Brain diseases: Substance abuse and co-occurring disorders

Mark Publicker, MD FASAM

Addiction

• A chronic but treatable brain disease characterized by• Loss of control• Compulsive use• Use despite known harm• Relapse• The emergence of a negative affect state

Questions

Does mental illness cause substance abuse?

Does substance abuse cause mental illness?

Questions

Are there differences in populations Primarily psychiatric Primarily substance dependent

Comorbid substance abuse

Common problem in psychiatric patients

Contributes to treatment failure and non-compliance

Increased health care costs

Neurobiology

Same neurotransmitter systems Dopamine Serotonin GABA Glutamate Endogenous opioids

Neurobiology

Drugs of abuse interact and alter neural substrates of psychiatric disorders

More neuro-psychological impairment

Rand Survey 2001

3% US population has co-occuring disorders

Of these: 72% received no treatment in

previous 12 months Only 8% received both mental and

substance abuse treatment Only 23% of those in treatment

received “appropriate treatment”

Current situation in US treatment systems

Comorbid rates are high Different services are provided

according to entry portal

Co-morbid psychiatric disorders

Depression Anxiety disorders Bipolar disorder Schizophrenia

Co-morbid psychiatric disorders

Attention deficit hyperactivity disorder

Post traumatic stress disorder Antisocial personality disorder

Epidemiology substance abuse disorders

50% lifetime prevalence for psychiatric patients

Among individuals with alcohol use disorders, about 22% will also have a drug use disorder

Among individuals with a drug use disorder, almost half (47%) will have an alcohol use disorder

Schizophrenia: 70%prevalence rates Earlier onset of symptoms

Epidemiology Affective disorders are very common. Up to

67% of alcohol-dependent patients, 53% of cocaine-dependent patients, and 75% of opiate-dependent patients have comorbid affective disorders

Approximately 25-50% of alcohol dependent individuals meet criteria for an anxiety disorder

Approximately 30-60% of patients with an SUD have comorbid Antisocial Personality Disorder

14

15

Order of Onset Mental disorders typically emerge before

comorbid substance use disorders

This pattern is somewhat stronger for women than men

Data from a large epidemiologic study found that the median age of onset of mental disorders was 11 yrs old as compared to 21 yrs old for substance disorder

16

Diagnostic Difficulties

Substance intoxication and withdrawal can mimic nearly any psychiatric disorder

Stimulants/hallucinogens/cannabinoids= mania and schizophreniaAlcohol/opiate/sedative-hypnotic

withdrawal= depressive and anxiety disorder

Diagnostic Difficulties Assess which disorder developed first

Ask about symptoms during periods of abstinence. Minimum acceptable period of abstinence necessary for diagnostic clarity will differ by diagnosis:

Anxiety/depression: most symptom overlap, 2-4 weeks important.

Psychosis/mania 2-4 days sufficient in most cases.Ask about family history

Consult multiple sources of information

Substance Use and SuicideSubstance Use and Suicide

Substance induced depressionSubstance induced depression May resolve quickly with treatment but is May resolve quickly with treatment but is

still very dangerousstill very dangerous Increased suicidal thoughts, ideationIncreased suicidal thoughts, ideation

High risk group: Diagnosis of major High risk group: Diagnosis of major depression + alcohol or drug depression + alcohol or drug abuse/dependenceabuse/dependence

Rates are 20-120X the general Rates are 20-120X the general populationpopulation

Epidemiology Schizophrenia: substance abuse

associated with higher rates of homelessness, non-compliance, medical illness and violence

Bipolar disorder: rates estimated to be 50-70% Associated with worse prognosis

Epidemiology

Unipolar depression: 30-50% Associated with treatment resistance and

greater severity Worsens alcohol dependence treatment

outcomes

Epidemiology

ADHD: 50% of substance abuse patients Increases risk of substance abuse Effective childhood treatment reduces

risk

Epidemiology PTSD: increased risk of substance abuse

Hypothalamic and noradrenergic mechanisms

Substance abuse increases PTSD symptoms which in turn intensify substance abuse

Post traumatic stress disorder Withdrawal symptoms overlap with arousal

symptoms Increased stress sensitizes the Locus Ceruleus

Post traumatic stress disorder

Increased noradrenaline increases stress

Increased fear responses in amygdala

Epidemiology - Nicotine Nicotine-dependent patients with

comorbid disorders: 7.1% US population consume 34.2% of all cigarettes smoked

Self-medication hypothesis

Nicotine decreases stress reactivity Schizophrenia: nicotine used to deal

with negative symptoms: Sleepiness Dysphoria Antipsychotic adverse effects Improve cognitive function

Cannabis

Heavy adolescent use increases psychiatric risk Depression Anxiety disorders Schizophrenia

Summary High rates of comorbidity Each increases the risk of the other and

complicates their management Concurrent treatment yields best results