Depression and Recovery or “The fingers of the hand”

1. Depression and Recoveryor“The fingers of the hand” Omar S. Manejwala, M.D. William J. Farley Center Williamsburg, VA www.farleycenter.com

2. Overview • CONTEXT • Specific Depressive Disorders • Suicide • Neurobiology of Depression • Prevalence of Dual Diagnosis • Diagnostic Difficulties • Barriers to Recovery in Dual Diagnosis • Treatment Principles: Medications, Therapy, 12-step approaches

3. Source? “But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”

4. “Alcoholics Anonymous” p133 “But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitated to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”

5. Source? “The AA member- medications and other drugs” pamphlet "...A.A. members and many of their physicians have described situations in which depressed patients have been told by A.A.'s to throw away the pills, only to have depression return with all its difficulties, sometimes resulting in suicide. We have heard, too, from schizophrenics, manic depressives, epileptics, and others requiring medication that well-meaning A.A. friends often discourage them from taking prescribed medication. Unfortunately, by following a layman's advice, the sufferers find that their conditions can return with all their previous intensity”

6. “The AA member- medications and other drugs” pamphlet "It becomes clear that just as it is wrong to enable or support any alcoholic to become re-addicted to any drug, it's equally wrong to deprive any alcoholic of medication which can alleviate or control other disabling physical and/or emotional problems."

7. Narcotics Anonymous Fellowship Services states… "The question of prescription medication should be decided between the member, their doctor, and the member's Higher Power. Our pamphlet "In Times Of Illness" and our 10th Tradition, make this abundantly clear. We strongly recommend telling our doctors about our history so that when prescription medication is absolutely necessary they can prescribe it knowing that we are recovering addicts."

8. AA grapevine October 1956 • “One with the Angels” m.p.g. Boston, MA • In July of 1950, while attending the Cleveland Convention and not having had a drink for many months, I became psychotic. I lost contact with reality. I lost my sanity, in the clinical sense. • For ten months I was treated in a Maryland hospital. The illness required electric shock treatments and intensive psycho-therapy. • On one occasion, just before discharge, I asked my doctor how he related my alcoholism to my psychosis. He showed how the fingers of the hand are distinct, separate and still connected. Thus closely are alcoholism and mental disease kin.

9. State of the evidence • Recent meta-analysis (Nunes & Levin) of depression treatment in patients with substance use disorders • 300 trials between 1973-2003 • Only 44 were placebo controlled • Only 14 met inclusion criteria for rigor (randomized, etc) • 8 studies focused on EtOH • In 4 of those studies, patients were drinking at the time of the study • The only clear findings were that antidepressants worked better for depression if patients were sober and they didn’t improve abstinence rates

10. Overview • Context • SPECIFIC DEPRESSIVE DISORDERS • Suicide • Neurobiology of Depression • Prevalence of Dual Diagnosis • Diagnostic Difficulties • Barriers to Recovery in Dual Diagnosis • Treatment Principles: Medications, Therapy, 12-step approaches

11. Some “depressive” disorders commonly seen • Major Depressive disorder • Dysthymia • Premenstrual dysphoric disorder • Bipolar disorder (Type I, II, mixed) • Bereavement • Depressed mood is a symptom, NOT an illness

12. Symptoms of major depressive disorder • Depressed mood* • Loss of interest/ pleasure in activities (including sex) • Weight loss, weight gain (>5%/month) or appetite change • Sleep disturbance • Fatigue/loss of energy • Psychomotor agitation/retardation • Worthlessness/excessive or inappropriate guilt • Poor concentration (its not always ADD!) • Recurrent thoughts of death/suicide

13. Exclusionary/Other Criteria for Diagnosis of Major Depressive Disorder • Not better accounted for by: • Bereavement • Substance induced mood disorder • Dysphoria of some psychotic states • Certain medical illnesses (e.g. hypothyroidism) Also there can never have been a history of a manic episode. Durational Criteria

14. Bipolar disorder (manic-depression) • Elevated, expansive or irritable moods • Inflated self-esteem/grandiosity • Decreased need for sleep (as opposed to insomnia) • Flight of ideas • Distractibility, poor concentration (its not always ADD!) • Increase in goal directed activity or psychomotor agitation • Excessive involvement in behaviors with a high-risk for painful consequences. • Probably more common in our chronic relapse population. 56.1% of bipolar patients had a SUD in the ECA study (flawed)

15. Medical Illnesses commonly associated with depression comorbidity: • Epilepsy • Huntington’s disease • Infections (HIV, neurosyphillis) • Migraines • MS • Narcolepsy • Cancer • Wilson’s disease • Parkinson’s Disease • Cushing’s disease • Menses-related • Post-partum • Parathyroid disorders and thyroid disorders • SLE • Immune/inflammatory disorders • Certain medications

16. Overview • Context • Specific Depressive Disorders • SUICIDE • Neurobiology of Depression • Prevalence of Dual Diagnosis • Diagnostic Difficulties • Barriers to Recovery in Dual Diagnosis • Treatment Principles: Medications, Therapy, 12-step approaches

17. Suicide • People with an EtOH use disorder 20x more likely to complete suicide than general population. • Between 18% and 66% of suicide victims have alcohol in their blood at the time of death (Roizen 1988; Welte et al. 1988, Collier et al. 1986, Berkelman et al. 1985).

18. Suicide Risk Factors • Previous suicide attempts • History of mental disorders, particularly depression • History of alcohol and substance abuse • Family history of suicide • Family history of child maltreatment • Feelings of hopelessness • Impulsive or aggressive tendencies • Barriers to accessing mental health treatment • Loss (relational, social, work, or financial)

19. Suicide Risk Factors • Physical illness • Easy access to lethal methods • Unwillingness to seek help because of the stigma attached to mental health and substance use disorders or suicidal thoughts • Cultural and religious beliefs—for instance, the belief that suicide is a noble resolution of a personal dilemma • Local epidemics of suicide • Isolation, a feeling of being cut off from other people

20. Suicide—contact with GP • Among suicide completers, 80% had contact with a physician in the 6 months prior • Majority of suicide completers are under the care of a physician at the time of their death • Among suicide attempters the picture is comparable • 1/3 of suicide attempters contacted their physician the week prior to the attempt.

21. Suicide Protective factors • Effective clinical care for mental, physical, and substance abuse disorders • Easy access to a variety of clinical interventions and support for help seeking • Family and community support • Support from ongoing medical and mental health care relationships • Skills in problem solving, conflict resolution, and nonviolent handling of disputes • Cultural and religious beliefs that discourage suicide and support self-preservation instincts

22. Overview • Context • Specific Depressive Disorders • Suicide • NEUROBIOLOGY OF DEPRESSION • Prevalence of Dual Diagnosis • Diagnostic Difficulties • Barriers to Recovery in Dual Diagnosis • Treatment Principles: Medications, Therapy, 12-step approaches

23. Neurobiology of Depression “Chemical Imbalance” hypothesis postulates that reduced levels of brain serotonin or norepinephrine leads to depression.

24. Mood regulatory neural networks Biological vulnerability Exogenous Stressors Gender FH Gene polymorphism Temperament Pre-natal insults homeostasis Trauma Abuse Life events Medical illness Mood Regulatory Circuits Depressive Episode Adapted from H. Mayburg, MD

25. Neural Network hypothesis • In this paradigm, disruption of the regulatory network causes inability to respond to endogenous and exogenous stress. • This network regulates homeostatic responses in: • Affect • Cognitive process • Psychomotor activity • Circadian rhythm

26. Opening up the Mood Regulating Circuits Box Biological vulnerability Exogenous Stressors Gender FH Gene polymorphism Temperament Pre-natal insults homeostasis Trauma Abuse Life events Medical illness Mood Regulatory Circuits Depressive Episode Adapted from H. Mayburg, MD

27. The neural network model cont’d Cognitive Processing attention – memory - action CBT Meds PF9/46, PM6, Par40, hc, aCg24b, mCg24c, pCg Emotion-Cognition Integration Salience self-reference reinforcement mF9/10 rCg24a oF11 cd-vst, thal amg mb-sn Mood State sgCg25 a-ins, hth, bstem DBS Autonomic Responses arousal – vegetative – circadian Adapted from Helen Mayburg, MD

28. Kindling • Alcoholism and bipolar disorder may be related d/t the concept of neuronal sensitization • Subsequent episodes of illness are often more frequent and more intense • Similar to epilepsy in this regard • Use of antikindling agents may be beneficial in this population

30. Overview • Context • Specific Depressive Disorders • Suicide • Neurobiology of Depression • PREVALENCE OF DUAL DIAGNOSIS • Diagnostic Difficulties • Barriers to Recovery in Dual Diagnosis • Treatment Principles: Medications, Therapy, 12-step approaches

31. Prevalence of SUD in psychiatric treatment settings • The “flip side” • 30% of depressive d/o patients and 50% of Bipolar patients in inpatient settings meet criteria for a SUD • In VA studies the rates have been as high as 64% lifetime SUD prevalence and 29% SUD in the last 30 days! • This not only argues for a high incidence of SUD in these conditions, but a clear association of substance use with decompensation, since these were inpatients.

32. Affective/SUD comorbidities by substance of abuse • Bipolar d/o is more common among cocaine dependent patients than alcoholics • The prevalence of depressive d/o among treatment seeking alcoholics ranges from 15-67% depending on the study • 98% of patients presenting for substance abuse treatment report the symptom of depression

33. What conclusions about prevalence can be drawn? • Data are conflicting d/t failure to exclude substance induced illnesses, study design, etc. • All affective disorders are common in SUD patients, and Bipolar d/o has the highest rate of SUD of any psychiatric illness • Depression and dysthymia are more common in opiate dep and alcohol dep.

34. Overview • Context • Specific Depressive Disorders • Suicide • Neurobiology of Depression • Prevalence of Dual Diagnosis • DIAGNOSTIC DIFFICULTIES • Barriers to Recovery in Dual Diagnosis • Treatment Principles: Medications, Therapy, 12-step approaches

35. Distinguishing SUD from DD • Mood instability and depression are among the most common symptoms reported in people with substance use disorders • People with substance use disorders who don’t experience mood symptoms are in the minority • Depressed mood is almost universal in early recovery, especially during detoxification • Protracted withdrawal states can have affective lability that is difficult to distinguish from a primary mood disorder.

36. Comorbidity of Affective and SUD • ECA: 32% of Affective d/o pts had SUD • Among those with MDD: • 16.5% had alcohol use disorder • 18% had drug use disorder • Among those with Bipolar disorder: • 56.1% had substance use disorder • In both the ECA and the NCS, Bipolar d/o was the axis I condition most likely to also have a SUD comorbidity.

37. Diagnostic Difficulties • Diagnostic difficulties at the interface of SUD and Affective disorders are reflected in varying prevalence rates across studies • In some cases of “true” affective disorder, substance use predates onset of affective symptoms i.e. “which came first” may not help you distinguish.

38. Diagnostic Difficulties • Periods of abstinence, while extremely helpful in clarifying diagnosis are… • Often inaccurately reported • Sometimes never present or too short to be useful • Often characterized by the dysphoria of untreated alcoholism / addiction • Occasionally characterized by exposure to prescription medications that further complicate diagnostic clarity e.g. sedative/hypnotics, opiates, stimulants

39. Diagnostic Difficulties • For example, a recent study of 207 cocaine addicts using the DIS (diagnostic interview schedule) found… • Current rate of affective illness 17% • Lifetime prevalence of affective illness 28% • 65% of subjects reported that drug use onset preceded affective illness onset • The primary problem with all these studies is that they simply haven’t been done rigorously in recovering populations

40. Diagnostic Confusion • Stimulant and alcohol intoxication can produce symptoms indistinguishable from mania or hypomania • Withdrawal from these agents is frequently indistinguishable from depression and dysthymia • Withdrawal from CNS depressants can produce anxiety and agitation • PAWS

41. Substances induce psychiatric symptoms Withdrawal mimics psychiatric disorders Protracted withdrawal states not-well defined and mimic primary psychiatric conditions Clean time vs. Dry Time Substances can cause OR exacerbate psychiatric syndromes. Psychiatric disorders often overlap symptoms with each other Multiple psychiatric comorbidities can be common, e.g. depression and anxiety disorders. Many psychiatric disorders are cyclic and timing of dx difficult Initial onset of a “true” psychiatric disorder can be precipitated by substance intoxication or withdrawal. Some problems with diagnosis “The best way to clarify diagnosis is through observation during a period of abstinence”

42. Diagnostic Confusion • Mania is generally easier to diagnose than depression in people with a SUD • Manic symptoms induced by substance use tend to resolve in days; depressive symptoms can take weeks or in some cases, months • Methamphetamine and hallucinogens can be the exception to this rule, as substance-induced mania with these agents can persist for weeks.

43. Dorus et al 1987 • 171 inpatients in EtOH-treatment • National prevalence estimate for current MDD is 5% • ETOHics are at a higher risk for MDD

44. When to diagnose? • Diagnosing too early can lead to overtreatment and mismatching and possibly poorer outcomes. • Overtreatment can undermine the person’s sense that AA/NA is the primary treatment of their alcoholism / addiction • Diagnosing too late can lead to higher risk of relapse, poorer outcomes, and suicide. • What clinical features predict comorbidity rather than substance-induced affective d/o?

45. Differentiating Illnesses • Affective symptoms that predate onset of substance use d/o • Affective symptoms during extended periods of abstinence • Strong family h/o affective d/o • Positive h/o response to affective d/o treatment “hedging your bets”

46. Differentiating Illnesses…”hedging your bets” • Chronic relapser despite multiple treatment attempts • Frequently affective illnesses in this population are excluded owing to rigid application of diagnostic criteria • Alcoholics and addicts with extensive treatment exposure and multiple relapses should be more carefully evaluated and medication trials considered.

47. Differentiating Illnesses…”The luxury of being a purist” • We don’t have it. • RCTs for antidepressants exclude current or recent substance use or substance use disorders. • The dually diagnosed are heterogeneous with respect to severity of substance use disorder, substances used, periods of abstinence, trauma history, type of affective illness

48. Risks of overtreatment“so just put everyone on an antidepressant?” • NO!!! • Integrating depression treatment with recovery principles is extremely difficult. • Prescribing without that integration is dangerous and may lead to relapse • Risks of ADRs, precipitating AD-induced mania, etc. • Terminal uniqueness…

49. Overview • Context • Specific Depressive Disorders • Suicide • Neurobiology of Depression • Prevalence of Dual Diagnosis • Diagnostic Difficulties • BARRIERS TO RECOVERY IN DD • Treatment Principles: Medications, Therapy, 12-step approaches

50. Factors that interfere with recovery in DD • Increased level of social isolation • Low energy • Impaired concentration • Suicidality • Anxiety • 12-step approaches are heavily socially driven