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

2. Learning Objectives At the completion of this class, students will be able to: 1.Consider the clinical implications of concurrent psychiatric and substance use disorders. 2.Identify and describe the unique drug-related problems encountered by patients with concurrent psychiatric and substance use disorders.

3. 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.

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

5. Epidemiology Population% with Comorbid SUD Major Depression27% Bipolar Disorder56% Schizophrenia47% Anxiety Disorders24% General Population17% Regier et.al. JAMA 1990;264(19):2511-2518.

6. Epidemiology PopulationAny 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 1990;264(19):2511-2518.

7. 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? Case Study

8. 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

9. DSM-IV Substance-Induced Psychosis SubstanceIntoxicationWithdrawal Alcohol  Amphetamines  Cannabis  Cocaine  Hallucinogens  Inhalants  Opioids  Phencyclidine  Sed/Hyp 

10. 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”

11. DSM-IV Substance-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

12. DSM-IV Substance-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

13. 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

14. Possible Relationships The psychiatric disorder and the substance use disorder have common risk factors. Example: Personality disorders leading to substance abuse

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

16. 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. Case Study

17. What is the likely substance use disorder? What is the likely psychiatric disorder? Case Study

18. 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 DSM-IV Substance Dependence  3 criteria leading to significant impairment/distress:

19. DSM-IV Major Depressive Episode  5 symptoms for 2 weeks from previous functioning: depressed mood loss of interest/pleasure  appetite  sleep psychomotor agitation fatigue must include 1 of these worthlessness  concentration thoughts of death and represents a change

20. Does this patient require pharmacotherapy? What DRPs would you anticipate in this patient? Case Study

21. 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

22. Drug-Related Problems in a Comorbid Population Drug interactions Medication compliance Abuse/addiction potential of psychotherapeutic agent

23. Drug Interactions Combining prescribed psychotherapeutic drugs with:  Alcohol  Street drugs  Nicotine  OTC psychotropic drugs

24. Weiss RD et.al., Medication compliance among patients with bipolar disorder and substance use disorder. J Clin Psychiatry 1998;59:172-174. n=44, 55% female, age 37  9 years > 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 Compliance

25. Abuse of Psychiatric Medications anticholinergic agents benzodiazepines

26. 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

27. 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

28. 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

29. 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