1. Copyright Alcohol Medical Scholars Program 1 Comorbidity General Lecture Marc A. Schuckit, M.D. Department of Psychiatry University of California, San Diego

2. Copyright Alcohol Medical Scholars Program 2 Some Explanations for Comorbidity 1. Substance induced temporary disorders 2. Substances intensify prior psychiatric conditions 3. A few psychiatric disorders increase the risk for substance use disorders

3. Copyright Alcohol Medical Scholars Program 3 Rationale Drugs can cause psychiatric symptoms These last days to weeks They clear spontaneously

4. Copyright Alcohol Medical Scholars Program 4 Source: Brown S, Schuckit M. (1988) J Stud Alcohol;49:412-417. Hamilton Depression Score > 20* Weeks Abstinent 40% 16 20% 30% 10% 0% 1243 * Mood swings last longer

5. Copyright Alcohol Medical Scholars Program 5 Source: Brown S, Schuckit M. J Stud Alcohol. 1990;51:34-41. Anxiety In 171 Primary Alcoholics Symptom Withdrawal palpitations and/or shortness of breath80% Panic while drinking 4% Panic while sober 2% Generalized anxiety while sober 4%

6. Copyright Alcohol Medical Scholars Program 6 When 2+ Disorders Are Observed: Which one(s) should be treated? What is best therapy? Will disorders and/or treatments interact?

7. Copyright Alcohol Medical Scholars Program 7 Comorbidity is Common in SUD 2 / 3 have 2nd diagnosis BUT Most are ASPD and other SUD Many others are organic

8. Copyright Alcohol Medical Scholars Program 8 Studies of Children Of Alcoholics Don't reveal increased psychiatric disorders

9. Copyright Alcohol Medical Scholars Program 9 Diagnosis Can Indicate: When to intervene Treatment with best asset to risk ratio

10. Copyright Alcohol Medical Scholars Program 10 DSM IV Major Depressive Episode A. 5/9 symptoms for two weeks with either (1) depressed mood or (2) loss of interest or pleasure B-E. Exclusion criteria MDD is diagnosed by symptoms and history

11. Copyright Alcohol Medical Scholars Program 11 Alcoholism Course Fluctuating: –controlled use –problems –abstinence 20% spontaneous remission

12. Copyright Alcohol Medical Scholars Program 12 Anxiety Disorders Panic Disorder with or without Agoraphobia Agoraphobia Social Phobia Specific Phobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Generalized Anxiety Disorder

13. Copyright Alcohol Medical Scholars Program 13 Depressive Symptoms in Alcoholics 80% Sadness 30% - 40% Depressive Episodes Question: What is the best treatment?