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John Tsuang, M.D., M.S. Associate Clinical Professor Department of Psychiatry,

John Tsuang, M.D., M.S. Associate Clinical Professor Department of Psychiatry, University of California Los Angeles Director of Dual Diagnostic Treatment Program Harbor - UCLA Medical Center Johntsuang@yahoo.com. Outline. Prevalence Psychiatric symptoms and abstinence

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John Tsuang, M.D., M.S. Associate Clinical Professor Department of Psychiatry,

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  1. John Tsuang, M.D., M.S. Associate Clinical Professor Department of Psychiatry, University of California Los Angeles Director of Dual Diagnostic Treatment Program Harbor - UCLA Medical Center Johntsuang@yahoo.com

  2. Outline Prevalence Psychiatric symptoms and abstinence Diagnosis of dual diagnosis patients Pharmacological Treatment

  3. Prevalence of dual diagnosis patients

  4. Prevalence of Dual Diagnosis Epidemiological Catchment Area (ECA) Study N= 20291 • lifetime prevalence rates for alcohol, drug, and mental disorders 32.7% • lifetime prevalence rates for any non-substance abuse mental disorders 22.5% • Alcohol disorders 13.5% • Other drug disorders 6.1% *Regier, AJ Psych 1990

  5. Mental Disorder Patients: • Life prevalence of additive disorders 29% (OR = 2.7) • Alcohol disorders 22% (OR = 2.3) • Other drug disorders 15% (OR = 4.5) • 45%-70% abuse alcohol or drugs

  6. Affective Disorders (8.3%) Substance Abuse Disorders 32% (OR =2.6) Alcohol 22% Drug 19%

  7. Subtypes of Affective Disorders Bipolar I Disorder Substance Abuse Disorders 61% (OR = 7.9) Alcohol 46% Drug 40% Unipolar major depression Substance Abuse Disorders 27% (OR = 1.7) Alcohol 16% Drug 18%

  8. Anxiety Disorder (14.6%) Substance Abuse Disorders 23.7% (OR = 1.7) Alcohol 18% Drug 12%

  9. Subtypes of Anxiety Disorders Panic Disorder (10.6%) Substance Abuse Disorders 35.8% (OR = 2.9) Obsessive-Compulsive Disorder(2.5%) Substance Abuse Disorders 32.8% (OR = 2.5) Phobia (12.6%) Substance Abuse Disorders 22.9% (OR = 1.6)

  10. Schizophrenia Spectrum Disorders (1.5%) Substance Abuse Disorders 47% (OR = 4.6) Alcohol 33.7% Drug 27.5%

  11. Antisocial Personality Disorder (2.6%) - Substance Abuse Disorders 83.6% Alcohol 74% Drug 42%

  12. Borderline Personality Disorder (0.2%-1.8%) • Second only to mood disorders, ASPD • 25-67% of BPD receiving treatment have substance use disorders • 57% when not used substance abuse as a criteria • Miller, 1994, Dulit, 1990, Dimeff, Principles of Addiction Medicine, 3rd Ed, Chase, 2003

  13. Alcohol Disorders (%Mental Disorders= 36.6%) OR Anxiety Disorder 19% 1.0 ASPD 14% 21.0 Affective Disorders 13% 1.9 Schizophrenia 4% 3.3

  14. Drug Disorders (% mental disorders= 53%) OR Anxiety Disorders 28% 2.5 Affective Disorders 26% 4.7 ASPD 18% 13.4 Schizophrenia 7% 6.2

  15. Relationship between Psychiatric Symptoms and Abstinence

  16. Remission of Depressive Symptoms with Abstinence 40% 30% % Patients with Moderate Depression N=177, no pre-existing mood syndrome 20% 10% 0% 1 2 3 4 16 Abstinence Weeks Brown S, Schuckit M. J Stud Alcohol. 1988;49:412-417.

  17. Hamilton depression scores during 4 weeks of hospitalization Brown S, Schuckit M. J Stud Alcohol. 1988;49:412-417.

  18. Anxiety scores during 4 weeks of hospitalization Brown S, Irwin, M. Schuckit M. J Stud Alcohol. 1991;52:55-61.

  19. Diagnostic Issues • A PERIOD OF ABSTINENCE (JAIL/ PRISON, HOSPITAL) • SUSTAINED PSYCHIATIRC SYMPTOMS DURING ABSTINENCE (AMOUNT OF TIME REQUIRED??) • ONSET OF PSYCHIATRIC SYMPTOMS VERSUS SUBSTANCE ABUSE PROBLEMS (PRIMARY VS. SECONDARY) • FAMILY HISTORY OF PSYCHITRIC ILLNESSES • CROSS SECTIONAL VERSUS LONGITUDINAL DIAGNOSIS

  20. Psychotic symptoms and abstinence • 165 chronic psychotic patients with cocaine abuse or dependence • 6 weeks of abstinence needed for diagnosis of schizophrenia • 81% could not make a definitive diagnosis • 78% insufficient abstinence, 24% poor memory • After 18 months, 75% still diagnostic uncertain • Shaner, Psych Ser, 1996

  21. Diagnosis of Dual Diagnosis Patients

  22. Heterogeneous Population of Dual Diagnosis Patients • Addiction Only • Mildly-Moderately Severe • Highly Severe • Diagnostic Uncertainty • Mee-Lee, David (2001) ASAM PPC-2R. ASAM • Tsuang, J, Shaner, 1997

  23. Addiction Only Patients • Patients with substance abuse or dependence problems • No axis I and/or II psychiatric diagnosis or mental health issues • Need addiction service only

  24. Mildly to Moderately Severe • Sub threshold diagnosis (traits of Axis I or II psychiatric disorders) • Diagnosis of Axis I or II, stable on treatment • Anxiety or mood disorders- stable • Bipolar mood disorder- resolving • Need primary substance abuse treatment, available psychiatric treatment capability

  25. Highly Severe • Axis I or II psychiatric diagnosis-unstable • Schizophrenia spectrum disorders • Severe mood disorders with psychosis • Severe anxiety disorders • Severe personality disorders • Needs concurrent psychiatric and substance abuse treatment

  26. Diagnosis Uncertainty • Time • Additional information • Newer, effective and safe medications • Treat unclear diagnosis?

  27. IntegratedTreatment Program Treatment approach • Combine mental health/Substance abuse treatment - Outpatient/inpatient • Comprehensiveness • Medication management • Outreach • Social support Drake, Psych Ser 2001, Tsuang, Psych Ser 1999, Ho, AJP 1999

  28. Pharmacological Treatment of Dual Diagnosis Patients

  29. Pharmacological Treatment of Affective Disorders • Tertiary/Secondary Amines (Serotonin/NE)- Amitriptline, Desipramine • Monoamine Oxidase Inhibitors (Serotonin/ NE/Dopamine)- Phenelzine, tranlcypromine • Selective Serotonin Reuptake Inhibitors (Serotonin)- Fluoxetine, Paroxetine, Sertraline, Fluvoxamine, Citalopram (Celexa)

  30. Pharmacological Treatment of Affective Disorders • NE-Dopamine Reuptake Inhibitors - Bupropion • Nontricylic Serotonin-NE Reuptake Inhibitors-Venlafaxine • Serotonin Antagonist& Reuptake Inhibitors- Nefazodone, Trazodone • NE-Serotonin Antagonist-Mirtazapine (Remeron)

  31. Treatment of Depression and Alcohol Addiction • TCSs (Imipramine, desipramine) • SSRIs (fluoxetine, sertraline, nefazodone) • McGrath, 1996, Mason, 1996, Gorelick 1989, Cornelius, 1997, Pettaniti, 2000, Boy-Byrne, 2000)

  32. Treatment of Depression and Opioid Addiction • TCAs (doxepin, amitriptyline, desipramine, imipramine) for methadone patients • Brady, 2003 ASAM

  33. Treatment of Depression and Cocaine Addiction • TCAs (desiprmaine) • NE-Dopamine Reuptake Inhibitors - Bupropion • Nontricylic Serotonin-NE Reuptake Inhibitors-Venlafaxine • Rao, 1995, Weiss, 1989, Kosten, 1989

  34. Lithium Carbonate Valproic acid (Depakote) Chlorpromazine Olanzapine (Zyprexa) Risperidone (Risperidal) Quetiapine (Seroquel) Lamotrigine (Lamictal) Carbamazepine (tegretol) Gabapentin (neurontin) Oxcarbazepine (trileptal) Tiagabine (gabitril) Topirmate (topamax) Tarascon PP 2002 Pharmacological Treatment of Bipolar Patients

  35. Treatments of Substance Abuse and Bipolar Disorder • Lithium • Valproate (Depakote) • Carbamazepine (Tegretol) • Brady, 2003 ASAM, Tohen, 1990, Bowden, 1995, O’Connell, 1991, Brady, 1995

  36. Pharmacological Treatment of Anxiety Disorders • Benzodiazepines- Chlordiazepoxide, Clonazepam, Diazepam, Lorazepam • Anticholingeric/Antihistaminergic- Diphenhydramine, Hydroxyzine • Barbiturates • Others-Buspirone, Chloralhydrate, Zolpidem (Ambien), Zaleplon (Sonata)

  37. Treatment of substance abuse and anxiety disorders • Antidepressants (SSRIs, Trazadone, TCAs) • Anticonvulsants • Antihypertensives • Atypical antipsychotic medications • Buspirone • Bendiazepines (contraindicated) • Nitenson, ASAM 2003

  38. Pharmacological Treatment of Schizophrenia • Dopamine Antagonists Haloperidol, Fluphenazine • Serotonin/Dopamine Receptor Antagonists Clozaril, Risperidone, Olanzapine, Quetiapine, ziprasidone, aripiprazole • Depo

  39. Treatment of Substance Abuse and Psychotic Symptoms • Newer Atypical Agents • Reduce negative symptoms • Reduce cognitive deficits • Reduce severity of detoxification • May improve abstinence • Cravings for substances of abuse • Not a magic bullet!! • Ziedonis, ASAM 2003, Buckley, 1998, Smelson, 1997, Farren, 2000, Tsuang, 2001, Tsuang, 2004

  40. Treatment Recommendations • A period of abstinence is optimal (wait after detoxification) • Duration to wait (??) • If symptoms mild, diagnosis unclear, can wait • If symptoms severe, no remission during abstinence, early treatment justified

  41. Avoid These Agents for Treatment of Substance Dependence • MAOI • Opiates • Barbiturates • Stimulants • Short Acting BZDs • Tricyclics (metabolism, cardiac conduction)

  42. Pharmacological Strategiesfor Treatment ofSubstance Use Disorders • Initiate and Facilitate Abstinence • Treat Withdrawal Symptoms (acute/protracted) • Relapse Prevention • Treat Associated Psychiatric Syndromes • Decrease Craving • Aversive Agents

  43. Current Pharmacological Agents for Treatment of Stimulant Dependence • Dopaminergic Agents (Agonist, partial agonist, antagonist)-Bromocriptine, Levodopa, Amantadine • Serotonergic Agents-Sertraline, Fluoxetine, Desipramine • Others- Carbamazepine, Bupropion, Selogiline, Modafinil (Provigil), Disulfiram

  44. Current Pharmacological Agents for Treatment of Alcohol Dependence • BZD, Anti-Seizure Medications, Anti-Hypertensive Medications for Withdrawal • Disulfiram/Calcium Carbamide • Naltrexone (ReVia) • Acamprosate (Amino Acid Derivative)-Mimics GABAa Receptor/Amino Acid derivative • Ondansetron-SHT3 antagonist

  45. Current Pharmacological Agents for Treatment of Opiate Dependence • Clonidine for Withdrawal • BZDs for Withdrawal • Naltrexone for Withdrawal and Maintenance • Methadone for Maintenance • LAAM for Maintenance • Buprenorphine for Withdrawal and Maintenance

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