Comorbid Psychiatric Syndromes and Substance Dependence

Marc A. Schuckit, M.D.

September 14, 1999/Kona, Hawaii

Outline and Bibliography.

I. Psychiatric symptoms are common in the context of substance dependence.

A. 2 out of 3 individuals with substance use disorders meet criteria for another psychiatric syndrome.

B. Half of these are other substance use disorders or ASPD.

C. When patients do present with these multiple syndromes, the clinician must determine which to address, and whether the treatment of one interferes with the treatment of others.

II. In addressing these problems, diagnosis is the key to prognosis and treatment.

A. Clinicians must distinguish between drinking or substance use versus dependence, sadness versus major depression, hyperactivity versus mania, and anxiety symptoms versus full-blown DSM-IV anxiety disorders.

B. Furthermore, in order to choose the optimal treatment, it is essential to distinguish between temporary psychiatric syndromes caused by medical disorders, medications, or substances of abuse versus independent psychiatric disorders.

C. This presentation will review the clinical approach to these complex problems , highlighting a variety of different disorders.

III. Depressive symptoms in substance dependence.

A. Temporary depressive symptoms can occur related to a variety of medical conditions.

B. Symptoms of sadness are common, especially with brain depressants and stimulants.

C. There are multiple explanations for the relationship between substance dependence and depressive episodes.

D. A major explanation is a substance-induced temporary depression. These relate to the direct effects of the substances in the brain.

E. The distinction between induced and independent major depressions in the context of substance dependence is made through a timeline.

F. There are multiple sources of data that support the importance of substance induced depressions. This presentation will review data gathered from our own laboratory as well as from the Collaborative Study on the Genetics of Alcoholism.

1. Alcohol causes depression.

2. Many alcoholics present with depressive symptoms.

3. The majority of depressive symptoms are substance induced.

4. Depressive symptoms in the context of independent and induced depressions are very similar.

5. Independent and induced depressions breed true.

6. The depressive symptoms are temporary.

7. Children of alcoholics show no increase in major depressive episodes.

IV. Similar data can be given regarding bipolar disorders.

A. It is essential to distinguish between acute or protracted withdrawal related overactivity versus true mania.

B. Most cases of apparent bipolar disorder in substance dependent individuals are temporary substance-induced conditions.

C. Even after controlling for these factors, however, there is a greater than chance relationship between independent bipolar disorder and substance dependence.

D. There are a number of potential explanations for this relationship, including genetic factors.

V. Similar conclusions can be drawn regarding the major anxiety disorders.

VI. There are few data to support the importance of "self-medication" for most psychiatric disorders.

VII. The treatment implications of these data are discussed, with an emphasis on the use of a timeline approach. Specific case vignettes will be presented.

VIII. Bibliography.

1. Raimo, EB, Schuckit, MA: Alcohol dependence and mood disorders. Addict Behav 1998; 23: 933-946

2. Schuckit, MA, Hesselbrock, VM: Alcohol dependence and anxiety disorders: what is the relationship? Am J Psychiatry 1994; 151: 1723-1734

3. Schuckit, MA, Tipp, JE, Bergman, M, Reich, W, Hesselbrock, VM, Smith, TL: Comparison of induced and independent major depressive disorders in 2,945 alcoholics. Am J Psychiatry 1997; 154: 948-957

4. Schuckit, MA, Tipp, JE, Smith, TL, Buckolz, KK: Periods of abstinence following the onset of alcohol dependence in 1,953 men and women. J Stud Alcohol 1997; 58: 581-589

5. Schuckit, MA, Tipp, JE, Bucholz, KK, Nurnburger, JI, Hesselbrock, VM, Crowe, RR, Kramer, J: The life-time rates of three major mood disorders and four major anxiety disorders in alcoholics and controls. Addiction 1997; 92: 1289-1304.

6. Schuckit, MA: Alcohol, anxiety, and depressive disorders. Alcohol Health & Research World 1996; 20: 81-85.

7. Schuckit, MA, Smith, TL: An 8-year follow-up of 450 sons of alcoholic and control subjects. Arch Gen Psychiatry 1996; 53:202-210.

8. Schuckit, MA, Hesselbrock, VM, Tipp, J, Nurnberger, JI, Anthenelli, RM, Crowe, RR: The prevalence of major anxiety disorders in relatives of alcohol dependent men and women. J Stud Alcohol 1995; 56: 309-317.