Anxiety, depression, and substance use disorders: diagnosis, treatment, and prescribing practices.

Attending physicians routinely encounter patients with signs and symptoms of anxiety and mood disorders as well as psychoactive substance use and psychoactive substance-induced organic mental disorders. These symptoms may represent either primary disorders or pathology that is secondary to other disorders. This article describes some of the relationships between substance use disorders and symptoms of anxiety and depressive disorders. In addition, some patients with these disorders may have a concurrent substance use disorder or be at high risk for developing one. Routine treatment of anxiety disorders with psychoactive drugs can be successful in many patients but may lead to iatrogenic dependence in high-risk patients. Prescribing for high-risk patients should include a stepwise treatment protocol having three progressive levels: (1) conservative, nonpharmacological approaches; (2) nonpsychoactive pharmacotherapy, including the use of anxioselective agents, such as buspirone; and (3) psychoactive pharmacotherapy, such as the use of benzodiazepines. Proper prescribing practices for high-risk patients are described in terms of diagnosis, dosage, duration, discontinuation, dependence, and documentation.     

Anxiety sensitivity and drug or alcohol use in individuals with anxiety and substance use disorders

Anxiety sensitivity (AS) has been linked to both pathological anxiety and substance use problems. We evaluated relations between AS and substance use situations among individuals with substance use disorders (SUDs) and concurrent DSM-IV anxiety disorders. We predicted that AS would be most strongly associated with substance use in situations involving negative emotions and interpersonal conflict in substance abusers with anxiety disorders. This group was compared to substance abusers with concurrent mood disorders and substance abusers without other disorders (N=88). AS was positively related to negative emotion situations substance use for substance abusers with anxiety disorders and for substance abusers without other disorders. Contrary to predictions, significant differences between these groups were not found. The relationship between AS and negative emotion situations substance use remained after controlling trait anxiety in a combined group (anxiety disorders and substance abuse only groups). AS did not predict substance use for participants with concurrent mood disorders. Identification of factors that place anxious patients at risk for substance use problems will have implications for treatment and for the prevention of this form of maladaptive coping.     

Depressive Symptoms and Associated Clinical Characteristics in Outpatients Seeking Community-Based Treatment for Alcohol and Drug Problems

Background: Comorbid psychiatric and substance use disorders are common and associated with poorer treatment engagement, retention, and outcomes. This study examines the presence of depressive symptoms and the demographic and clinical correlates in a diverse sample of substance abuse treatment seekers to better characterize patients with co-occurring depressive symptoms and substance use disorders and understand potential treatment needs. Methods: Baseline data from a randomized clinical effectiveness trial of a computer-assisted, Web-delivered psychosocial intervention were analyzed. Participants (N = 507) were recruited from 10 geographically diverse outpatient drug treatment programs. Assessments included the self-report Patient Health Questionnaire, and measures of coping strategies, social functioning, physical health status, and substance use. Results: One fifth (21%; n = 106) of the sample screened positive for depression; those screening positive for depression were significantly more likely to screen positive for anxiety (66.9%) and posttraumatic stress disorder (PTSD; 42.9%). After controlling for anxiety and PTSD symptoms, presence of depressive symptoms remained significantly associated with fewer coping strategies (P = .001), greater impairment in social adjustment (P < .001), and poorer health status (P < .001), but not to days of drug use in the last 90 days (P = .14). Conclusions: Depression is a clinically significant problem among substance abusers, and, in this study, patients who screened positive for depression were more likely to have co-occurring symptoms of anxiety and PTSD. Additionally, the presence of depressive symptoms was associated with fewer coping strategies and poorer social adjustment. Coping skills are a significant predictor of addiction outcomes, and it may be especially important to screen for and enhance coping among depressed patients. Evidence-based interventions that target coping skills and global functioning among substance abusers with depressive symptoms may be important adjuncts to usual treatment.     

Comparing Depressed Psychiatric Inpatients with and Without Coexisting Substance Use Disorders

ABSTRACT

Objectives: To better understand the complexities of coexisting substance abuse, this study explored psychosocial and clinical differences between individuals diagnosed only with a depressive disorder and those diagnosed with a depressive disorder coexisting with a substance use disorder.

Methods: Rates and sequelae of comorbidity were explored based on the medical records of patients admitted to the Alaska Psychiatric Institute (the only state-funded psychiatric hospital in Alaska) between January 1, 1993 and April 30, 2004. During this period, there were a total of 13,894 admissions for 7,317 patients. Of these patients, 469 met criteria for pure depressive disorders (with no past or current other psychiatric diagnoses); of these, 321 (68.4%) had coexisting substance use disorder and 148 (31.6%) had no coexisting substance use disorder.

Results: Findings revealed that patients with a depressive disorder and coexisting substance use have greater complexity in terms of psycho-social circumstances, demographics, and clinical presentation than do patients with a depressive disorder only; however, such patients have fewer admissions, shorter lengths of stay, and fewer total days in hospital.

Conclusions: These findings suggest that care must be taken when diagnosing individuals with depression as the presence of a coexisting substance use disorder may call for a different intervention strategy. These results differ from prior research examining coexisting schizophrenia and substance use disorders, suggesting that a substance use disorder has differing sequelae depending upon the type of coexisting psychiatric disorder.     

Risks of major depressive disorder and anxiety disorders among Thais with alcohol use disorders and illicit drug use: Findings from the 2008 Thai National Mental Health survey

Little is known about the risks of mood and anxiety disorders among Asians with alcohol use disorders and the effect of illicit drug use in this population. All participants from the 2008 Thai National Mental Health survey (N=17,140) were assessed for current major depressive disorder, anxiety disorders, and alcohol use disorders by using the Mini International Neuropsychiatric Interview (MINI) and were interviewed for illicit drug use within one year prior to their assessment. Logistic regression modeling was used to determine (a) whether alcohol use disorders were associated with major depressive disorder and anxiety disorders and (b) whether the use of illicit drugs increased these associations. Sex, age, marital status, region, and educational level were found to be significantly associated with major depressive disorder and anxiety disorders and were taken into account in the regression analysis. Compared with the general population, individuals with alcohol use disorders alone had significantly increased risks of major depressive disorder (OR 2.49, 95%CI 1.76-3.53 in men and OR 4.09, 95%CI 2.31-7.26 in women) and anxiety disorders (OR 2.21, 95%CI 1.46-3.36 in men and OR 4.34, 95%CI 2.35-8.03 in women). The risks became higher among individuals with both alcohol use disorders and illicit drug use (OR 3.62, 95% CI 1.64-8.01 in men and OR 11.53, 95%CI 1.32-100.65 in women for major depressive disorder, and OR 3.20, 95%CI 1.36-7.51 in men and OR 13.10, 95%CI 1.48-115.60 in women for anxiety disorders). In conclusion, alcohol use disorders were significantly associated with major depressive disorder and anxiety disorders. Illicit drug use was an important factor in increasing these associations, especially in women. Screening for depression, anxiety, and illicit drug use should be done in individuals with alcohol use disorders.     

Retrospective use of alcohol and other substances by college students: psychometric properties of a new measure

Using a new retrospective measure, interviews regarding alcohol and other substance use for the 5-year period preceding entry to college were conducted twice (with a 3-week interval) among 111 college students. Test-retest reliability was uniformly high across alcohol and substance use items (mean of Pearson correlations=.85), as were intraclass correlation coefficients (mean=.81) and kappa coefficients. A latent growth model (LGM) was specified and evaluated to test a hypothesized linear trend in alcohol use across the 5-year interval referenced by the retrospective measure. Furthermore, convergent and discriminant validity were provided as the slope (or rate of acceleration) parameter associated with the retrospective assessment predicted current alcohol disorders but not other disorders (e.g., depressive or anxiety disorders). The intercept predicted both current substance disorders (principally marijuana disorders) and anxiety disorders. Findings were discussed with regard to the use of this retrospective interview measure to screen for serious alcohol and other substance use prior to new students entering college, thereby affording opportunity for early interventions.     

Pharmacotherapy of Comorbid Mood,Anxiety, and Substance Use Disorders

Mood and anxiety disorders commonly co-occur with substance use disorders. Exploration of the neurobiology of substance use disorders and mood and anxiety disorders have found that the neural circuitry in mood, anxiety, and substance use disorders is clearly overlapping. These discoveries have encouraged the exploration of a number of pharmacotherapeutic agents in the treatment of co-occurring mood, anxiety, and substance use disorders. In this article, recent data on the pharmacotherapeutic treatment of mood and anxiety disorders in individuals with substance use disorders are reviewed. Some of the barriers to the use of pharmacotherapy in individuals with substance use disorders are discussed.     

Pharmacotherapy of comorbid mood, anxiety, and substance use disorders

Mood and anxiety disorders commonly co-occur with substance use disorders. Exploration of the neurobiology of substance use disorders and mood and anxiety disorders have found that the neural circuitry in mood, anxiety, and substance use disorders is clearly overlapping. These discoveries have encouraged the exploration of a number of pharmacotherapeutic agents in the treatment of co-occurring mood, anxiety, and substance use disorders. In this article, recent data on the pharmacotherapeutic treatment of mood and anxiety disorders in individuals with substance use disorders are reviewed. Some of the barriers to the use of pharmacotherapy in individuals with substance use disorders are discussed.     

The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders

The current study examined the relationship between co-occurring substance use and Axis I psychiatric disorders and treatment utilization and outcome among homeless individuals (N=365) who participated in an episode of intensive outpatient substance use treatment. Compared to patients without a co-occurring diagnosis, homeless patients with a diagnosis of major depressive disorder or PTSD participated in more substance use treatment. Diagnostic status did not predict 12-month alcohol or drug treatment outcome. Substance use treatment programs appear to successfully engage homeless individuals with major depressive disorder and PTSD in treatment. Such individuals appear to achieve similar benefits from standard substance use treatment as do homeless individuals without such disorders.     

Advances in recognition and treatment of social anxiety disorder: a 10-year retrospective

Social anxiety disorder frequently begins in early life and is associated with the subsequent development of comorbid conditions such as depressive and substance use disorders. Social anxiety disorder, particularly the generalized subtype, is characterized by marked impairment in numerous functional domains, including education and social relations. Paroxetine, the first medication to receive an indication in the United States for the treatment of social anxiety disorder, has been shown to be effective in 50% to 60% of patients. The mechanism of action of paroxetine in the treatment of social anxiety disorder is at present unclear. A possible role for early treatment to prevent complications of social anxiety disorder should be explored.     

Anxiety disorders among patients with co-occurring bipolar and substance use disorders

Bipolar and substance use disorders are known to co-occur frequently, but limited attention has been paid to anxiety disorders that may accompany this dual diagnosis. Therefore, we examined the prevalence and nature of anxiety disorders among treatment-seeking patients diagnosed with current bipolar and substance use disorders, and investigated the association between anxiety disorders and substance use. Among 90 participants diagnosed with bipolar disorder I (n = 75, 78%) or II (n = 15, 22%), 43 (48%) had a lifetime anxiety disorder, with post-traumatic stress disorder (PTSD) occurring most frequently (n = 21, 23%). We found that those with PTSD, but not with the other anxiety disorders assessed, began using drugs at an earlier age and had more lifetime substance use disorders, particularly cocaine and amphetamine use disorders, than those without PTSD. Further examination revealed that (1) most participants with PTSD were women, (2) sexual abuse was the most frequently reported index trauma, and (3) the mean age of the earliest index trauma occurred before the mean age of initiation of drug use. Our findings point to the importance of further investigating the ramifications of a trauma history among those who are dually diagnosed with bipolar and substance use disorders.     

Polydrug dependence and psychiatric comorbidity among heroin injectors

The prevalence of diagnoses of substance dependence, anxiety disorders and depressive disorders were estimated in a sample of 222 heroin injectors, using the Composite International Diagnostic Interview. Subjects had a median of three lifetime substance diagnoses and two current diagnoses. A total of 60% met the criteria for a lifetime anxiety disorder, and 51% had a current anxiety disorder. A depressive disorder was diagnosed in 41% of subjects, with 30% having a current diagnosis. There were significant positive correlations between the number of lifetime drug dependence diagnoses and the number of lifetime anxiety and affective disorders (r = 0.41), and the number of current drug dependence diagnoses and the number of current comorbid diagnoses (r = 0.32). After controlling for other variables, the only significant independent predictor of the number of lifetime and current dependence diagnoses was the number of comorbid diagnoses.     

Concurrent anxiety and substance use disorders among outpatients with major depression: clinical features and effect on treatment outcome

BackgroundDepressed patients often present with comorbid anxiety and/or substance use disorder. This report compares the four groups defined by the disorders (anxiety disorder, substance use disorder, both, and neither) in terms of baseline clinical and sociodemographic features, and in terms of outcomes following treatment with citalopram (a selective serotonin reuptake inhibitor).MethodsThe Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial enrolled 2838 outpatients with non-psychotic major depressive disorder (MDD) from 18 primary and 23 psychiatric care clinics. Clinical and sociodemographic features were assessed at baseline. These baseline features and the treatment outcomes following treatment with citalopram were compared among the four groups.ResultsParticipants with non-psychotic MDD and comorbid anxiety and/or substance use disorder showed several distinctive baseline sociodemographic and clinical features. They also showed greater depression severity; length of illness; likelihood of anxious, atypical or melancholic features; more intolerance/attrition; and worse remission/response outcomes with treatment. Participants with either anxiety or substance use disorder showed outcomes generally intermediate between those with both and those with neither.ConclusionsComorbid anxiety and/or substance use disorder are clinically identifiable, and their presence may define distinct MDD subgroups that have more problems and worse pharmacological treatment outcomes. They may benefit from more aggressive, multi-faceted treatment and psychosocial rehabilitation targeted at reducing their psychological comorbidity and functional impairment.     

Reasons for substance use and vulnerability factors in patients with substance use disorder and anxiety or mood disorders

This cross-sectional study examined the reasons for substance use and the presence of vulnerability factors such as substance sensitivity, sensation seeking, and symptoms related to the attention deficit hyperactivity disorder (ADHD) in patients with substance use disorder (SUD) and comorbid mood and anxiety disorders by using the Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS), a novel instrument designed to explore the spectrum of substance use and its clinical correlates. Study participants included 61 patients with SUD and mood or anxiety disorder, and two comparison groups including 35 patients with SUD only and 50 controls not in treatment for mental disorders or SUD. We found that patients with co-morbid mood or anxiety disorder had significantly higher scores on the SCI-SUBS domains 'substance sensitivity' and 'self-medication' as compared to those with SUD only. Scores on 'sensation seeking' and 'ADHD' domains were similar between both groups of patients and higher than in controls. Patients with comorbid mood or anxiety disorders showed a higher sensitivity to substances and were more prone to self-medication than those with SUD only. These characteristics should be taken into account in the diagnostic assessment and in long-term treatment to decrease the risk of relapse.     

Axis I psychiatric comorbidity among adult inhalant dependents seeking treatment

The present study aimed to investigate the prevalence of Axis I disorders in adult inhalant-dependent patients in comparison to other substance-dependent patients and subjects without substance use disorders. The inhalant-dependent group consisted of 83 male inpatient and outpatient adults diagnosed according to DSM-IV criteria. This group was compared with 74 other substance-dependent patients and with 70 subjects without alcohol and substance use disorder diagnoses. Ninety-three percent of the inhalant dependents had a lifetime history of at least one type of comorbid Axis I disorder, while 77% of the same subjects had at least one type of any affective disorder and 75.9% of them had at least one type of anxiety disorder. Prevalence of Axis I disorders among inhalant dependents was 72.3% for lifetime major depression, 41% for major depression during the past month, 24% for dysthymic disorder, 20.5% for inhalant-induced depressive disorder, 27.7% for panic disorder, 30% for PTSD, 36.1% for social phobia and 20.5% for generalized anxiety disorder. The rate of lifetime axis I disorders was higher in patients with inhalant dependency in comparison to the other two groups. This finding suggests that inhalant-dependent adults have high rates of comorbid psychiatric problems, and that it is important to determine Axis I disorder comorbidity in this population before making an inpatient or outpatient treatment plan.     

Pharmacotherapy for bipolar disorder and comorbid conditions: baseline data from STEP-BD

Relatively absent from previous studies of the pharmacotherapy for bipolar disorder is examination of the impact of comorbidity on treatment choices. This has occurred despite the presence of high levels of comorbid anxiety and substance use disorders, and the association of these disorders with severity and course markers of bipolar disorder. In this study, we examined comorbid disorders, identified by structured interviews, and the pharmacotherapy reported at study entry by the first 1000 patients entered into a large, multicenter study of bipolar disorder (Systematic Treatment Enhancement Program for Bipolar Disorder). Our study focused on the degree to which comorbid conditions are linked to the reported use of mood stabilizers deemed "minimally adequate" and the association between specific comorbidities and pharmacotherapy treatment, such as the use of anxiolytics in patients with anxiety disorders. Despite the presence of high levels of comorbidity, the presence of these disorders was only minimally associated with pharmacotherapy. Of the sample of bipolar outpatients, only 59% reported pharmacotherapy use meeting criteria for "minimally adequate" mood stabilizer, regardless of comorbid diagnoses, rapid cycling, or bipolar I or II status. Moreover, the cross-sectional use of "comorbidity-specific" pharmacotherapy for anxiety disorders, substance use disorders, and attention deficit disorder in this outpatient sample of patients with bipolar disorders was limited, suggesting that comorbid conditions in patients with bipolar disorder may be undertreated. Our findings highlight the need for greater clinical guidance and treatment options for patients with bipolar disorder and comorbidity.     

Transdiagnostic processes linking anxiety symptoms and substance use problems among adolescents

Numerous anxiety syndromes co-occur with substance use problems in adolescents, though the mechanisms underlying these comorbidities are not well understood. There are 3 transdiagnostic processes—anxiety sensitivity (fear of anxiety-related sensations), distress tolerance (capacity to withstand emotional distress), and negative urgency (propensity to respond impulsively to negative emotion)—that have been implicated in various anxiety and substance use problems. To examine whether anxiety sensitivity, distress tolerance, and negative urgency statistically mediated relations between symptoms of 3 different anxiety disorders (social anxiety, generalized anxiety, and panic disorders) and alcohol and cannabis use problems, cross-sectional analysis of high school students in Los Angeles (N = 3002) was assessed via paper and pencil questionnaires. When mediators were entered simultaneously, negative urgency accounted for a significant 33 to 85% of the covariance between anxiety symptomatology and substance use problems over and above the other trandiagnostic processes. This pattern was consistent across all 3 anxiety syndromes and both alcohol and cannabis problems. Anxiety sensitivity and distress tolerance did not account for positive associations between anxiety symptoms and substance use problems. Negative urgency may be an important mechanism underlying the relationship between various types of anxiety and substance use problems in adolescence, and thus represents a possible target for preventive interventions targeting adolescent anxiety and substance use.     

Benefits and risks of using antidepressants in children and adolescents

The present controversy about the use of selective serotonin re-uptake inhibitors in paediatric patients has been the subject of many publications. This article summarises the available data on the efficacy and safety of selective serotonin re-uptake inhibitors and other non-tricyclic antidepressants in children and adolescents with mental disorders. These data are compared with those related to the efficacy and safety of tricyclic antidepressants. If selective serotonin re-uptake inhibitors appear to be the drugs of choice in depressive and anxiety disorders, their effects are strongest in non-obsessive-compulsive anxiety disorders, intermediate in obsessive-compulsive disorders and more modest in major depressive disorders. All antidepressants may induce psychiatric and suicide-related adverse events. In this respect, the balance of benefit and risk seems to favour fluoxetine as the first-choice antidepressant. Above all, this review emphasises research questions that need to be answered fully about the potential role of antidepressants in the management of children and adolescents with psychiatric disorders. Given these unanswered questions, the use of antidepressant medications in children and adolescents should remain cautious and well monitored.     

The Effects of Heroin Addiction on Teeth

Abstract

The present study aimed to investigate the prevalence of Axis I disorders in adult inhalant-dependent patients in comparison to other substance-dependent patients and subjects without substance use disorders. The inhalant-dependent group consisted of 83 male inpatient and outpatient adults diagnosed according to DSM-IV criteria. This group was compared with 74 other substance-dependent patients and with 70 subjects without alcohol and substance use disorder diagnoses. Ninety-three percent of the inhalant dependents had a lifetime history of at least one type of comorbid Axis I disorder, while 77% of the same subjects had at least one type of any affective disorder and 75.9% of them had at least one type of anxiety disorder. Prevalence of Axis I disorders among inhalant dependents was 72.3% for lifetime major depression, 41% for major depression during the past month. 24% for dysthymic disorder, 20.5% for inhalant-induced depressive disorder, 27.7% for panic disorder. 30% for PTSD, 36.1% for social phobia and 20.5% for generalized anxiety disorder. The rate of lifetime axis I disorders was higher in patients with inhalant dependency in comparison to the other two groups. This finding suggests that inhalant-dependent adults have high rates of comorbid psychiatric problems, and that it is imponant to determine Axis I disorder comorbidity in this population before making an inpatient or outpatient treatment plan.     

Axis I and Axis II disorders in alcoholics and drug addicts: fact or artifact?

OBJECTIVE: It has been argued that Axis I and Axis II disorders diagnosed in substance users refer to substance-induced conditions rather than to independent psychiatric conditions; this argument will be referred to as the substance-related artifact hypothesis. Furthermore, Axis II symptoms co-occurring with Axis I disorders have been attributed to the contamination of personality assessment by mood and/or anxiety state effects (the trait-state artifact hypothesis). The present study is the first to prospectively examine the validity of these two hypothesized "artifacts" in substance users. METHOD: In 276 individuals (57.6% female) applying for substance use treatment, current substance use disorders, mood/anxiety disorders and Axis II disorders were diagnosed using semistructured interviews both at baseline and at 1-year follow-up. The substance-related artifact hypothesis is tested by examining the covariation between recovery from substance use disorders on the one hand and recovery from and/or improvement of mood/anxiety and Axis II disorders on the other hand. The trait-state artifact hypothesis is tested by examining the covariation between recovery from mood/anxiety disorders on the one hand and recovery from and/or improvement of Axis II disorders on the other hand. RESULTS: Recovery from substance use disorders covaried with recovery from and improvement of mood/anxiety disorders, but not with recovery from or improvement of Axis II pathology. Furthermore, recovery from mood/anxiety disorders covaried with recovery from and improvement of personality disorders, in particular Cluster C disorders. CONCLUSIONS: Results from this study suggest that mood/anxiety disorders, but not personality disorders, diagnosed among people with substance use disorder may partly reflect substance-related artifacts. Furthermore, this study provides evidence for the contention that semistructured interview assessment of Axis II, at least without inquiry on an item-by-item basis, is susceptible to contamination by mood/anxiety state effects.