SOCW 4340 Introduction to Alcohol/Drug Addiction CHAPTER 10 Mental Health and Drugs

Introduction 33% of People with mental illness also abuse substances 50-70% of drug abusers have mental disord Neurotransmitters same Drugs may cause symptoms Stimulants – mania, anxiety, psychosis Stimulant withdrawal – depression, anxiety Depressants – depression Psychedelics – hallucination/psychosis

Substance related disorders Substance use Dependence – impairment - continue in spite of consequences Abuse – disruption of life function - continue in spite of consequences Substance induced Intoxication Withdrawal Disorders – delirium, dementia, amnesia, etc.

Determining factors Heredity Environment Use of drugs

Determining factors Heredity Schizophrenia Bipolar Depression Anxiety Binge eating Gambling ADHD Greatly increased risk if stressed by environment or drugs

Determining factors Environment Stress depletes norepinephrine Abuse/molestation – 75% of female addicts Environment potentiates risk of abuse

Determining factors Psychoactive drugs Change balance of neurotransmitters Drugs may induce mental disorder in any person Predisposed brain more likely to suffer permanent harm Type of drug impacts type of harm Predisposed to depression – alcohol/sed-hyp Predisposed to schizophrenia - psychedelics

Dual diagnosis Mental disorder and substance abuse Preexisting Thought – psychotic/schizophrenia Mood – affective - depression. Bipolar Anxiety panic/ADHD Substance induced Stimulant induced psychotic disorder Alcohol induced mood disorder Marijuana induced delirium

Dual diagnosis Must distinguish between symptoms and the disease Abusers often present with symptoms that may disappear with sobriety

Dual diagnosis Epidemiology Alcohol 44% Drugs 64% Mentally ill 29-34% abusers Manic depressive 61% Schizophrenia 47% Prisoners with mental illness 81%

Dual diagnosis Patterns Preexisting – self medication Substance induced – neurotransmitter imbalance

Diagnosis Address all symptoms Avoid making diagnosis until abuser sober Factors Particular pattern Preexisting mental illness Self medication Age of onset Relationship of the symptoms to substance use

Diagnosis Increased population on streets Decreasing IP facilities Substance abuse up Increase in number and expertise of practitioners Increased awareness OP pays more – over-diagnosis Disruptive – unwanted at substance abuse centers or at psychiatric treatment centers

Mental health vs. substance abuse Cure the disease, abuse will go away Get them sober, MH problems will resolve MH – partial recovery OK MH – stigma MH/some SA – medications MH – shepherding, SA – self-reliance MH – supportive, SA - confrontive

Mental health vs. substance abuse MH sharing info easier MH – more professionals, SA recovering addicts MH – scientific approaches, SA, less structured MH – prevent getting worse, SA hit bottom MH – individual, SA – one size fits all

Mental health vs. substance abuse Must treat simultaneously SA must connect with MH Each must see the other as a complement Case management improves outcome

Multiple diagnosis Polydrug use Other medical problems Chronic pain Hepatitis Epilepsy Cancer Heart/kidney disease Diabetes Sickle cell Sexual dysfunction HIV – triple diagnosis

Disorders Thought – schizophrenia Mostly inherited Hallucinations Delusions Inappropriate affect Ambivalence Poor association Impaired ability to care for oneself Autism Poor job performance Strained social relations

Disorders Thought – schizophrenia Usually late teens/early adult Drugs mimic Stimulants Steroids Mdma/marijuana Psychedelics Withdrawal from downers

Disorders Major depressive disorder 15% of all have in lifetime 9% per year Depressed mood Diminished interest Diminished pleasure Sleep disturbance Inability to concentrate Worthlessness Suicidal thoughts Most of the day for 1 week

Disorders Major depressive disorder Alcohol Amphetamine withdrawal Psychedelic 80% due to drugs, not heredity

Disorders Bipolar affective disorder Depression/normalcy/mania Depression can be suicidal Mania Persistent elevated, expansive, irritated mood Inflated self esteem Depressed need for sleep Talkative Flight of ideas Distractibility Goal directed activity Excessive involvement with pleasurable activities

Disorders Bipolar affective disorder Usually begins in 20s Drugs Stimulants Psychedelics

Disorders Anxiety 16% of adults per year PTSD – persistent re-experience 20-25% of those in drug treatment Panic - intense fear/discomfort when no real danger Agoraphobia Social phobia Simple (specific) phobia OCD GAD Toxic effects of stimulants Withdrawal from opioids, sed/hyp or alcohol

Disorders Dementias Developmental disorders Brain dysfunction due to physical changes Marijuana and prescription drugs mimic Developmental disorders Retardation Autism Communication ADHD Psychedelic use can be mistaken for DD

Disorders Somatoform Physical symptoms without obvious cause Hypochondria Munchausen’s Stimulant psychosis – bugs Psychedelics

Disorders Personality Inflexible behavior leading to distress/impairment Anger Disruptive behavior Hard to treat

Disorders Eating Weak impulse control Co-occur with many other disorders and substance use – depression/PTSD

Disorders Gambling Impulse control Alcohol Stimulants, esp. methamphetamine

Substance-induced Disorders Alcohol induced Impulse control Violence Suicide Unsafe sex High risk behavior Sleep Suppresses REM Sleep

Substance-induced Disorders Alcohol induced Anxiety Withdrawal related Last 2-3 days Depression 45% have concurrent major depressive disorder After 4 weeks of sobriety 6% Antidepressants contraindicated

Substance-induced Disorders Alcohol Psychosis Develop after decades of heavy drinking Hallucinations Delusional thoughts Antipsychotics effective (not during withdrawal) Dementia Neurotoxic Cognitive deficits May regain some function Mimics Alzheimer’s

Substance-induced Disorders Stimulant induced Impulse control Mania Resolve without treatment if only induced Medication not indicated if non-abstinent Panic Drug use increases panic focus – can become chronic even if abstinent

Substance-induced Disorders Stimulant induced Depression Imbalance of neurotransmitters Can last 10 weeks Antidepressants helpful during detox only Anxiety Intoxication Withdrawal Treatment

Substance-induced Disorders Stimulant induced Psychosis Short term and long term in some For those, each use increases frequency and duration Can last for months after last use Cognitive impairment Transient damage Permanent damage Revealed by high tech imaging

Substance-induced Disorders Marijuana Delirium Disturbance of consciousness Change in cognition Memory Multi-step tasking 3 months to clear Psychosis Paranoia Hallucinations Tend to be transient

Substance-induced Disorders Panic While intoxicated Amotivational syndrome Chicken and egg question

Treatment Rebalancing brain chemistry Education – primary prevention Cannot change hereditary factors Improve environment Avoid stressors Leave abusive relationship Avoid drug users Sleep Avoid bad situations New friends Self-help Nutrition

Treatment Stabilize both mental and substance abuse problems Homicidal/suicidal Detox Diagnosis Psycho-pharmaceuticals helpful

Treatment Impaired cognition 50% of patients Reasoning, memory impaired May not be ready to help with treatment for weeks/months Treatment must match patient capabilities

Treatment Developmental arrest Arrested emotional development Lack of maturation Low frustration tolerance Can’t work toward goal independently Lie to avoid punishment Test limits Feelings expressed as behavior Shallowness of mood Fear of rejection Live in present (no hope) Denial, non-compliant For me or against me - absolutes

Treatment Therapies Counseling Group Psychopharmacology Primary treatment for mental illness 1st Achieve abstinence 2nd Maintain abstinence 3rd Continued therapy – emphasis on abstinence

Psychopharmacology Used only after thorough assessment Short term, medium term, lifetime basis Increase neurotransmitter release Block receptor Inhibit reuptake Inhibit metabolism (MAO) Enhance Monitor and adjust dose - mandatory

Psychopharmacology Prescribed vs. street Most not addicting Compliance is a problem Sense of control

Psychopharmacology Depression Serotonin/norepinephrine Most drugs increase SSRI – prozac, zoloft Serotonin syndrome Sexual dysfunction Tricylics work well for chronic MAOs – block metabolism – food drug interactions Stimulants increase norepinephrine - amps

Psychopharmacology Bipolar Lithium Stabilizes mostly highs Side effects Non-compliance Requires monitoring

Psychopharmacology Psychoses Phenothiazines Haldol, etc. Excess dopamine related Medications block receptors Treat symptoms, not disease Muscle problems, tremor, sedation, apathy

Psychopharmacology Anxiety disorders Benzodiazepines Buspirone SSRIs Safer than barbs/mepro Act quickly Addictive-poor choice for addict GABA Buspirone Serotonin modulator 1-2 weeks for 1st response SSRIs OCD – poor results in general Panic - SSRIs

Psychopharmacology Compliance Patient must take the med for it to work Feedback and face-to-face required