Psychiatric Disorders and Psychiatric Disorders and Psychotherapy of Substance Psychotherapy of Substance

AbuseAbuse

Robert M. Weinrieb, M.DRobert M. Weinrieb, M.D

Department of PsychiatryDepartment of Psychiatry

University of PennsylvaniaUniversity of Pennsylvania

Attitudes Toward the Treatment of AddictsAttitudes Toward the Treatment of Addicts

At completion of residency, more At completion of residency, more physicians have negative attitudes physicians have negative attitudes toward SUD pts and are less toward SUD pts and are less optimistic about benefits of treatment optimistic about benefits of treatment than at the start of med schoolthan at the start of med school

--Geller, et al, 1989--Geller, et al, 1989

So, Why is That ?So, Why is That ?

1.1. Historically, substance abuse Historically, substance abuse disorders (SUDs) were treated disorders (SUDs) were treated independently of medical community independently of medical community by paraprofessionalsby paraprofessionals

2.2. Mental health services also rejected Mental health services also rejected pts with SUDs pts with SUDs

3.3. House staff see recidivist patients House staff see recidivist patients with multiple complex problems and with multiple complex problems and are not trained to deal with themare not trained to deal with them

““Attitude Adjustment”Attitude Adjustment”

1.1. An adequate knowledge baseAn adequate knowledge base

2.2. A positive attitude toward the patient A positive attitude toward the patient and the benefits of treatment and the benefits of treatment

3.3. A sense of responsibility for the A sense of responsibility for the clinical problemclinical problem

- J. A. Renner, Jr. Biol Psychiatry, - J. A. Renner, Jr. Biol Psychiatry, 20042004

Topics to be DiscussedTopics to be Discussed

1. Dual Diagnosis1. Dual Diagnosis

• Definition, epidemiology, a caseDefinition, epidemiology, a case

• Effects on medical care outcomesEffects on medical care outcomes

2. Psychotherapy of Addiction 2. Psychotherapy of Addiction

• Theory, examples, outcomesTheory, examples, outcomes

Definition of Dual DiagnosisDefinition of Dual Diagnosis

• Dual Diagnosis is defined by having a Dual Diagnosis is defined by having a major psychiatric diagnosis comorbid major psychiatric diagnosis comorbid with a Substance Use Disorder (SUD)with a Substance Use Disorder (SUD)

• Psychiatric symptoms are common in the Psychiatric symptoms are common in the context of substance abuse context of substance abuse

• 2/3 individuals with SUD have another 2/3 individuals with SUD have another psychiatric syndrome (Axis I) psychiatric syndrome (Axis I)

Dual Diagnosis CaveatsDual Diagnosis Caveats

• Many of these psychiatric syndromes Many of these psychiatric syndromes are temporary are temporary

Psychiatric Symptoms Due to Psychiatric Symptoms Due to AcuteAcute Effects of Drugs, ETOH Effects of Drugs, ETOH

• Stimulants Stimulants (cocaine, amphetamines)(cocaine, amphetamines)

Anxiety (panic, PTSD) mania, paranoia, Anxiety (panic, PTSD) mania, paranoia, hallucinations, delusionshallucinations, delusions

• Sedative/hypnoticsSedative/hypnotics (Etoh, benzos, (Etoh, benzos, opiates)opiates)

DepressionDepression

Psychiatric Symptoms Due to Psychiatric Symptoms Due to Withdrawal Withdrawal from Drugs, ETOHfrom Drugs, ETOH

• Stimulants Stimulants (cocaine, amphetamines)(cocaine, amphetamines)

Depression Depression

• Sedative/hypnoticsSedative/hypnotics (Etoh, benzos, (Etoh, benzos, opiates)opiates)

Anxiety, panic, depression, hallucinosisAnxiety, panic, depression, hallucinosis

Source: Brown S, Schuckit M. (1988) J Stud Alcohol;49:412-417.

Hamilton Depression Score Hamilton Depression Score >> 20* 20*

Weeks Abstinent

40%

16

20%

30%

10%

0%1 2 43

* For Alcohol

Source: Brown S, Schuckit M. J Stud Alcohol. 1990;51:34-41.

Anxiety In 171 Primary AlcoholicsAnxiety In 171 Primary Alcoholics

SymptomSymptom

• Withdrawal palpitations and/or Withdrawal palpitations and/or shortness of breathshortness of breath 80%80%

• Panic while drinkingPanic while drinking 4% 4%

• Panic while soberPanic while sober 2%2%

• Generalized anxiety while soberGeneralized anxiety while sober 4% 4%

Psychiatric Symptoms: Psychiatric Symptoms: Primary vs. Secondary Primary vs. Secondary

• PrimaryPrimary or “Self-Medication or “Self-Medication Hypotheses”Hypotheses”

Independent psychiatric disorder precedes Independent psychiatric disorder precedes SUDSUD

• Secondary Secondary or “The Disease Concept”or “The Disease Concept”

Substance induced psychiatric symptomsSubstance induced psychiatric symptoms

• Both are true,Both are true, but secondary symptoms but secondary symptoms are more commonly trueare more commonly true

Epidemiology of Dual Diagnosis Disorders Epidemiology of Dual Diagnosis Disorders

• Epidemiologic Catchment Area Study Epidemiologic Catchment Area Study (ECA)(ECA)

• People who present for treatment for a People who present for treatment for a SUD are ~3 X more likely to have a SUD are ~3 X more likely to have a second psychiatric disorder vs. those second psychiatric disorder vs. those without SUDwithout SUD

• Most comorbidity (dual diagnosis) is Most comorbidity (dual diagnosis) is accounted for by Antisocial Personality accounted for by Antisocial Personality Disorder (Axis II) and another SUDDisorder (Axis II) and another SUD

How to Make a Diagnosis When 2+ How to Make a Diagnosis When 2+ Disorders Are ObservedDisorders Are Observed

1.1. Take a good history Take a good history

2.2. Be able to differentiate among acute and Be able to differentiate among acute and withdrawal symptoms of alcohol and drugswithdrawal symptoms of alcohol and drugs

3.3. Were psychiatric symptoms present during Were psychiatric symptoms present during a clean period of more than 4 weeks? a clean period of more than 4 weeks?

Case Example of Dual Diagnosis Case Example of Dual Diagnosis

45 y/o male using cocaine for 5 years. Is 45 y/o male using cocaine for 5 years. Is depressed with paranoid thoughts. He stabbed depressed with paranoid thoughts. He stabbed himself while trying to fend off an “intruder” in his himself while trying to fend off an “intruder” in his truck. Brought in by police who witnessed the truck. Brought in by police who witnessed the stabbing-no intruder was seenstabbing-no intruder was seen

Important questions:Important questions:

1. Did the psychiatric symptoms precede his 1. Did the psychiatric symptoms precede his alcohol dependence?alcohol dependence?

2. Were there periods of time lasting more than 4 2. Were there periods of time lasting more than 4 weeks during which psychiatric symptoms were weeks during which psychiatric symptoms were present? present?

3. Presumptive diagnosis?3. Presumptive diagnosis?

Treatment for Dual Diagnosis Treatment for Dual Diagnosis

• Integration of therapy is necessary Integration of therapy is necessary (medications, groups and individual (medications, groups and individual tx)tx)

• Sometimes “coercion” or drug courtsSometimes “coercion” or drug courts

• Clinical Trials: Seeking Safety (Post-Clinical Trials: Seeking Safety (Post-Traumatic Stress D/O)Traumatic Stress D/O)

Why Improve Medical Care in Why Improve Medical Care in Dual Diagnosis Patients?Dual Diagnosis Patients?

• SUDs reduce life expectancy by ~14 SUDs reduce life expectancy by ~14 yearsyears

• Studies of on-site tx of patients with Studies of on-site tx of patients with serious mental illness and SUD found;serious mental illness and SUD found;

1.1. Reduced mortality (by up to 1/3)Reduced mortality (by up to 1/3)

2.2. Increase abstinence from Increase abstinence from drugs/alcoholdrugs/alcohol

3.3. Modest cost Modest cost

Initiation of Treatment of SUDs Initiation of Treatment of SUDs

1.1. Engagement (Stages of Change)Engagement (Stages of Change)--Prochaska and Prochaska and

DiClementeDiClemente

• PrecontemplationPrecontemplation• ContemplationContemplation

• Action Action • MaintenanceMaintenance

Approach to Treatment of SUDsApproach to Treatment of SUDs

1.1. DetoxificationDetoxification

2.2. Relapse preventionRelapse prevention

3.3. Maintenance of recoveryMaintenance of recovery

Examples of Psychotherapies of Examples of Psychotherapies of Addiction to ReviewAddiction to Review

1.1. 12 Step (Minnesota Model of Alcoholics 12 Step (Minnesota Model of Alcoholics Anonymous) - for Anonymous) - for drug or alcoholdrug or alcohol

2.2. Brief Interventions for Brief Interventions for problem drinkingproblem drinking

3.3. Therapeutic Communities - Therapeutic Communities - mostly drugsmostly drugs

4.4. Contingency Reinforcement - Contingency Reinforcement - mostly mostly drugsdrugs

Still More Psychotherapies of Still More Psychotherapies of AddictionAddiction

5.5. PROJECT MATCH FOR PROJECT MATCH FOR ALCOHOL ALCOHOL DEPENDENCEDEPENDENCE:: Motivational Enhancement Therapy, Motivational Enhancement Therapy, Cognitive Behavioral Therapy, 12 Step Cognitive Behavioral Therapy, 12 Step Facilitation TherapyFacilitation Therapy

6.6. Alternative Therapies (harm reduction, Alternative Therapies (harm reduction, aversive therapy, hypnosis, aversive therapy, hypnosis, accupuncture, mindfulness, yoga, accupuncture, mindfulness, yoga, telephone treatment, etc) - telephone treatment, etc) - for drugs, for drugs, alcohol and/or nicotinealcohol and/or nicotine

12 Step (Minnesota Model) for Alcohol 12 Step (Minnesota Model) for Alcohol DependenceDependence

• Self-help, not professional therapySelf-help, not professional therapy

• 12 Steps and 12 Traditions12 Steps and 12 Traditions

• In a study of Twelve-Step Facilitation In a study of Twelve-Step Facilitation (TSF) vs. Motivational Enhancement (TSF) vs. Motivational Enhancement and Cognitive Behavioral Therapy, and Cognitive Behavioral Therapy, ~40% of TSF pts stayed in AA 10 ~40% of TSF pts stayed in AA 10 years after treatment. years after treatment.

Brief Interventions for Brief Interventions for Moderate Alcohol ProblemsModerate Alcohol Problems

• Administered by health professionals in medical Administered by health professionals in medical settings (physicians, nurses)settings (physicians, nurses)

• Sessions are brief (5-30 minutes)Sessions are brief (5-30 minutes)• Goal is to improve medication compliance or Goal is to improve medication compliance or

reduce harmful drinking behaviorsreduce harmful drinking behaviors• Mixed results:Mixed results:

Wallace et al., 1988Wallace et al., 1988: reduction drinking 45% tx vs. 25% : reduction drinking 45% tx vs. 25% controlcontrol

Fleming et al, 1999Fleming et al, 1999: reduction drinking 14% tx vs. 20% : reduction drinking 14% tx vs. 20% controlcontrol

Project MATCH for Alcohol DependenceProject MATCH for Alcohol Dependence

• Motivational Enhancement Motivational Enhancement TherapyTherapy

• Individual Cognitive-Behavioral Individual Cognitive-Behavioral Psychotherapy Psychotherapy

• AA and Therapeutic CommunitiesAA and Therapeutic Communities

Motivational Enhancement Therapy Motivational Enhancement Therapy (MET)(MET)

• ““Directive, client-centered counseling Directive, client-centered counseling style for eliciting behavior change by style for eliciting behavior change by helping clients to explore and resolve helping clients to explore and resolve ambivalence”ambivalence”

• Express empathy, develop Express empathy, develop discrepancy, avoid argumentation, roll discrepancy, avoid argumentation, roll with resistance, support self-efficacywith resistance, support self-efficacy

• Highly acceptable to patientsHighly acceptable to patients• Requires training and supervision for Requires training and supervision for

counselorscounselors

Cognitive-Behavioral Coping SkillsCognitive-Behavioral Coping Skills

•Coping with cravings and urges to drinkCoping with cravings and urges to drink

•Problem solvingProblem solving

•Drink refusal skillsDrink refusal skills

•Planning for emergencies and coping Planning for emergencies and coping with a lapsewith a lapse

TWELVE STEP FACILITATION THERAPYTWELVE STEP FACILITATION THERAPY

•Encouragement to attend AA meetingsEncouragement to attend AA meetings

Project MATCHProject MATCH

75

20

73

19

75

15

0

20

40

60

80

CBT MET TSF

Baseline 12 Month FU

Reduction in Percentage of Drinking DaysReduction in Percentage of Drinking Days

Psychotherapies for Drug Dependence Psychotherapies for Drug Dependence

Crack cocaine Cocaine powder

Psychotherapy: Psychotherapy: Therapeutic Community Therapeutic Community for Drugs for Drugs ((Heroin +/or CocaineHeroin +/or Cocaine))

• Peer support (live in 6 mo-three years)Peer support (live in 6 mo-three years)

• Moral/ethical teachings “right living”Moral/ethical teachings “right living”

• Assume responsibility for oneself and Assume responsibility for oneself and concern for othersconcern for others

• Drop out is 70%Drop out is 70%

• No maintenance medication for opiates No maintenance medication for opiates (methadone or suboxone), thus(methadone or suboxone), thus

70%-85% relapse70%-85% relapse

Treatment of Cocaine DependenceTreatment of Cocaine Dependence

• Cocaine dependence is difficult to treatCocaine dependence is difficult to treat

1.1. Most patients do not get clean as Most patients do not get clean as outpatientsoutpatients

2.2. Less than half are clean 6 months after Less than half are clean 6 months after

treatmenttreatment

3.3. Long-term, flexible treatment neededLong-term, flexible treatment needed

Contingency Management for Contingency Management for Drug DependenceDrug Dependence

• Rewards or incentives given for targeted Rewards or incentives given for targeted behaviors such as verified drug free urine behaviors such as verified drug free urine toxicology screenstoxicology screens

• Examples: Take-home doses for Examples: Take-home doses for methadone maintained ptsmethadone maintained pts

• Vouchers redeemable for goodsVouchers redeemable for goods

• Some controversySome controversy

Voucher Treatment Improves Short-term Voucher Treatment Improves Short-term AbstinenceAbstinence

0%

10%

20%

30%

40%

50%

60%

% continuously

abstinent

12 Weeks

Vouchers Standard Treatment

(Higgins, 1994)

Individual Drug Counseling for Cocaine Individual Drug Counseling for Cocaine Dependence is EffectiveDependence is Effective

0%

5%

10%

15%

20%

25%

30%

35%

40%

% c

on

tin

uo

usl

y a

bst

inen

t

12 Weeks

Individual Drug counseling

Group Drug Counseling

Cognitive Behavioral Therapy

Supportive/expressive Therapy

Alternative Therapies for AddictionAlternative Therapies for Addiction

• Harm ReductionHarm Reduction• Aversive TherapyAversive Therapy• HypnosisHypnosis• AcupunctureAcupuncture• Mindfulness and Yoga Mindfulness and Yoga • Telephone Treatment**Telephone Treatment**

**Found to have efficacy in randomized **Found to have efficacy in randomized controlled trialscontrolled trials

Summary: Dual Diagnosis Summary: Dual Diagnosis

1.1. Is the SUD is Is the SUD is Primary or SecondaryPrimary or Secondary

2.2. Provide Integrated Therapy Provide Integrated Therapy • Physicians to prescribe medicationsPhysicians to prescribe medications• Counselors to provide counselingCounselors to provide counseling• Family supportFamily support• Housing Housing

Conclusion 1.Conclusion 1. Psychotherapy of Alcohol Use DisordersPsychotherapy of Alcohol Use Disorders

Clearly effectiveClearly effective for alcohol use disorders for alcohol use disorders

• 70% reduction in drinking at one year for 70% reduction in drinking at one year for dependence (Project MATCH)dependence (Project MATCH)

• Brief interventions for problem drinkers Brief interventions for problem drinkers show show mixed results mixed results

Conclusion 2.Conclusion 2. Psychotherapy of Cocaine Use Disorders Psychotherapy of Cocaine Use Disorders

Moderately effectiveModerately effective for cocaine for cocaine dependencedependence

• Less than 50% clean from cocaine Less than 50% clean from cocaine at 6 monthsat 6 months

Conclusion 3. Conclusion 3. Psychotherapy of Opiate Use DisordersPsychotherapy of Opiate Use Disorders

IneffectiveIneffective for opiate dependence for opiate dependence

• Up to 70% drop out from Up to 70% drop out from Therapeutic CommunitiesTherapeutic Communities

• 70%-85% relapse without 70%-85% relapse without maintenance medications maintenance medications (methadone, suboxone) (methadone, suboxone)