1. Treating Co-Occurring Disorders Across the Life Span Sheila B. Blume, M.D. Women Across the Life Span: A National Conference on Women, Addiction and Recovery July 12, 2004

2. DEFINITIONS OF “DUAL DIAGNOSIS” 1. SUBSTANCE DISORDER + PHYSICAL ILLNESS 2. ALCOHOL DISORDER + OTHER DRUG DISORDER 3. SUBSTANCE DISORDER + PSYCHIATRIC DISORDER AXIS I ONLY AXIS I AND ASPD AXIS I AND AXIS II

3. ALCOHOLISM AS A SYMPTOM “Alcohol addiction is a symptom rather than a disease… There is always an underlying personality disorder evidenced by obvious maladjustment, neurotic character traits, emotional immaturity, or infantilism.” Source: R.P. Knight, 1937

4. DSM I-1952 ALCOHOL ADDICTION COULD NOT BE DIAGNOSED IF AN “UNDERLYING DIAGNOSIS” IS PRESENT

5. POSSIBLE RELATIONSHIPS IN DUAL DIAGNOSIS 1.Addiction----------> Mental Illness 2.Mental Illness ----------> Addiction 3.------> Mental Illness (separate causes) ------> Addiction 4.------> Mental Illness (common cause) ------> Addiction 5. Switch of Addictions

6. DUAL DIAGNOSIS: DUAL DIAGNOSIS: COMPLEX INTERRELATIONSHIPS 1. 1. Substance use may help to alleviate symptoms of the psychiatric disorder 2. 2. Substance use may help to alleviate side effects of therapeutic medications 3. 3. Substance use may precipitate psychiatric illness or lead to biological changes that increase risk of mental disorder 4. 4. All of the above take place

7. LONGITUDINAL STUDY, 2002 N= 736, 50% Female, mostly Caucasian, upstate NY Followed from age 5 to late 20s, rated 5 times   Early SUDs predicted: SUDs   Early MDD predicted: MDD, Alcohol Dep   Early freq of TOBACCO use predicted: Alc Dep, SUDs   Early heavier ALC use predicted: MDD, Alc Dep, SUDs   Early MARUJUANA use predicted: MDD, Alc Dep, SUDs   Early Illicit DRUG use predicted: MDD, Alc Dep, SUDs   BOYS > GIRLS: SUDs only   Income, parent education: + Alc Dep, - MDD Source: Brook et al. Arch Gen Psych 59:1039-1044, 2002

8. Early Substance Abuse Increases Likelihood of Developing Psychiatric Disorders in Late Twenties Increased Likelihood of Psychiatric Disorders in Late Twenties Substances Abused in Childhood, Adolescence, and/or Early Twenties Longitudinal study participants who abused tobacco, alcohol, marijuana, and other illicit substances in earlier years were more likely to have diagnoses of major depressive disorder (MDD), alcohol dependence, or substance use disorders (SUDs) in their late 20s.

9. DUAL DIAGNOSIS THROUGHOUT THE LIFESPAN ADOLESCENCE: ADHD  Anxiety disorders Conduct disorders  Eating disorders Depression  Gambling disorders PTSD ADULTHOOD: All of the above Psychoses (schizophrenia, organic, postpartum, etc.) ASPD Personality disorders (incl. Borderline PD) GERIATRIC: All of the above Chronic organic syndromes of later life

10. Lifetime prevalence of comorbid mental and addictive disorders in the United States, combined community and institutional five-site Epidemiologic Catchrnent Area data, standardized to the U.S. Population Comorbidity, 72% Lifetime Prevalence of Cormorbid Mental and Addictive Disorders in the U.S.

11. 12-MONTH CO-OCCURRENCE OF ADDICTIVE AND MENTAL DISORDERS AGES 15-54 If Psychiatric Dx. Any Addiction Also Addiction Major Depression23%18% Dysthymia 2%19% Mania 2%37% Any Affective25%18% General Anxiety Disorder 8%21% Panic Disorder 5%18% PTSD 8%18% Social Phobia17%17% Simple Phobia15%14% Agoraphobia 8%18% Any Anxiety36%15% Any Mental Disorder43%15 % Source: Kessler et al, National Comorbidity Study, American Journal of Orthopsychiatry 66:17-31, 1996

12. CO-OCCURRING DISORDERS, U.S. NHSDA Survey (2001, gen. population, ages 12 and older) Alcohol/other drug, abuse/dependence: 16.6 million Alcohol only: 11 million Other drug (s) only: 3.2 million Both alcohol and drug: 2.4 million NCS Data (1990s, ages 15-54)  42.7% with 12-month addictive disorder had at least one 12-month mental disorder  14.7% with a 12-month mental disorder had at least one 12-month addictive disorder.

13. CO-OCCURRING DISORDERS, Cont. ECA Data (1980s, 18 and older)  47% with schizophrenia also had a substance use disorder (more than 4 times as likely as the general population).  61% with bi-polar disorder also had a substance use disorder (more than 5 times as likely as the general population). Source: SAMHSA Report to Congress on Co-occurring Disorders, 2001

14. CO-OCCURRING DISORDERS: CO-OCCURRING DISORDERS: GENDER DIFFERENCES NCS Data (1990s, ages 15-54) % with lifetime addictive disorder who had at least one mental disorder: Males:57% Males:57% Females:72% Females:72% ECA data (1980s, 18 and older) % with lifetime addictive disorder who had at least one mental disorder: Males:44% Males:44% Females:65% Females:65%

15. PERSONALITY DISORDERS AND SUBSTANCE USE DISORDERS: NESARC 2000-2001 12–month prevalenceIf A/D, PD If PD, A/D Any Alcohol Dis.8.5% 28.6% 16.4% Alcohol Abuse 4.7% 20.0% 6.2% Alcohol Dep.3.8% 40.0% 10.2% Any Drug Dis. 2.0% 47.7% 6.5% Drug Abuse 1.4% 38.0% 3.5% Drug Dep. 0.6% 70.0% 2.9% Any Personality Dis. 14.8% Obs-comp 7.9% Paranoid 4.4% ASPD 3.6% Source: Grant BF et al. Arch General Psych 61:361-368, 2004

16. UNDERSTANDING RATES OF COMORBIDITY To understand the meanings of statistics in this area and compare the findings of various studies consider the following: Note that lifetime prevalence differs from 6- or 12–month prevalence and lifetime risk Note that lifetime prevalence differs from 6- or 12–month prevalence and lifetime risk Note the age range included in the study (e.g. the ECA study differs from the NCS) Note the age range included in the study (e.g. the ECA study differs from the NCS) Note the range of diagnoses included in the study: Note the range of diagnoses included in the study: Selected Axis I (mood and anxiety disorders) Selected Axis I (mood and anxiety disorders) Axis I, plus ASPD only from Axis II Axis I, plus ASPD only from Axis II Axis I and Axis II Axis I and Axis II Does it include eating disorders? Pathological gambling? Does it include eating disorders? Pathological gambling?

17. Lifetime Prevalence of Key Diagnoses: Comparison of Individuals with Alcohol Abuse or Dependence to Total ECA population (5-site ECA data, weighted to U.S. population, in percent) TOTALThose with Alcohol Population Abuse and/or Dependence DiagnosisMenWomen MenWomen Drug abuse and/or 7 51931 dependence Antisocial personality 4 0.811510 Phobic Disorder 9 161331 Major Depression 3 7 519 Panic Disorder 1 2 2 7 Somatization 0.02 0.2 0.070.87 Mania 0.3 0.4 1 4 _________________________________________________________ Source: Helzer, Journal of Studies on Alcohol, vol. 49, pp. 219-24, 1988

18. Lifetime and Current Prevalence of Psychopathology Among Hospitalized Alcoholics* _______________________________________________________________________________________ MenWomenTotal (N=231),%(N=90),% (N=321),% ____________________________________________________________________________ No additional psychopathology 252023 Antisocial personality**492041 Substance Abuse45(8)***38(13)43(9) Depression32(18)52(38)38(23) Obsessive-compulsive disorder12(4)13(7)12(5) Panic disorder8(5)14(9)10(6) Mania5(2)3(1)4(2) Somatization1(1)2(2)1(1) Schizophrenia2(2)3(1)2(2) ___________________________________________________________________________________________________________________________ *Diagnoses are without exclusion criteria **Diagnosis of antisocial personality was modified to exclude two items that are related to abuse ***Percentages in parentheses indicate current diagnosis Source: Hesselbrock, Archives of General Psychiatry, vol. 42, pp. 1060-66, 1986

19. PSYCHIATRIC COMORBIDITY IN OPIATE DEPENDENTS ( N=716) Lifetime Prevalence %One Month Prevalence % Lifetime Prevalence %One Month Prevalence % DiagnosisMaleFemale MaleFemale Any Axis I15.833.4 5.011.2 Affective Disorder:11.427.5 2.1 5.3 Major Dep. 8.723.7 1.3 5.3 Major Dep. 8.723.7 1.3 5.3 Dysthymia 2.4 4.4 Dysthymia 2.4 4.4 Bipolar 0.8 0.0 0.8 0.0 Bipolar 0.8 0.0 0.8 0.0 Anxiety Disorder: 6.110.7 3.4 6.8 Panic Disorder 2.1 1.8 0.3 0.9 Panic Disorder 2.1 1.8 0.3 0.9 GAD 0.3 0.0 0.3 0.0 GAD 0.3 0.0 0.3 0.0 OCD 0.5 0.0 0.5 0.0 OCD 0.5 0.0 0.5 0.0 Simple Phobia 1.9 5.3 1.9 3.6 Simple Phobia 1.9 5.3 1.9 3.6 Social Phobia 1.9 3.6 0.8 2.7 Social Phobia 1.9 3.6 0.8 2.7 Agoraphobia 0.0 0.6 0.0 0.3 Agoraphobia 0.0 0.6 0.0 0.3 Eating Disorder 0.0 1.5 0.0 0.0 Schizophrenia 0.0 0.3 0.0 0.3 Source: Brooner et al, Archive of General Psychiatry 54:71-80, 1997

20. PRIMARY DISORDER - earlier onset - onset during prolonged remission (3 to 6 months) SECONDARY DISORDER - later onset - relapse following primary disorder during prolonged remission Disorders: Primary and Secondary

21. WHICH CAME FIRST? WHICH CAME FIRST? (Major Depression/Alcoholism) AlcoholismDepression Primary Primary Primary Primary PopulationMenWomenMen Women Research volunteers62% 40%38%60% Inpatients59% 35%41%65% General population78% 34%22%66% Sources:ECA Helzer & Pryzbeck, 1985 Hesselbrock, 1985 Roy, 1991

22. Meta-analysis of Eight Longitudinal Studies (U.S., Canada, Scotland) 2-10 Years For MEN and WOMEN: DepressionPredictsDepression Alcohol IntakePredictsAlcohol Intake For MEN: Alcohol IntakePredictsDepression For WOMEN: Alcohol IntakePredictsDepression (stronger effect) over short intervals DepressionPredictsAlcohol Intake over long intervals Source: Hartka et al, 1989 (submitted to British Journal of Addiction)

23. PRIMARY VERSUS SECONDARY DEPRESSION IN ADDICTIVE ADOLESCENTS BoysGirls N=26N=25 Alcohol/Drug Primary60%28% Depression Primary30%40% Same Time10%32% Source: Deykin et al, American Journal of Psychiatry 149:1341-1347, 1992

24. WHICH CAME FIRST? NATIONAL COMORBIDITY STUDY AGES 15-54 WOMEN MEN Add 1 st Ment 1 st Add 1 st Ment 1 st Add 1 st Ment 1 st Add 1 st Ment 1 st Any Affective 31% 59% 50% 40% Any Anxiety 13%85% 20% 74% Antisocial 6%40%7% 89% Any Mental 11%85% 14% 82% Source: Kessler et al, National Comorbidity Study, American Journal of Orthopsychiatry 66:17-31, 1996

25. PRIMARY PSYCHIATRIC DIAGNOSIS IN COCAINE AND ALCOHOL DEPENDENT PATIENTS Total with Co-occurring Disorders (including ASPD): Men:56% Women:68% Primary Diagnosis: Men (50) Women (50) Men (50) Women (50) Total Primary Total Primary Total Primary Total Primary Major Depression 18 4 20 10 Bipolar 3 1 5 2 Panic Disorder 5 1 9 8 Social Phobia 7 7 5 5 PTSD 11 8 23 18 Source: NIDA Notes Vol 12 No.4, 1997, work of Kathleen Brady MD and colleagues at Med University of South Carolina.

26. COGA SAMPLE All Alcoholic1° AlcoholNo Psych Women Dependent WomenDiagnosis Women Dependent WomenDiagnosis ANOREXIA1.4%1.26%0.34% BULIMIA6.2%3.46%0.6% - Eating Disorders Correlate With ASPD - Eating Disorders Correlate With Major Depression Women WomenWomen Women WomenWomen Amphet/CocaineCannabisOpiate ANOREXIA2.3%2.0%2.5% BULIMIA8.2%8.4%7.5% Source: Schuckit, 1997, Addiction 92(10)

27. PATHOLOGICAL GAMBLING IN CHEMICALLY DEPENDENT ADULTS SOUTH OAKS HOSPITAL LIFETIME N = 458 ADULTS Problems 10% Path Gamb 9% Total 19% N=100 ADOLESCENTS Problems 14% Path Gamb 14% Total 28% YALE ADDICTION CLINIC N=198 COCAINE DEPEND CURRENT PATH GAMB Males 19.0% Females 5.5%

28. 309.81 POST TRAUMATIC STRESS DISORDER A. Traumatic Events (intense event, response) B. Event Re-experienced (1 or more) (1) recurrent memories/intrusive thoughts (1) recurrent memories/intrusive thoughts (2) recurrent dreams (2) recurrent dreams (3) acting or feeling as if recurring (3) acting or feeling as if recurring (including during intoxication) (including during intoxication) (4) distress at related cues (4) distress at related cues (5) physiological reaction to related cues (5) physiological reaction to related cues

29. 309.81 POST TRAUMATIC STRESS DISORDER C. Persistent Avoidance/Numbering (3 or more) (1) thoughts (1) thoughts (2) activities (2) activities (3) memory gaps (3) memory gaps (4) diminished interest in activities (4) diminished interest in activities (5) restricted affects (5) restricted affects (6) sense of shortened future (6) sense of shortened future

30. D. Persistent Increased Arousal (2 or more) (1) sleep (2) anger (3) concentration (4) hypervigilance (5) startle E. More then 1 Month, Significant Distress, Impairment 309.81 POST TRAUMATIC STRESS DISORDER

31. REVIEW OF PTSD AND SUBSTANCE USE DISORDERS – Higher rates of exposure to trauma in women/men – Higher rates of exposure in chemically dependent women/general pop. (30-60% vs. 10%) – Higher rates of PTSD in women/men (general) – Higher rates of PTSD in chemically dependent women/chemically dependent men – Higher rates of chemical dependency in PTSD 40-50% – Higher rates of PTSD in cocaine, opiates than marijuana, alcohol Source: Najavits, 1997, American Journal Addictions, 6(4):273-281

32. PTSD IN ADOLESCENTS WITH SUBSTANCE USE DISORDERS – Dual diagnosis more prevalent/adults – Dual diagnosis more prevalent girls/boys PTSDBOYSGIRLSTOTAL Lifetime24.3%45.3%29.6% 4 weeks 12.2%40.0%19.2% PTSD 1º 28%59% (N= 222 boys; 75 girls) Source: Deykin & Buka, 1997, A.J. Psych 154:752-757

33. DIFFERENTIAL DIAGNOSIS 1. Substance Toxicity – Acute (e.g. hallucinations) – Long term (e.g. organic brain syndrome) 2. Substance Withdrawal (e.g. anxiety) 3. Comorbid Physical Disorder (e.g. ammonia delirium) 4. Comorbid Psychiatric Disorder – primary – secondary

34. DIAGNOSIS: SUBSTANCE-INDUCED MOOD OR ANXIETY DISORDER Use these diagnoses when the prominent mood or anxiety symptoms: have their onset during or just after intoxication or withdrawal are in excess of those usually seen require independent clinical attention are most likely due to the substance e.g. Alcohol-induced Mood disorder with depressive features, onset during intoxication

37. TREATMENT SETTINGS  Inpatient Secure  Inpatient Open  Partial Hospital  Halfway House; Residence  Outpatient (including methadone)  Ancillary – social, vocational  Self-help – in all settings

38. NON-PHARMACOLOGICAL TREATMENT  Psychotherapies  Behavior Therapies  Relaxation Training  Psychoeducation

39. PRINCIPLES OF MEDICATIONS TREATMENT 1. Addiction Potential – benzodiazepines – sedatives/hypnotics – opiates – Stimulants 2. Danger of Interaction with Alcohol – MAOI – Sedating antidepressants

42. BENZODIAZEPINE USE: REAL WORLD 1) V.A. 129 M. H. Clin: 128,029 OPs Tx for Depr: 1 yr. 36% filled Rx for BZ (30% of those with SUDs) 78% 90 day supply or over (82% of 65+) 61% 180 day supply or over 2) New Hampshire Medicaid: 9,884 pts; 18-64 y/o; 5 yrs. BZ in + SUD BZ in - SUD MDD66%*49% Bipolar75%58% Schizophrenia63%54% Other psych disord. 48%*40% * more fast acting/high potency BZs Sources: Valenstein et al Am Jour Psych 161:654-661, 2004 Clark et al Jour Clin Psych 65:151-155, 2004

43. BZ USE/ABUSE IN DUAL DIAGNOSIS PATIENTS · 6 year longitudinal study: · N = 203 patients (74% male) Outpatients · Severe Mental Disorder (Schz/Schzaffective 75%; Bipolar 25%) · in State C.M.H. System · All had Substance Use Disorder PATIENTS WITH BZ PRESCRIPTION: 43% of patients had prescription for BZ during study period Higher symptom scores Lower quality of life scores 15% developed BZ abuse (vs. 6% of patients without BZ Rx) Source: Brunette, MF et al. Psych Services 54:1395-1401, 2003

44. ARE PEOPLE RECEIVING HELP? 2002 (SAMHSA REPORT, 2004) 1) 8% of adult population (or 18 million) have SMI* 2) Of those with SMI23% SUD 3) Of non-SMI 8% SUD 4) Of the 4 million Dually Diagnosed persons, for the last year: 52% No treatment 34% MH treatment only 2% SUD treatment only 12% Both MH and SUD Ttreatment 5) More women (49%) MH Treatment > men(26%) 6) More Treatment age 26-49, Metrop (MH,SUD) *SMI = Serious mental illness: Past 12 mo. DSM-IV Diagnosis + functional impairment Source: SAMHSA Report 6/23/04: Adults with Co-Occurring SMI and SUD. (available on-line)

45. CONCLUSIONS: CONCLUSIONS: 1. 1. Co-occurring disorders are common in the general population, and even more so in clinical populations in SUD treatment 2. 2. They are more common in women than men (men have more ASPD and pathological gambling) 3. 3. They differ in prevalence through the lifespan 4. 4. To understand statistics, look for: -- Age range of population studied -- Diagnoses included (Axis I only? Does Axis I include Pathological Gambling, Bulimia? Axis I plus ASPD? Axis II? other SUDs?)

46. CONCLUSIONS: 5. 5. There are complex relationships between comorbid diagnoses 6. 6. Each patient should be evaluated for co-occurring physical, psychiatric and other substance diagnoses 7. 7. Use diagnosis of Substance-induced mood or anxiety disorder when onset is during intoxication or withdrawal 8. 8. The distinction between primary versus secondary diagnosis can be useful; a time line can help distinguish these 9. 9. Primary diagnoses are more likely to need independent treatment and vigorous follow-up, although both may need this

47. CONCLUSIONS (cont.): 10. 10. Consider non-pharmacological treatments as well as medications for comorbid disorders 11. 11. Choose medications that do not have abuse potential whenever possible 12. 12. Alert/remind/train patient and family to be aware of early signs of possible recurrence of psychiatric disorder 13. 13. Outcome best if both disorders are diagnosed and treated simultaneously in coordinated manner. Communication is a key factor in success.