks

Biological vulnerability

Mood RegulatoryCircuits

Exogenous Stressors

Depressive Episode

homeostasisGenderFHGene polymorphismTemperamentPre-natal insults

TraumaAbuseLife eventsMedical illness

Adapted from H. Mayburg, MD

2626

Neural Network hypothesisNeural Network hypothesis

• In this paradigm, disruption of the regulatory In this paradigm, disruption of the regulatory network causes inability to respond to network causes inability to respond to endogenous and exogenous stress.endogenous and exogenous stress.

• This network regulates homeostatic This network regulates homeostatic responses in:responses in:– AffectAffect– Cognitive processCognitive process– Psychomotor activityPsychomotor activity– Circadian rhythmCircadian rhythm

2727

Opening up the Mood Opening up the Mood Regulating Circuits BoxRegulating Circuits Box

Biological vulnerability

Mood RegulatoryCircuits

Exogenous Stressors

Depressive Episode

homeostasisGenderFHGene polymorphismTemperamentPre-natal insults

TraumaAbuseLife eventsMedical illness

Adapted from H. Mayburg, MD

2929

The neural network model The neural network model cont’dcont’d

PF9/46, PM6, Par40, hc, aCg24b,

mCg24c, pCg

sgCg25a-ins, hth, bstem

mF9/10rCg24aoF11

cd-vst, thalamg

mb-sn

Cognitive Processingattention – memory - action

MoodState

Adapted from Helen Mayburg, MD

Autonomic Responsesarousal – vegetative – circadian

Emotion-Cognition IntegrationSalience self-reference reinforcement

CBT

DBS

Meds

3030

KindlingKindling

• Alcoholism and bipolar disorder may Alcoholism and bipolar disorder may be related d/t the concept of neuronal be related d/t the concept of neuronal sensitizationsensitization

• Subsequent episodes of illness are Subsequent episodes of illness are often more frequent and more intenseoften more frequent and more intense

• Similar to epilepsy in this regardSimilar to epilepsy in this regard• Use of antikindling agents may be Use of antikindling agents may be

beneficial in this populationbeneficial in this population

3131

3232

OverviewOverview

• ContextContext• Specific Depressive DisordersSpecific Depressive Disorders• SuicideSuicide• Neurobiology of DepressionNeurobiology of Depression• PREVALENCE OF DUAL DIAGNOSISPREVALENCE OF DUAL DIAGNOSIS• Diagnostic DifficultiesDiagnostic Difficulties• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis• Treatment Principles: Medications, Treatment Principles: Medications,


3333

Prevalence of SUD in Prevalence of SUD in psychiatric treatment settingspsychiatric treatment settings

• The “flip side”The “flip side”– 30% of depressive d/o patients and 50% of 30% of depressive d/o patients and 50% of

Bipolar patients in inpatient settings meet Bipolar patients in inpatient settings meet criteria for a SUDcriteria for a SUD

– In VA studies the rates have been as high as 64% In VA studies the rates have been as high as 64% lifetime SUD prevalence and 29% SUD in the last lifetime SUD prevalence and 29% SUD in the last 30 days!30 days!

– This not only argues for a high incidence of SUD This not only argues for a high incidence of SUD in these conditions, but a clear association of in these conditions, but a clear association of substance use with decompensation, since these substance use with decompensation, since these were inpatients.were inpatients.

3434

Affective/SUD comorbidities by Affective/SUD comorbidities by substance of abusesubstance of abuse

• Bipolar d/o is more common among Bipolar d/o is more common among cocaine dependent patients than cocaine dependent patients than alcoholicsalcoholics

• The prevalence of depressive d/o The prevalence of depressive d/o among treatment seeking alcoholics among treatment seeking alcoholics ranges from 15-67% depending on the ranges from 15-67% depending on the studystudy

• 98% of patients presenting for 98% of patients presenting for substance abuse treatment report the substance abuse treatment report the symptomsymptom of depression of depression

3535

What conclusions about What conclusions about prevalence can be drawn?prevalence can be drawn?

• Data are conflicting d/t failure to Data are conflicting d/t failure to exclude substance induced illnesses, exclude substance induced illnesses, study design, etc.study design, etc.

• All affective disorders are common in All affective disorders are common in SUD patients, and Bipolar d/o has the SUD patients, and Bipolar d/o has the highest rate of SUD of any psychiatric highest rate of SUD of any psychiatric illnessillness

• Depression and dysthymia are more Depression and dysthymia are more common in opiate dep and alcohol dep.common in opiate dep and alcohol dep.

3636

OverviewOverview

• ContextContext• Specific Depressive DisordersSpecific Depressive Disorders• SuicideSuicide• Neurobiology of DepressionNeurobiology of Depression• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis• DIAGNOSTIC DIFFICULTIESDIAGNOSTIC DIFFICULTIES• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis• Treatment Principles: Medications, Treatment Principles: Medications,


3737

Distinguishing SUD from DDDistinguishing SUD from DD

• Mood instability and depression are among Mood instability and depression are among the most common symptoms reported in the most common symptoms reported in people with substance use disorderspeople with substance use disorders

• People with substance use disorders who People with substance use disorders who don’tdon’t experience mood symptoms are in experience mood symptoms are in the minoritythe minority

• Depressed mood is almost universal in early Depressed mood is almost universal in early recovery, especially during detoxificationrecovery, especially during detoxification

• Protracted withdrawal states can have Protracted withdrawal states can have affective lability that is difficult to affective lability that is difficult to distinguish from a primary mood disorder.distinguish from a primary mood disorder.

3838

Comorbidity of Affective and Comorbidity of Affective and SUDSUD

• ECA: 32% of Affective d/o pts had SUDECA: 32% of Affective d/o pts had SUD• Among those with MDD:Among those with MDD:

– 16.5% had alcohol use disorder16.5% had alcohol use disorder– 18% had drug use disorder18% had drug use disorder

• Among those with Bipolar disorder:Among those with Bipolar disorder:– 56.1% had substance use disorder56.1% had substance use disorder

• In both the ECA and the NCS, Bipolar In both the ECA and the NCS, Bipolar d/o was the axis I condition most likely d/o was the axis I condition most likely to also have a SUD comorbidity.to also have a SUD comorbidity.

3939

Diagnostic DifficultiesDiagnostic Difficulties

• Diagnostic difficulties at the interface Diagnostic difficulties at the interface of SUD and Affective disorders are of SUD and Affective disorders are reflected in varying prevalence rates reflected in varying prevalence rates across studiesacross studies

• In some cases of “true” affective In some cases of “true” affective disorder, substance use predates onset disorder, substance use predates onset of affective symptoms i.e. “which came of affective symptoms i.e. “which came first” may not help you distinguish.first” may not help you distinguish.

4040


• Periods of abstinence, while extremely Periods of abstinence, while extremely helpful in clarifying diagnosis are…helpful in clarifying diagnosis are…– Often inaccurately reportedOften inaccurately reported– Sometimes never present or too short to Sometimes never present or too short to

be usefulbe useful– Often characterized by the dysphoria of Often characterized by the dysphoria of

untreated alcoholism / addictionuntreated alcoholism / addiction– Occasionally characterized by exposure Occasionally characterized by exposure

to prescription medications that further to prescription medications that further complicate diagnostic clarity e.g. complicate diagnostic clarity e.g. sedative/hypnotics, opiates, stimulants sedative/hypnotics, opiates, stimulants

4141


• For example, a recent study of 207 For example, a recent study of 207 cocaine addicts using the DIS (diagnostic cocaine addicts using the DIS (diagnostic interview schedule) found…interview schedule) found…– Current rate of affective illness 17%Current rate of affective illness 17%– Lifetime prevalence of affective illness 28%Lifetime prevalence of affective illness 28%– 65% of subjects reported that drug use onset 65% of subjects reported that drug use onset

preceded affective illness onsetpreceded affective illness onset

– The primary problem with all these studies is The primary problem with all these studies is that they simply haven’t been done rigorously that they simply haven’t been done rigorously in recovering populationsin recovering populations

4242

Diagnostic ConfusionDiagnostic Confusion

• Stimulant and alcohol intoxication can Stimulant and alcohol intoxication can produce symptoms indistinguishable produce symptoms indistinguishable from mania or hypomaniafrom mania or hypomania

• Withdrawal from these agents is Withdrawal from these agents is frequently indistinguishable from frequently indistinguishable from depression and dysthymiadepression and dysthymia

• Withdrawal from CNS depressants can Withdrawal from CNS depressants can produce anxiety and agitationproduce anxiety and agitation

• PAWSPAWS

4343

Some problems with Some problems with diagnosisdiagnosis• Substances induce Substances induce

psychiatric symptomspsychiatric symptoms• Withdrawal mimics Withdrawal mimics

psychiatric disorderspsychiatric disorders• Protracted withdrawal Protracted withdrawal

states not-well defined states not-well defined and mimic primary and mimic primary psychiatric conditionspsychiatric conditions

• Clean time vs. Dry TimeClean time vs. Dry Time• Substances can cause Substances can cause

OR exacerbate OR exacerbate psychiatric syndromes. psychiatric syndromes.

• Psychiatric disorders Psychiatric disorders often overlap symptoms often overlap symptoms with each otherwith each other

• Multiple psychiatric Multiple psychiatric comorbidities can be comorbidities can be common, e.g. depression common, e.g. depression and anxiety disorders. and anxiety disorders.

• Many psychiatric Many psychiatric disorders are cyclic and disorders are cyclic and timing of dx difficulttiming of dx difficult

• Initial onset of a “true” Initial onset of a “true” psychiatric disorder can psychiatric disorder can be precipitated by be precipitated by substance intoxication or substance intoxication or withdrawal.withdrawal.

“The best way to clarify diagnosis is through observation during a period of abstinence”

4444

Diagnostic ConfusionDiagnostic Confusion

• Mania is generally easier to diagnose than Mania is generally easier to diagnose than depression in people with a SUDdepression in people with a SUD

• Manic symptoms induced by substance use Manic symptoms induced by substance use tend to resolve in days; depressive symptoms tend to resolve in days; depressive symptoms can take weeks or in some cases, monthscan take weeks or in some cases, months

• Methamphetamine and hallucinogens can be Methamphetamine and hallucinogens can be the exception to this rule, as substance-the exception to this rule, as substance-induced mania with these agents can persist induced mania with these agents can persist for weeks.for weeks.

4545

Dorus et al 1987Dorus et al 1987

• 171 inpatients in 171 inpatients in EtOH-treatmentEtOH-treatment

• National National prevalence prevalence estimate for estimate for current MDD is 5%current MDD is 5%

• ETOHics are at a ETOHics are at a higher risk for MDDhigher risk for MDD

0

10

20

30

40

50

60

70

80

day 1 Day 28

% d

epre

ssed Alcoholic

Inpatients

Generalpopulation

4646

When to diagnose?When to diagnose?

• Diagnosing too early can lead to Diagnosing too early can lead to overtreatment and mismatching and overtreatment and mismatching and possiblypossibly poorer outcomes. poorer outcomes.

• Overtreatment can undermine the Overtreatment can undermine the person’s sense that AA/NA is the primary person’s sense that AA/NA is the primary treatment of their alcoholism / addictiontreatment of their alcoholism / addiction

• Diagnosing too late can lead to higher risk Diagnosing too late can lead to higher risk of relapse, poorer outcomes, and suicide.of relapse, poorer outcomes, and suicide.

• What clinical features predict comorbidity What clinical features predict comorbidity rather than substance-induced affective rather than substance-induced affective d/o?d/o?

4747

Differentiating IllnessesDifferentiating Illnesses

• Affective symptoms that predate Affective symptoms that predate onset of substance use d/oonset of substance use d/o

• Affective symptoms during extended Affective symptoms during extended periods of abstinenceperiods of abstinence

• Strong family h/o affective d/oStrong family h/o affective d/o• Positive h/o response to affective d/o Positive h/o response to affective d/o

treatmenttreatment

““hedging your bets”hedging your bets”

4848

Differentiating Differentiating Illnesses…”hedging your bets”Illnesses…”hedging your bets”

• Chronic relapser despite multiple Chronic relapser despite multiple treatment attemptstreatment attempts

• Frequently affective illnesses in this Frequently affective illnesses in this population are excluded owing to rigid population are excluded owing to rigid application of diagnostic criteriaapplication of diagnostic criteria

• Alcoholics and addicts with extensive Alcoholics and addicts with extensive treatment exposure and multiple treatment exposure and multiple relapses should be more carefully relapses should be more carefully evaluated and medication trials evaluated and medication trials considered.considered.

4949

Differentiating Illnesses…Differentiating Illnesses…”The luxury of being a purist””The luxury of being a purist”• We don’t have it.We don’t have it.

• RCTs for antidepressants exclude RCTs for antidepressants exclude current or recent substance use or current or recent substance use or substance use disorders.substance use disorders.

• The dually diagnosed are The dually diagnosed are heterogeneous with respect to heterogeneous with respect to severity of substance use disorder, severity of substance use disorder, substances used, periods of substances used, periods of abstinence, trauma history, type of abstinence, trauma history, type of affective illnessaffective illness

5050

Risks of overtreatmentRisks of overtreatment “so just put everyone on an “so just put everyone on an

antidepressant?”antidepressant?”• NO!!!NO!!!

• Integrating depression treatment with Integrating depression treatment with recovery principles is extremely recovery principles is extremely difficult.difficult.

• Prescribing without that integration is Prescribing without that integration is dangerous and may lead to relapsedangerous and may lead to relapse

• Risks of ADRs, precipitating AD-Risks of ADRs, precipitating AD-induced mania, etc.induced mania, etc.

• Terminal uniqueness…Terminal uniqueness…

5151

OverviewOverview

• ContextContext• Specific Depressive DisordersSpecific Depressive Disorders• SuicideSuicide• Neurobiology of DepressionNeurobiology of Depression• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis• Diagnostic DifficultiesDiagnostic Difficulties• BARRIERS TO RECOVERY IN DDBARRIERS TO RECOVERY IN DD• Treatment Principles: Medications, Treatment Principles: Medications,


5252

Factors that interfere with Factors that interfere with recovery in DDrecovery in DD

• Increased level of social isolationIncreased level of social isolation

• Low energyLow energy

• Impaired concentrationImpaired concentration

• SuicidalitySuicidality

• AnxietyAnxiety

• 12-step approaches are heavily socially 12-step approaches are heavily socially drivendriven

5353

Terminal Uniqueness Terminal Uniqueness

• ““Terminal uniqueness” is a cognitive Terminal uniqueness” is a cognitive distortion present substance use disorders.distortion present substance use disorders.

• Confronting “terminal uniqueness” is Confronting “terminal uniqueness” is frequently essential in addiction tx.frequently essential in addiction tx.

• What to do with the dually diagnosed What to do with the dually diagnosed person who really is different, in some person who really is different, in some respects?respects?

5454

Homogenizing Disease in Homogenizing Disease in Recovery “Terminal Recovery “Terminal Uniqueness”Uniqueness”• Of course, everybody is Of course, everybody is bothboth unique unique andand

similar. similar. • The key issue is “uniqueness” The key issue is “uniqueness” with with

respect to the disease processrespect to the disease process, or the , or the requirement to engage in behaviors or requirement to engage in behaviors or cognitive processes that arrest the cognitive processes that arrest the disease process.disease process.

• Contrasting the special issues in the Contrasting the special issues in the management of dual dx with the management of dual dx with the cognitive distortion of terminal cognitive distortion of terminal uniqueness can be tough. uniqueness can be tough.

5555

The 12-step program member and The 12-step program member and medicationsmedications

• People are told they are not different, then People are told they are not different, then find that they are (e.g. dual diagnosis vs. find that they are (e.g. dual diagnosis vs. terminal uniqueness)terminal uniqueness)

• They are told by peers and even sponsors to They are told by peers and even sponsors to discontinue medications or to seek multiple discontinue medications or to seek multiple medical opinions until they find the one that medical opinions until they find the one that states they can go without medications.states they can go without medications.

• Peers within 12-step communities have Peers within 12-step communities have themselves been misdiagnosed as having themselves been misdiagnosed as having primary affective illness and therefore primary affective illness and therefore mistrust doctors and their capacity to make mistrust doctors and their capacity to make the diagnosis.the diagnosis.

5656

How we discuss medications with How we discuss medications with the dually diagnosed:the dually diagnosed:

• Remind the Dually Diagnosed that they are Remind the Dually Diagnosed that they are not unique with respect to their alcoholism, not unique with respect to their alcoholism, or the specific treatments needed for that.or the specific treatments needed for that.

• Caution the Dually Diagnosed against Caution the Dually Diagnosed against accepting pseudomedical advice from accepting pseudomedical advice from recovering peersrecovering peers

• Advise the Dually Diagnosed that all Advise the Dually Diagnosed that all attempts to discontinue or dose-adjust attempts to discontinue or dose-adjust psychotropic medications should be psychotropic medications should be medically managed.medically managed.

5757

OverviewOverview

• ContextContext

• Specific Depressive DisordersSpecific Depressive Disorders

• SuicideSuicide

• Neurobiology of DepressionNeurobiology of Depression

• Prevalence of Dual DiagnosisPrevalence of Dual Diagnosis

• Diagnostic DifficultiesDiagnostic Difficulties

• Barriers to Recovery in Dual DiagnosisBarriers to Recovery in Dual Diagnosis

• TREATMENT PRINCIPLESTREATMENT PRINCIPLES

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Classes of Classes of MedicationsMedications

• SSRISSRI• TCATCA• SNRI, “other” (Serzone, SNRI, “other” (Serzone,

Effexor, Remeron, Wellbutrin, Effexor, Remeron, Wellbutrin, Cymbalta)Cymbalta)

• MAOiMAOi• LithiumLithium• Atypicals (Seroquel, abilify, Atypicals (Seroquel, abilify,

geodon, zyprexa, risperdal)geodon, zyprexa, risperdal)• SynthroidSynthroid• BusparBuspar• StratteraStrattera

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Issues we consider when Issues we consider when prescribing to recovering prescribing to recovering patientspatients• Patients with substance use disorders Patients with substance use disorders

can be more side-effect sensitivecan be more side-effect sensitive• Sensitivity may be “primed” by Sensitivity may be “primed” by

substance withdrawal cycles and side substance withdrawal cycles and side effects can precipitate cravings and effects can precipitate cravings and relapserelapse

• Where possible “start low, go slow”Where possible “start low, go slow”• Conflicting experience but many dually Conflicting experience but many dually

diagnosed patients may require diagnosed patients may require combined therapy and higher target combined therapy and higher target doses.doses.

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Issues to consider in Issues to consider in prescribing to recovering prescribing to recovering patientspatients• ““Off label” prescribing is commonOff label” prescribing is common

– The problems of the FDA label, The problems of the FDA label, “psychotic depression” etc. “psychotic depression” etc.

• PRN indications should be clearly PRN indications should be clearly explainedexplained

• Frequent reevaluation is necessary in Frequent reevaluation is necessary in the first 18-24 months of recovery the first 18-24 months of recovery owing to overlap of psychiatric illness owing to overlap of psychiatric illness and protracted withdrawal states.and protracted withdrawal states.

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Medication versus TherapyMedication versus Therapy

• Those who have both SUD and Major Those who have both SUD and Major Depressive Disorder should be offered Depressive Disorder should be offered both medication and therapy if appropriateboth medication and therapy if appropriate

• Personal preference should be a guiding Personal preference should be a guiding principleprinciple

• Because therapy can be distracting and Because therapy can be distracting and difficult in early recovery, when focus on AA difficult in early recovery, when focus on AA is most needed, meds can often be more is most needed, meds can often be more effective.effective.

• Medication is certainly the option for Medication is certainly the option for severe illnesssevere illness

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Early Recovery and TherapyEarly Recovery and Therapy

• Intensive psychotherapy and Intensive psychotherapy and exploration of trauma can be exploration of trauma can be extremely dangerous in early recoveryextremely dangerous in early recovery

• Particularly when sexual trauma or Particularly when sexual trauma or PTSD is present, therapy should lean PTSD is present, therapy should lean towards supportive and 12-step towards supportive and 12-step facilitative approaches until a resilient facilitative approaches until a resilient ego emerges. ego emerges.

• Remembering the therapeutic benefit Remembering the therapeutic benefit of AA / NA of AA / NA

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Types of Types of PsychotherapyPsychotherapy

• Brief psychodynamicBrief psychodynamic

• Interpersonal therapyInterpersonal therapy

• Cognitive Behavioral TherapyCognitive Behavioral Therapy

• Marital Therapy (esp useful for wives Marital Therapy (esp useful for wives with MDD)with MDD)

• Group TherapiesGroup Therapies

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Cognitive Behavioral Cognitive Behavioral TherapyTherapy

• ““Feeling Good” David Burns, M.D.Feeling Good” David Burns, M.D.

• Aaron BeckAaron Beck

• Albert Ellis “Rational Emotive Therapy”Albert Ellis “Rational Emotive Therapy”

• Cognitions fuel emotional states and can Cognitions fuel emotional states and can be modifiedbe modified

• Really quite effective particularly for the Really quite effective particularly for the mild-moderate varietiesmild-moderate varieties

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Cognitive Behavioral Therapy Cognitive Behavioral Therapy and 12-step recoveryand 12-step recovery• CBT may be particularly well suited to CBT may be particularly well suited to

Dually diagnosed 12-step members.Dually diagnosed 12-step members.

Positive Thinking

Feeling Better

Behavioral Change

12-step recovery Cognitive Therapy

Hitting BottomFeeling Miserable

Depression interrupts the cycle

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If Psychotherapy works, how can it be an illness?If Psychotherapy works, how can it be an illness?

A landmark study in 1991 by Martin et. al A landmark study in 1991 by Martin et. al showed that responders to venlafaxine had showed that responders to venlafaxine had similar changes in regional cerebral blood similar changes in regional cerebral blood flow at 6 weeks as responders to flow at 6 weeks as responders to psychotherapypsychotherapy

• Psychotherapy, if it works for these illnesses, Psychotherapy, if it works for these illnesses, does so by modifying brain chemistrydoes so by modifying brain chemistry

Venlafaxine (right basal ganglia, right posterior temporal Psychotherapy (right basal ganglia, right posterior cingulate)

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General Principles of General Principles of Treatment with Affective/SUD Treatment with Affective/SUD comorbiditiescomorbidities• ““But doc I’m not an alcoholic/drug But doc I’m not an alcoholic/drug

addict. I was just medicating my addict. I was just medicating my mania/depression”mania/depression”

• SUD are primary disorders. If patients SUD are primary disorders. If patients meet criteria for both disorders, both meet criteria for both disorders, both must be treated.must be treated.

• Why? Patient reports are typically Why? Patient reports are typically inaccurate when they report that they inaccurate when they report that they only used or experienced only used or experienced consequences of use during affective consequences of use during affective disturbances. disturbances.

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General Principles of General Principles of Treatment with Affective/SUD Treatment with Affective/SUD comorbiditiescomorbidities• Unless illnesses are severe, patients Unless illnesses are severe, patients

should be able to participate in should be able to participate in standard addiction treatmentstandard addiction treatment

• Access to psychotherapy and Access to psychotherapy and medication treatment is criticalmedication treatment is critical

• Avoid interruptions in treatmentAvoid interruptions in treatment• Educate patients on the dangers of Educate patients on the dangers of

obtaining pseudomedical obtaining pseudomedical consultation from recovering peers.consultation from recovering peers.

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General Principles of General Principles of Treatment with Affective/SUD Treatment with Affective/SUD comorbiditiescomorbidities• Treating depression in these patients Treating depression in these patients

definitely reduces depressive symptom definitely reduces depressive symptom intensity and episode frequency and intensity and episode frequency and improves quality of life.improves quality of life.

• Treating depression in these patients Treating depression in these patients probably reduces risk of relapse probably reduces risk of relapse

• For example, Cornelius et al 1997 For example, Cornelius et al 1997 found that Prozac in depressed found that Prozac in depressed alcoholics reduced depression alcoholics reduced depression andand drinkingdrinking

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General Principles of General Principles of Treatment with Affective/SUD Treatment with Affective/SUD comorbiditiescomorbidities• Special attention must be paid to Special attention must be paid to

helping patients with comorbid helping patients with comorbid affective illness integrate into 12-affective illness integrate into 12-step approachesstep approaches

• More intense primary addiction More intense primary addiction treatment may be needed, and some treatment may be needed, and some studies suggest initial treatment studies suggest initial treatment duration should be longer.duration should be longer.

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Support Groups for Dual DxSupport Groups for Dual Dx

• Groups for patients with comorbid Groups for patients with comorbid substance use d/o and affective substance use d/o and affective disordersdisorders

• May be most effective if separated into May be most effective if separated into unipolar and bipolar illnessunipolar and bipolar illness

• Should not be a replacement for Should not be a replacement for addiction treatment and recovery-addiction treatment and recovery-enhancing approachesenhancing approaches

• Can be 12-step based, cognitive Can be 12-step based, cognitive behavioral, or other approachbehavioral, or other approach

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What about Bipolar What about Bipolar disorder?disorder?

• Lithium has been the mainstay of Lithium has been the mainstay of treatment for decadestreatment for decades

• Substance use disorder may predict Substance use disorder may predict poor response to lithiumpoor response to lithium

• Some practitioners will use multiple Some practitioners will use multiple meds or valproic acid derivatives to meds or valproic acid derivatives to treat these patientstreat these patients

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What about Bipolar What about Bipolar disorder?disorder?• Patients with Bipolar/SUD comorbidity may:Patients with Bipolar/SUD comorbidity may:

– Have more mixed symptomsHave more mixed symptoms– Have more rapid cyclingHave more rapid cycling– Be more likely to be nonadherent with medsBe more likely to be nonadherent with meds– Have greater rates of misdiagnosisHave greater rates of misdiagnosis

Misdiagnosis of bipolar disorder as unipolar Misdiagnosis of bipolar disorder as unipolar depression is particularly problematic because depression is particularly problematic because antidepressants can precipitate manic episodes. antidepressants can precipitate manic episodes.

Symptoms of PAWS can predispose to poor bipolar Symptoms of PAWS can predispose to poor bipolar hygienehygiene

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Documents

Depression and Recovery or “The fingers of the hand” Omar S. Manejwala, M.D. William J. Farley Center Williamsburg, VA