1. The Treatment of Patients with Mood Disorders and Substance Use Disorders Roger D. Weiss, MD Chief, Division of Alcohol and Drug Abuse, McLean Hospital Professor of Psychiatry, Harvard Medical School Belmont, MA, USA

2. Likelihood of SUDs in people with psychiatric diagnoses (ECA) Diagnosis Odds ratio n Bipolar disorder6.6 n Schizophrenia4.6 n Panic disorder2.9 n Major depression1.9 n Anxiety disorder1.7

3. SUD in bipolar disorder n Lower medication adherence ■ More ■ Relapses ■ Hospitalizations ■ Homelessness ■ Suicide

4. Substance abuse in patients with psychiatric illness n Enhanced reinforcement n Mood change n Escape n Hopelessness n Poor judgment n Inability to appreciate consequences

5. The Self-Medication Hypothesis n Intolerance of specific emotions n The importance of a “drug of choice” n More useful in describing substance use rather than dependence

6. Diagnosing Psychiatric Disorders in Patients with SUDs  How long should you wait until a patient has been off all drugs and alcohol before you can diagnose any psychiatric disorder?  How much does diagnosis or primary vs. secondary depression matter?

7. Treatment of patients with SUD and mood disorder n Pharmacotherapy n Psychosocial treatment

8. Pharmacotherapy

9. Co-occurring disorder pharmacotherapy n Typically focuses on treatment of the psychiatric disorder, though more recent studies have focused on SUD as well n Choice of medication is typically based on the usual considerations n Side effect profile n Family history of medication response n Likelihood of medication adherence

10. McLean Hospital Study of Gender, Mood, and Recovery from Alcohol Dependence McLean Hospital Study of Gender, Mood, and Recovery from Alcohol Dependence (Greenfield et al., 1998) n Followed 101 patients (60 men, 41 women) hospitalized for alcohol dependence n Monthly assessment visits x 1 year n SCID diagnoses of MDD were made a) regardless of drinking and b) > 3 mos. abstinent

11. Depression and Gender as Predictors of Time to Relapse 1.00 Days Since Study Entry 050100150200250300 0.00 0.25 0.50 0.75 Chance of No Relapse Female, not dep Male, not dep Male, dep Female, dep

12. Relation of Depression and Discharge Antidepressants to Time to First Drink 1.00 Days Since Study Entry ( Greenfield et al., Arch Gen. Psychiatry, 1998 ) 0 50100150200250300 0.00 0.25 0.50 0.75 Chances of Abstinence No dep, discharge antidep Dep, discharge antidep Dep, no discharge antidep No dep, no discharge antidep

13. Medication studies of Medication studies of co-occurring SUDs and mood disorders n All trials have compared medication vs. placebo n No head-to-head studies of 2 active medications

14. Placebo Effect 1. Very strong in substance dependent populations 2. Difficult to distinguish between placebo effect & study participation effect, particularly in disorders involving voluntary behavior such as substance use disorders

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16. Pharmacotherapy of SUD & Depression Pharmacotherapy of SUD & Depression n Most recent controlled studies show improvement in depression n Tricyclics have most robust effect n SSRIs most helpful in late-onset alcoholics, may worsen early-onset alcoholics n Less improvement in substance use (often correlated with mood improvement), but not worsening (ie, not enabling) n Pneumonia model

17. Valproate for Alcohol Dependence & BD n 24-week trial of valproate vs. placebo in 59 pts on lithium n Valproate patients had n Fewer heavy drinking days n Less drinking on heavy drinking days n No differences in manic, depressive sx Salloum et al., 2005

18. Medication adherence in patients with BD & SUD n Patients with BD & SUD were asked about lifetime adherence to various medications n Answers ranged from “never” to “all the time” n We compared “all the time” to other responses Weiss et al., 1998

19. Lifetime adherence

20. Reasons for med non-adherence Lithium ■ Physical effects n=29 ■ Saw no need for meds ■ Wanted to use substances Valproate ■ “Hassle” to take (lab tests) n=13 ■ Forgot ■ Wanted to use Benzodiazepines ■ Took more to get “high” n=21 ■ Impatient, so took more ■ Couldn’t think clearly

21. Reasons for non-adherence (cont’d) Neuroleptics ■ Physical effects (EPS) n=19 ■ Impatient, modify substance use, or get high ■ Saw no need TCAs ■ Impatient, so took more n=10 ■ Saw no need ■ Meds not working, so took less SSRIs ■ Wanted to use n=17 ■ Felt manic ■ Meds not working, so took less

22. Psychosocial Treatment

23. Models of dual diagnosis treatment  Sequential n Parallel n Integrated

24. Models of integrated treatment  Depends on the disorders & their relationship  “Integrated” treatment means different things to different people

25. Integrated Group Therapy (IGT): Core principles n Cognitive-behavioral model focuses on parallels between the disorders in recovery/relapse thoughts and behaviors n Interaction between the disorders n The single disorder paradigm: “bipolar substance abuse” n The central recovery rule

26. IGT structure n Check-in: substance use, mood, med adherence n Review last week’s group n Skill practice n Didactic/handout on integrated topic (e.g., dealing with depression without using alcohol and drugs) n Discussion

27. What is “integrated” about Integrated Group Therapy ? n Check-in focuses on mood, substance use, and medication adherence n Topics relevant to both disorders n Patients seen as having a single disorder: “bipolar substance abuse” n Relationship & similarities between the disorders & the recovery process stressed

28. Integrated Group Therapy: Sample topics n n Dealing with depression without using alcohol or drugs n Denial, ambivalence, acceptance n Taking medication n Self-help groups (for both SUD & BD) n Identifying and fighting triggers n Getting a good night’s sleep

29. The Central Recovery Rule No matter what n Don’t drink n Don’t use drugs n Take your medication as prescribed No matter what!

30. Findings of IGT research n 3 studies funded by National Institute on Drug Abuse n Compared IGT initially to either treatment as usual or standard manualized Group Drug Counseling (GDC) n All 3 studies showed significantly greater likelihood of abstinence in IGT patients n Fewer differences in mood outcomes

31. “Community-Friendly” Version of IGT vs. Group Drug Counseling

32. Making IGT more “community-friendly” n n IGT had had 2 successful studies, with 20 sessions led by therapists who had CBT and BD knowledge n n However, many community treatment programs don’t have counselors with experience in either CBT or BD, and can’t be paid for 20-session treatments n n These factors could reduce adoption of IGT in community treatment programs

33. Study of “Community-Friendly” version of IGT n n Made IGT more “community-friendly”   12 sessions, instead of 20   Groups were run by front-line drug counselors without formal CBT training or explicit BD knowledge n n Compared IGT to GDC Weiss et al., Drug and Alcohol Dependence, 2009

34. Patients n n 61 patients: 31 IGT & 30 GDC n n Current BD & substance dependence n n Substance use in the past 60 days n n A mood stabilizer regimen for ≥ 2 weeks

35. Results: Mood (p<.10)

36. Time to first abstinent month by treatment (p<.04) Month Abstinent (%) Baseline GDC IGT

37. Abstinence: IGT vs. GDC n ≥1 month abstinent: 71% vs. 40 %, p<.02 n Abstinent throughout treatment (3 mos.): 36% vs. 13%, p<.05

38. “Good clinical outcome” by treatment condition: Abstinent & no mood episodes in last month IGT GDC

39. Conducting an IGT Group

40. Structure of a 60-min. IGT session n Check-in/introductions (15’) n Review of last week’s group (5’) n Review of last week’s skill practice (5’) n Discuss session topic (20’) n Review session hand-out and wrap up (10’) n Hand out and discuss skill practice for next week (5’)

41. Conducting the check-in n Have you used drugs or alcohol during the past week? If so, on how many days? n How was your overall mood during the past week? n Did you take all of your medications as prescribed during the past week? If no, why not? n Did you face any high-risk situations or triggers in the past week? If yes, how did you deal with them?

42. Conducting the check-in (2) n Asking about how many days of use is important n Allows for assessment of improvement vs. worsening

43. Conducting the check-in (3) n The check-in establishes the tone of the group n It illustrates the “integrated” nature of IGT n Listen for the relevance of check-ins to the session topic n Come back to check-ins to illustrate session topic themes

44. Key principles of IGT n Parallels between the two disorders in the recovery and relapse processes n Interactions between the two disorders n The single disorder paradigm: “bipolar substance abuse” n The central recovery rule

45. Parallels in the recovery and relapse processes n The abstinence violation effect vs. stopping medication when depressed

46. Parallels in the recovery and relapse processes n Recovery vs. relapse thoughts and behaviors n “May as well thinking” vs. “It matters what you do” n Medication non-adherence vs. staying in bed all day vs. skipping AA

47. Combating hopelessness: “It matters what you do” Early sign of relapse to depression: not returning phone calls Early sign of relapse to depression: not returning phone calls One more call vs. one less call to make One more call vs. one less call to make Making concrete suggestions for taking one step at a time toward recovery Making concrete suggestions for taking one step at a time toward recovery You’re always on the road to getting better or getting worse; therefore, it matters what you do You’re always on the road to getting better or getting worse; therefore, it matters what you do

48. Interactions between the two disorders n Why use the term “bipolar substance abuse?” n “Drinking is bad for your mood” n “Playing around with your medication is bad for your addiction”

49. General guidelines for conducting IGT n Go back and forth between mood issues and substance use issues n Think about parallels: if a patient is talking about drinking, think about mood issues, and vice versa n Try to gently call on everyone, including people who are lost in their own thoughts n Be upbeat

50. General guidelines for conducting IGT (cont) n Focus on both successes and failures (“What did you do on the 4 days that you were sober that you didn’t do on the 3 days that you drank?)”

51. Therapist characteristics for IGT n Familiarity with SUD, BD ideal n Can be successfully run by front-line substance abuse counselors n Some knowledge of relapse prevention or CBT is very helpful n Empathic n Warm, friendly, non-confrontational

52. Who should be in an IGT group? n Willingness to enter a group that addresses both problems n Not acutely manic n Not intoxicated n IGT is designed to be delivered with pharmacotherapy as well; other psychosocial treatment is also encouraged

53. Adapting IGT to other settings n Change the length of the sessions n Add items to the check-in (e.g., exercise, self-help meeting attendance) n Add a preparation group n Broaden the population n Recite the central recovery rule at the end of the group n Use IGT principles in individual Rx

54. Current status of IGT n n Has been adapted for patients with psychotic illness as well n n In use in multiple clinical settings at McLean Hospital n n Currently in use in multiple clinical and research settings in U.S., Canada n n Book published in 2011 by Guilford Press

55. Now available!