Substance Abuse and CoOccurring Psychiatric Disorders

1
Substance Abuse and Co-Occurring Psychiatric
Disorders
Merrill Herman, M.D. American Society of
Addiction Medicine
2
Epidemiologic Catchment Area (ECA) Data
Mental Disorders increase risk for Substance Use
Disorders (SUDs) Major Depression -
Risk for SUD increased x 2 Panic Disorder
- Risk for SUD increased x 3
Schizophrenia - Risk for SUD
increased x 5 Bipolar Disorder -
Risk for SUD increased x 7 Mental Disorders are
more common amongst substance abusers than the
general population. Phobic Disorder 39
GAD - 10 MDD - 24 Bipolar
Disorder - 37 Dysthymia - 12
3
Diagnostic Issues

Psychopathology as a risk factor for
addiction (e.g., self-medication).
Psychiatric disorders and SUDs may affect the
course of each other, including symptom picture,
rapidity of onset and response to treatment.
Need to assess for psychiatric symptoms which
are secondary and due to acute or chronic
intoxication or withdrawal.
4
Substance-Induced vs. Primary Psychiatric
Disorders
Key Diagnostic Questions

• What came first? Psychiatric symptoms or drug
  use?
• Periods of abstinence and persistence of symptoms
• Impact of each drug used on psychiatric symptoms
  (e.g. which drugs alleviate or exacerbate
  symptoms)
• Family history of psychiatric illness

5
Psychopharmacologic Issues

• Indications - To treat psychiatric disorders and
  minimize potential relapse to
  substance use.
• When to use psychopharmacotherapy
• Any Primary/Endogenous Psychiatric Disorder
• Any Psychosis or mania irrespective of whether
  drug-induced or primary (e.g., antipsychotics,
  mood stabilizers)
• Secondary anxiety or mood disorders - If there
  has been clear, lasting, and severe past episodes
  that led to impaired function.
• Psychiatric Disorders that last more than 4 weeks
  after drug/alcohol use
• May need detoxification to ascertain
  psychiatric diagnosis
• e) Can use psychopharmacotherapy with other
  medications used to promote/maintain abstinence
  (e.g., methadone, acamprosate)

6
Psychopharmacology in Patients with Comorbid
Psychiatric and Substance Use Disorders
Summary 1) Effective in improving
psychiatric symptoms in many patients.
2) May improve overall response to
substance abuse treatment (less need to
self-medicate). 3) Medications work best
in context of therapeutic
alliance/psychotherapy. 4) Education of
patient is essential to therapeutic outcome.
5) Team communication between
psychiatrist, medical provider, and
counselor can reinforce adherence and
response to treatment.