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Physical & Mental Disorder Comorbidity in Substance Users © 2009 University of Sydney Learning outcomes • To be able to describe the common medical conditions and common mental disorders amongst those with substance use disorders • To be able to assess common medical conditions relevant to substance use disorders • To be able to assess common mental disorders relevant to substance use disorders • To be able to initiate management of both physical and mental disorder comorbidity General principles • Physical and mental disorders are common in individuals with substance use disorders • Assessment and management are more difficult in the presence of such comorbidity Comorbidity: Quick history • 1970 Feinstein first described as “any additional coexisting ailment” • 1990’s • term first used for mental or physical disorder and substance use disorders. Common physical comorbidity • Liver disease: – Alcohol – Hepatitis C • Interferon not possible if unstable substance use or psychiatric conditions – Obesity (fatty liver) exacerbated by alcohol and weight gain related to antipsychotics – or other conditions (e.g.) infections: local, systemic • Poor nutrition Common physical comorbidity • Late presentation for unrelated conditions • Poor treatment adherence for other conditions (e.g. diabetes) – Preoccupation with substance use – Disorganised e.g. for appointments – Limited finances/unemployment Common mental disorder comorbidity • 1 in 5 individuals with a substance use disorder also have an affective disorder; • 1 in 3 individuals with a substance use disorder also have an anxiety disorder; Teesson, Slade & Mills, 2009, ANZJP, in press • Individuals with cannabis dependence are twice as likely to experience psychotic symptoms. Mental Disorder Comorbidity in Australia: adult females anxiety affective 3.9 12.6 2.5 1.6 0.8 0.2 substance use 1.7 Teesson, Slade & Mills, 2009, ANZJP, in press; National Survey of Mental Health and Wellbeing (NSMHW), ABS, 2007 Mental Disorder Comorbidity in Australia: adult males anxiety substance use 4.3 6.7 1.3 0.9 0.6 2.0 affective 1.9 Teesson, Slade & Mills, 2009, ANZJP, in press; National Survey of Mental Health and Wellbeing (NSMHW), ABS, 2007 How common is trauma exposure & PTSD among people with SUDs in Australia? 100 80 60 40 20 0 93 83 73 91 89 75 57 33 29 6 Trauma 1 po pu l at io n SU D G en er al A ny m in es ph et a A m O pi o id s es Se da tiv s 5 C an na bi A lc oh ol 5 24 PTSD Mills et al., 2006, Am J Psychiatry, 163: 651-658. Reprinted with permission from the American Journal of Psychiatry (copyright 2006). American Psychiatry Association Mechanisms of co-morbidity: mental disorders • Substance use may cause mental disorders, through a variety of neurobiological mechanisms • Substance use may trigger the onset of mental disorder in susceptible individuals • Persons with mental disorders may seek to relieve their symptoms (or medication sideeffects) through psychoactive substance use • Substance use can cause life difficulties which can precipitate or worsen mental disorders Assessment • Screen all substance misuse patients for psychiatric symptoms & physical conditions • Seek corroborative history • Repeat substance use history when patient not intoxicated or acutely unwell • Repeat psychiatric history when patient not intoxicated or withdrawing Management principle • Treatment of all conditions should be considered, managed and monitored Initial Management • Alcohol dependence: – Management acute withdrawal - reducing regime benzodiazepines (maximum 7 days) – Engagement with programmes to maintain abstinence: Cognitive Behaviour therapy, motivational enhancement, AA, pharmacotherapy (naltrexone/acamprosate). • Opiate dependence – Manage withdrawal - symptomatic, reducing doses of long-acting opiate or maintenance • Cannabis dependence – Cognitive behaviour therapy, motivational enhancement. – Education about interaction of psychosis and cannabis use • Treat physical and psychosocial complications of substance misuse Barriers to treatment Patients with substance misuse may have: • Poor family/social support • Poor nutrition and living circumstances • Encountered real or perceived prejudice by health care staff • Difficulties with compliance: – Preoccupation with substance misuse – Disorganisation/intoxication – Limited finances/unemployment Further management • Engage in therapeutic relationship, set specific goals, and follow-up regularly • Re-evaluate need for treatment of comorbid conditions and treat as usual if symptoms remain Alcohol: Further management • Physical complications • Psychiatric complications – Depression & Anxiety • anxiety/agitation in withdrawal – Psychosis • Hallucinations Physical complications of alcohol dependence • Alcoholic liver disease • Acute fatty infiltration • Alcoholic hepatitis • Cirrhosis • Brain injury • Subdural haematomas • Frontal dementia • Wernicke’s/Korsakof f’s • Cerebellar dysfunction • Poor nutrition • Vitamin B1 • Vitamin B12 (neuropathy) • • Gastritis Delirium Tremens (Alcohol withdrawal syndrome) • Considerable morbidity untreated • May present as acute psychosis with confusion • Grand mal seizures possible Relationship between alcohol and depression • Depression is a risk factor for drinking as well as a complication of alcohol misuse • Social complications of alcoholism – Unemployment & relationship difficulties may precipitate or exacerbate depression • Comorbidity predicts a poor treatment response Alcohol and depression • Symptoms of depression hard to distinguish from complications of alcohol misuse – e.g. poor energy, disrupted sleep, loss of weight, social isolation • Symptoms of intermittent alcohol withdrawal may mimic anxiety disorders • Depressive symptoms and suicidal ideation must be regularly reassessed, particularly when patient no longer intoxicated Management principles where patient continues to use alcohol • Alcohol dependence: – Motivational interviewing to encourage reduction in alcohol or abstinence • Depression: – Education about relationship of alcohol and depression – Use of antidepressants • Little evidence that antidepressants reduce alcohol intake • Antidepressants do help with symptoms of depression, but on-going alcohol use remains a perpetuating factor for depression • Avoid tricyclic antidepressants (overdose risk) • SSRIs have most evidence of efficacy – Cognitive Behavioural Interventions Alcohol and psychosis • Withdrawal: Delirium tremens with prominent visual hallucinations • Alcoholic hallucinosis: Auditory hallucinations not in context of withdrawal (rare) Alcohol and hallucinations • Alcohol withdrawal – – – – – In setting of having recently stopped or cut down usually visual hallucinations – fleeting, early with clouded sensorium (i.e. DTs) Usually resolves within the week DTs potentially life-threatening • Alcoholic hallucinosis – – – – – Uncommon Auditory or visual hallucinations (usually auditory) with clear sensorium May occur in days to weeks after abstinence Lasts hours to weeks Drugs: Further management • Physical complications • Psychiatric complications – Depression & Anxiety • anxiety/agitation in withdrawal – PTSD – Psychosis Medical complications of injecting drug use • Local: abscesses, cellulitis, venous thrombosis • Systemic: infected thrombi may affect any organ e.g. kidney, brain, heart (endocarditis) • Blood borne viruses: Hepatitis C, Hepatitis B, HIV Management of PTSD and Substance Use Disorder • PTSD symptoms independent from drug disorder • Intervention should address both PTSD and SUDs concurrently • Traditionally exposure therapy was considered inappropriate for those with SUDs – The emotions experienced may be overwhelming and could lead to more substance use – Cognitive impairment associated with SUD could impair the patient’s ability to do imaginal tasks • Growing evidence for effectiveness of exposure therapy Illicit substance use in those with psychosis • In order of decreasing prevalence: – – – – – Cannabis Amphetamines LSD Heroin Tranquillisers Management of druginduced psychosis • Supervised withdrawal from drugs – E.g. inpatient detoxification, in a psychiatry ward if prominent psychiatric symptoms • Antipsychotic medication often not required long-term (e.g. amphetamine psychosis) • Relapse prevention: – Feedback on psychotic episode Relationship between cannabis and psychosis • May cause psychosis in intoxication (e.g. paranoid ideas) • Higher rate of use in those who later go on to develop schizophrenia - ? causal link • Use worsens outcome in psychotic disorders and may precipitate relapse • Some may use for perceived relief of positive symptoms/anxiety • Also associated with: amotivational syndrome, anxiety (mostly in withdrawal) and depression Relative risk of developing schizophrenia with use of cannabis: Swedish conscript study 7 6 5 4 3 2 1 0 No use 1-10 times 11-50 times 50+ times Risk of diagnosis 2.4 times higher in those who tried cannabis before 18 years. Dose response which decreased but persisted after adjustment for psych history. Hall, Degenhardt, & Teesson, 2004, Drug and Alcohol Review, 23: 433-443 Cannabis & Psychosis • Communicate the risk while honestly acknowledging the uncertainties that remain – people with psychosis or a first degree relative with psychosis should avoid using cannabis – one in seven people who use cannabis report unpleasant, psychotic-like symptoms; avoid use – discouraging young people from using cannabis daily or near daily Relationship between stimulants and psychosis • A common cause of psychosis in young people • History of stimulant use • Rapid recovery in hospital, often without specific treatment • Earlier intervention may prevent progression of symptoms Relationship between heroin and psychosis • Higher relative risk of heroin use in those with psychosis compared to general population • Psychosocial complications have most impact: – Already vulnerable patients may resort to crime or sex work to maintain habit (prevent withdrawals) – Heroin use will add to disorganisation, poor social support, and stigmatisation, further affecting access to care and compliance Case Study 1: Alcohol and depression Kate is 42 years old • Presents to ED after haematemesis • 1-2 bottles of wine daily for 4 years • Over the last 6 months she has become increasingly depressed - poor sleep, loss of weight, reduced enjoyment and social isolation. • She admits to feeling increasingly suicidal over the past 2 weeks. Case Study 1: Questions • What is the relationship between alcohol misuse and depression? • What medical complications should you screen for? • How does one manage comorbid depression and alcohol dependence? Case Study 1: Answers • Depression may be a contributing factor to the alcohol misuse, or may be caused or exacerbated by alcohol dependence • Kate needs assessment of her liver status, to exclude cirrhosis with portal hypertension. • Depression often lessens once the person stops drinking. Where it is safe to do so, you can wait a month before commencing antidepressants. – Where treatment is required an SSRI with lesser potential to provoke anxiety can be useful, e.g. citalopram or sertraline. Case Study 2: John John is 24 years old • Two previous admissions with ?schizophrenia. • Now admitted to a psychiatric unit – Suffering from prominent auditory hallucinations and paranoid delusions. – The day after admission he is noted to be suffering from opiate withdrawal (yawning, sweating, muscle cramps, diarrhoea) • Admits to injecting heroin daily for the past month. He also uses marijuana, which he believes helps with the side-effects of his psychiatric medication. Case study 2: Questions • What is the relationship between psychosis and substance misuse? • What medical conditions should you screen for? • How does one manage comorbid substance misuse and psychosis, in the short and long term? Case Study 2: Answers • Relationship between psychosis and substance misuse? – cannabis and heroin may both exacerbate and relieve psychosis – Drug induced psychosis (does he have schizophrenia?) • Medical conditions to exclude? – BBV, sepsis – Chest infections after cannabis • How to manage comorbid substance misuse and psychosis? – Encourage treatment be with psychiatry and addiction teams. Minimise drug use. Assertive case management to increase compliance with therapy. Contributors Associate Professor Kate Conigrave Royal Prince Alfred Hospital & University of Sydney Dr Glenys Dore Macquarie Hospital, Northern Sydney Health Dr Joanne Ferguson Rozelle & Concord Hospitals Professor Paul Haber Royal Prince Alfred Hospital & University of Sydney Dr Kezia Lange Royal Prince Alfred Hospital Professor Maree Teesson National Drug and Alcohol Research Centre, UNSW All images used with permission, where applicable