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Psychiatric Comorbidity in SUDs. The occurrence of psychiatric illness in an individual with a SUD In most settings, refers to occurrence of a diagnosable psychiatric disorder Comorbidity of SUDs and diagnosed psychiatric disorders is substantial
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Psychiatric Comorbidity in SUDs • The occurrence of psychiatric illness in an individual with a SUD • In most settings, refers to occurrence of a diagnosable psychiatric disorder • Comorbidity of SUDs and diagnosed psychiatric disorders is substantial • SUD individuals with comorbid psychiatric illness are referred to as: ‘Dual Diagnosis’
Psychiatric Comorbidity in NativeHawaiian & Pacific Islanders Compared to Other Populations: Measurement & Clinical Issues George Fein Ph.D. President and Senior Scientist, Neurobehavioral Research, Inc Victoria Di Sclafani Ph.D. John A. Burns School of Medicine, University of Hawaii at Manoa
Myths Regarding Psychiatric Comorbidity and SUDs Myth #1: It is very difficult for dual diagnosis individuals to achieve abstinence. Myth #2: It is very difficult for an abstinent individual to maintain abstinence with a current psychiatric diagnosis, especially if psychiatric medication management is needed.
Psychiatric Comorbidity • We will present illustrative data from three studies of alcoholics: 1. Long-Term (avg > 6 yrs) Abstinent Alcoholics 2. Treatment Naïve Actively Drinking Alcohol Dependent Sample 3. Older Long-Term (avg > 14 yrs) Abstinent Alcoholics Each group vs. its own age and gender comparable controls.
Psychiatric Diagnosis:Lifetime and Current • Long-term Abstinent Alcoholics • minimum 6 months, average 6.3 years abstinence • alcohol dependent sample 34-58 years old (n=52) • Age and gender comparable controls (n=48)
LTAA vs Controls Lifetime psychiatric diagnoses do not militate against achieving long-term abstinence; in fact, lifetime psychiatric diagnoses are the norm.
LTAA vs Controls Current psychiatric diagnoses (even those treated with medication) do not militate against maintaining long-term abstinence.
Treatment Naïve Alcoholics vs Controls Treatment Naïve Alcoholics do not evidence more Lifetime diagnoses than Controls.
Treatment Naïve Alcoholics vs Controls There is no difference between Treatment Naïve Alcoholics and Controls in current psychiatric diagnoses.
Older LTAA vs Controls Older Long-Term Abstinent Alcoholics tend to have somewhat more psychiatric morbidity than Controls but less than seen in Middle-Aged Alcoholics.
Older LTAA vs Controls Virtually no current psychiatric morbidity is found in Older Abstinent Alcoholics.
Tentative Conclusions • Middle-aged LTAA have major psychiatric morbidity. • Older LTAA have minimally more psychiatric morbidity than controls. • Treatment naïve alcoholics have comparable psychiatric morbidity to controls.
Sub-Diagnostic Psychiatric Comorbidity • Most studies ignore psychiatric symptoms that do not meet criteria for a diagnosis. • Subthreshold psychiatric disorder data (i.e., Sx LT the diagnostic threshold) are not presented, implying that Dx completely addresses the presence & severity of psychiatric morbidity. • Dx results in great loss of sensitivity, examining only tail of Sx distribution, leaving the bulk of the Sx distribution unexplored.
Sub-Diagnostic Psychiatric Comorbidity • Currency of symptoms is usually not assessed • unless diagnosis is met. • Thus, diagnostic thinking is reflected even in • the psychological measures we use.
Sub-Diagnostic Psychiatric Comorbidity • Psychological measures of attitudes, beliefs, reactions and thoughts also reflect psychiatric illness (e.g., depressive thinking, poor self-esteem, etc.) • Such measures and scales are usually not part of an assessment of psychiatric comorbidity, but often represent the psychological substrate for illness (e.g., socialized thinking is antithetical to antisocial behaviors).
Conclusions • Sub-diagnostic psychopathology carries the bulk of the difference between LTAA and NAC in psychiatric illness. • Continuous measures of psychiatric illness yield a more accurate picture of psychiatric comorbidity than the limited view that is provided by using only symptomatology that meets criteria for a diagnosis.
NRI Current Procedures: c-Dis Follow Up Questions • In the last 12 months, have you had [symptom]? • How old were you the first time you EVER had [symptom]? • When you first felt/experienced this [symptom], was it in the context of seeking/using/withdrawing from alcohol/drugs? • What percent of the time that you had [symptom] was it in association with seeking/using/withdrawing from drugs or alcohol?
Older Abstinent Alcoholics (OAA) • 49 men, 40 women • age: 60-85 years (mean = 67.5 years) • abstinent 6 mos – 44 yrs (mean = 14.8 yrs) • Older Non-Alcoholic Controls (ONC) • 24 men, 29 women • age: 60-85 years (mean = 69.3 yrs)
Diagnoses • 51.7% of OAA vs. 30.2% of ONC had a lifetime psychiatric Dx (χ2 = 5.40, p < .02). • 44.9% of OAA vs. 28.3% of ONC had a lifetime mood Dx (χ2 = 3.21, p = .07). • No differences in anxiety and externalizing diagnoses: p’s > 0.30 • Essentially NO current Diagnoses. • 4.5% of OAA and 3.8% of ONC
Symptoms and Psych Measures • Total Psychiatric Sx: 77% ↑ in OAA • 50% ↑ Anxiety Sx in OAA vs. ONC • 50% ↑ Mood Sx in OAA vs. ONC • 250% ↑ Externalizing Sx in OAA vs. ONC • Psychological Measures • OAA vs. ONC ↑ ASI, no diff STAI- T or S • OAA vs. ONC ↑ MMPI-Hy, no diff MMPI-D • OAA vs. ONC ↑ MMPI pD, ↓ CPI Soc Scale
Conclusions • Psychiatric disorder is more prevalent in OAA than ONC. • Psychiatric comorbidity is less in OAA compared with ONC compared to MAA vs. MNC. • Largest effects in externalizing domain. • Differences from middle-age study: • Cohort effects • Selective survivorship • Selection bias for participating is greater in older samples
Sensation Seeking Scales Measures are reported as mean ± standard deviation. Effect is significant: * p ≤ 0.05, ** p ≤ 0.01, ***p ≤ 0.001.
Conclusions • The propensity towards sensation seeking normalizes with long-term abstinence. • The measures are sensitive enough to detect gender differences within LTAA and NC. • We see increased sensation seeking in treatment naïve actively drinking alcoholics (after removing items associated with substance use).
Cognitive Function • Rey-Osterrieth Complex Figure (copy, immediate, and 20 minute delayed), Trail Making Test A and B, Symbol Digit Modalities Test, American version of the Nelson Adult Reading Test, Short Category Test, Controlled Oral Word Association Test, Paced Auditory Serial Addition Test, Block Design Stroop Color and Word Test • MicroCog (MC) Assessment of Cognitive Functioning • Global Clinical Impairment Score (GCIS) • 1 for each domain scoring 5-15th %ile • 2 for each domain scoring < 5th %ile • Summed across 9 domains
Conclusions Very long-term abstinence resolves most neuro-cognitive deficits associated with alcoholism, except for the suggestion of lingering deficits in spatial processing.
Cognitive Function in Older Long-Term Abstinent Alcoholics • 91 older (>60 years of age) abstinent alcoholics in 3 subgroups • OAA1: abstinence before age 50 (n=39) • OAA2: abstinence achieved 50-60 (n = 26) • OAA3: abstinence after 60 (n=26) • 39 older controls
Results • EAA were comparabe to controls, except those abstinent before 50 were worse than controls on auditory working memory • EAA had larger craniums than controls • effect was strongest for those who drank the longest and had shortest abstinence • Such individuals also performed better cognitively
Conclusions • Older alcoholics who drank late into life, but with than six months abstinence can exhibit normal cognitive functioning. • Selective survivorship and selection bias likely play a part in these findings. • Cognitively healthier alcoholics, with more brain reserve capacity, may be more likely to live into their 60’s – 80’s with relatively intact cognition, and to volunteer for studies such as ours. • Our results do not imply that all elderly alcoholics with long-term abstinence will attain normal cognition
Decision-Making • Iowa Gambling Task (IGT) • Task performance • Voxel-based morphometry • Balloon Analogue Risk Task • Preliminary error-related negativity (ERN) data from treatment-naïve drinking alcoholics
