Teenage chemical dependence and the prevalence of psychiatric disorders: Issues for prevention

Abstract

Initial figures indicating teenage chemical use, misuse, and dependence with coexistent psychiatric disorder are investigated because of increasing dual diagnosis admissions to medical, chemical dependence, and psychiatric inpatient units. A group of chemically dependent adolescents is further studied in comparison to a group of nonchemically dependent high school students. Data shows significantly more suicide attempts, early childhood abuse incidents, previous psychiatric interventions, special education classifications, and familial divorce and familial alcoholism in the chemical dependency group. Links to dual diagnosis results are discussed. Primary and secondary prevention discussion and conclusions follow from the data and its elaboration.     

Correlates of co-occurring ADHD in drug-dependent subjects: prevalence and features of substance dependence and psychiatric disorders

We examined the prevalence and course of psychiatric and substance dependence (SD) disorders in subjects with SD and attention deficit hyperactivity disorder (ADHD). METHOD: We interviewed 1761 adults with a lifetime diagnosis of cocaine and/or opioid dependence using the Semi-Structured Assessment for Drug Dependence and Alcoholism. Generalized linear regression with generalized estimating equation analysis was used to examine the associations between a lifetime diagnosis of ADHD and indicators of clinical course, and to identify unique correlates of ADHD. RESULTS: Lifetime ADHD prevalence in the SD sample was 5.22% (vs. 0.85% in a group of individuals without SD). ADHD was associated with an earlier age of first substance use, more SD and psychiatric diagnoses, a greater likelihood of attempted suicide, and more hospitalizations. After controlling for conduct disorder, there were unique effects of ADHD on age of first substance use and number of SD diagnoses. CONCLUSION: In subjects with cocaine or opioid dependence, ADHD is associated with greater SD and psychiatric comorbidity and a more severe course of illness.     

Drug-induced psychiatric disorders

This article is a review of the principal drug-induced psychiatric symptoms that are likely to be encountered in daily clinical practice as a result of drug abuse, overdoses or side effects of drugs prescribed for treatment. Many categories of medication have the potential to produce psychiatric symptoms, but antitubercular drugs, hypotensive agents and steroids have the highest incidence in clinical practice. Additionally, the problems of alcohol are all too frequently overlooked. The variety and frequency of secondary psychiatric symptoms which may be drug-related emphasise the importance of a careful consideration of all drugs taken by a patient with psychiatric complaints, to determine causal association with symptoms.     

Pharmacogenomics of psychiatric disorders

Pharmacogenomics, the utilization of genetic information to predict outcome of drug treatment (therapeutic and side-effects), holds great promise for clinical medicine. The pharmacotherapy of psychiatric disorders exhibits wide variability in therapeutic response with little scientific guidance for treatment on a patient-by-patient basis. The emerging field of pharmacogenomics holds great potential for refining and optimizing psychopharmacology. Key components for future development of the pharmacogenomics of psychiatric disorders include understanding the mechanism of drug action, identification of candidate genes and their variants, and well-conducted clinical trials. In this article, data from recent studies are examined with particular emphasis on methodological requirements and direction for future research.     

Substance-induced dissociative disorders and psychiatric nosology

Transient amnesias, fugues, twilight states, automatisms, depersonalization, and furors or explosive disorders can occur in association with, or be caused by, various medications or substance-induced organic brain states. Agents capable of precipitating dissociative-like states include alcohol, barbiturates and similarly acting hypnotics, benzodiazepines, scopolamine, clioquinol, beta-adrenergic blockers, marijuana and certain psychedelic drugs, general anesthetics, and others. The presentations of substance-induced dissociative states may resemble those of functional dissociative disorders, or organic and psychogenic dissociative factors may coexist and be intertwined or indistinguishable. Organic dissociative states are distinct from intoxication, amnestic disorder, frank delirium, or other organic mental disorders as specified in DSM-III and DSM-III-R, yet these diagnostic manuals have no inclusive category or coherent nosological approach to dissociative states not strictly psychogenic in etiology. Substance-induced and other organic dissociative disorders can have clinical, medicolegal, and neuropsychological significance. They provide a unique opportunity for the study of mind-brain relationships and should be included in psychiatric nosology.     

Radiopharmaceuticals in neurological and psychiatric disorders

The development of functional brain nuclear medicine techniques and their application in the investigation of neuropsychiatric disorders, have contributed significantly in the illumination of the underlying pathophysiological processes of these disorders. Furthermore, Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) brain studies provide information in early diagnosis, differential diagnosis, development of new drugs, and monitoring the response to therapeutic management. SPECT and PET brain imaging require the use of radiopharmaceuticals that cross the intact Blood Brain Barrier (BBB). Such radiotracers have been used in regional Cerebral Blood Flow (rCBF) SPECT and PET imaging and brain metabolism imaging with PET; these are well established methods in the diagnosis and management of various cerebral vascular diseases (e.g. stroke, dementia, epilepsy). Advances in radiotracer chemistry have resulted in the development of molecular imaging which represents the molecular and cellular processes of neuropsychiatric diseases. SPECT and PET molecular imaging has become available for the study of acetylcholinergic, dopaminergic and serotonergic systems, as well as for benzodiazepine and opioid receptors, with promising results. More studies are needed to validate the role of molecular imaging in the clinical practice of neuropsychiatric disorders.     

Epigenetic biomarkers in psychiatric disorders

The discovery of biomarkers in psychiatric disorders may help in the diagnosis, prevention and treatment of patients with these disorders. Here, I discuss the potential role of epigenetic biomarkers, that is, epigenetically altered genes and/or expression patterns of proteins or metabolites, in psychiatric disorders. Before epigenetic biomarkers can be clinically applied in these disorders, several issues need to be addressed. These include establishing a connection between biomarkers and the disease process; determining the predictive quality of the biomarkers; determining the effects of disease heterogeneity on the biomarkers; and identifying sample sources for the biomarkers that are easily accessible for testing.     

Use of carbamazepine in psychiatric disorders

Use of carbamazepine for the treatment of psychiatric disorders is reviewed. Carbamazepine's mechanism of action may be related to inhibition of kindling (repeated subtherapeutic electrical stimulation) in the temporal lobe and limbic system. In most published studies, carbamazepine was useful in affective disorders, especially in patients with bipolar manic disorders. In controlled, double-blind studies in patients with primary affective or schizoaffective disorders, carbamazepine significantly decreased manic symptoms and showed some antidepressant effect. Synergistic effects have been observed when carbamazepine is used with lithium. Carbamazepine has been reported to decrease symptoms in patients with aggression, dyscontrol syndromes, schizophrenia, and alcohol withdrawal syndrome, but few of these studies have been controlled, comparative trials; carbamazepine may be useful in patients with these disorders who do not respond to conventional therapies. Beneficial effects of carbamazepine in psychiatric disorders are usually observed with doses of 400-1600 mg/day and serum concentrations of 8-12 micrograms/mL. Carbamazepine is useful alone or in combination with other agents for bipolar affective disorders, especially in patients who are intolerant of or unresponsive to lithium. Serum carbamazepine concentration, hematological profile, and serum electrolytes should be monitored carefully to minimize the risk of toxicity.     

Alcoholism and psychiatric disorder in patients who present to different services in Wellington

Alcohol dependence and abuse have been commonly found to coexist with other psychiatric disorders. In order to further investigate this relationship two populations with combined dysfunctional alcohol use and psychiatric illness were studied, one at an alcohol treatment centre and one at a general hospital psychiatric service. Sixty of the 63 people screened at the alcohol treatment centre and 41 of the 43 people with an alcohol problem at the psychiatric unit, met the combined criteria, thus confirming that a very high proportion of people with alcohol problems, and who present for treatment, also have additional psychiatric disorders. The two sample populations were similar on sociodemographic variables. There were differences in the types of psychiatric disorders occurring at the two treatment centres with depression predominating at the psychiatric unit and anxiety disorders occurring more frequently at the alcohol treatment facility. Both samples showed a high rate of schizophrenia. The sample at the alcohol treatment centre showed higher levels of alcohol consumption and had higher rates of problems associated with alcohol. Service delivery issues are discussed in relation to these results. The importance of psychiatric symptoms in both the genesis of dysfunctional drinking and in service utilisation are highlighted.     

Induced psychiatric and somatic disorders to cannabis

Cannabis is the most consumed illicit drug. For a number of years it was thought to be not very toxic, although this idea has no scientific backup. The object of much controversy, it is a public health problem for the most vulnerable populations, adolescents, subjects with evolutive psychopathologies and certain highly cognitive situations: driving a car, the professional environment and students. Cannabis breeds, in international classifications of mental disorders, intoxication charts, abuse and dependence, although this last could have been challenged. The complications are basically anxious and psychotic. It is the object of a number of debates associated with schizophrenic disorders, where it seems to be a risk factor where there is a large consumption before the age of fourteen. Like all psychoactive substances, it is an aggravating factor in all evolutive psychopathologies.     

Use of olanzapine in non-psychotic psychiatric disorders

The history of antipsychotic medications begins in the 1950s with chlorpromazine, developed originally as an antihistamine but found to be an aid in the reduction of symptoms of delusions and hallucinations. This phenothiazine derivative was followed by numerous others in the same class (e.g., thioridazine) and then by antipsychotics in other classes (e.g., the popular haloperidol of the butyrophenone class). This group of medications is associated with a number of unpleasant side effects and complications. These included extrapyramidal symptoms (EPS), orthostatic hypotension, hyperprolactinemia and last, but certainly not least, tardive dyskinesia (TD). As a consequence, other alternative antipsychotics were developed in which D(2) blockade effect generally associated with EPS and TD was offset by 5-HT(2) antagonism. The first of this class was clozapine; however, it is associated with agranulocytopenia of sudden onset as well as seizure induction. However, olanzapine, a close structural relative, was soon synthesised for treatment of psychosis and particularly schizophrenia (Zyprexatrade mark, Eli Lilly). It was released in the US in November 1996 with FDA approval for that indication. However, antipsychotics have always been used for other psychiatric disorders, aside from schizophrenia. This includes, in particular, mania, where chlorpromazine use predated lithium as an effective treatment. Other uses for antipsychotics have included other mood disorders, dementia, childhood disorders and personality problems. Here, information on the application of olanzapine to non-schizophrenic disorders is reviewed. Despite the fact that the research post-dates FDA approval in 1996, there was already sufficient evidence for olanzapine's effectiveness in acute mania to obtain approval from the US FDA in March 2000. Other research supports its use as adjunctive therapy in depressive disorders. Phase IV studies and case reports have found limited support for olanzapine's use in a variety of other psychiatric disorders, behavioural disorders of dementia (including Alzheimer's disease), pervasive developmental disorder of childhood, obsessive-compulsive disorder and borderline personality disorder. In each of these latter diagnoses, double-blind studies are either underway or are planned to establish efficacy.     

Stress and hippocampal abnormalities in psychiatric disorders.

The hippocampus plays a main role in regulating stress response in humans, but is itself highly sensitive to neurotoxic effects of repeated stressful episodes. Hippocampal atrophy related to experimental stress has been reported in laboratory studies in animals. Several controlled brain imaging studies have also shown hippocampal abnormalities in psychiatric disorders, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and borderline personality disorder (BPD). This paper reviews the physiological role of the hippocampus in stress circuitry and the effects of stress on cognitive functions mediated by the hippocampus. We also review brain imaging studies investigating hippocampus in PTSD, MDD, and BPD. This literature suggests that individuals with PTSD, MDD, and BPD may suffer hippocampal atrophy as a result of stressors associated with these disorders. Prospective, longitudinal studies will be needed in high-risk offspring and first-episode subjects to explore the relationship between stress and hippocampal atrophy in these neuropsychiatric illnesses.     

Use of olanzapine in non-psychotic psychiatric disorders

The history of antipsychotic medications begins in the 1950s with chlorpromazine, developed originally as an antihistamine but found to be an aid in the reduction of symptoms of delusions and hallucinations. This phenothiazine derivative was followed by numerous others in the same class (e.g., thioridazine) and then by antipsychotics in other classes (e.g., the popular haloperidol of the butyrophenone class). This group of medications is associated with a number of unpleasant side effects and complications. These included extrapyramidal symptoms (EPS), orthostatic hypotension, hyperprolactinemia and last, but certainly not least, tardive dyskinesia (TD). As a consequence, other alternative antipsychotics were developed in which D₂ blockade effect generally associated with EPS and TD was offset by 5-HT₂ antagonism. The first of this class was clozapine; however, it is associated with agranulocytopenia of sudden onset as well as seizure induction. However, olanzapine, a close structural relative, was soon synthesised for treatment of psychosis and particularly schizophrenia (Zyprexa?, Eli Lilly). It was released in the US in November 1996 with FDA approval for that indication. However, antipsychotics have always been used for other psychiatric disorders, aside from schizophrenia. This includes, in particular, mania, where chlorpromazine use predated lithium as an effective treatment. Other uses for antipsychotics have included other mood disorders, dementia, childhood disorders and personality problems. Here, information on the application of olanzapine to non-schizophrenic disorders is reviewed. Despite the fact that the research post-dates FDA approval in 1996, there was already sufficient evidence for olanzapine’s effectiveness in acute mania to obtain approval from the US FDA in March 2000. Other research supports its use as adjunctive therapy in depressive disorders. Phase IV studies and case reports have found limited support for olanzapine’s use in a variety of other psychiatric disorders, behavioural disorders of dementia (including Alzheimer’s disease), pervasive developmental disorder of childhood, obsessive-compulsive disorder and borderline personality disorder. In each of these latter diagnoses, double-blind studies are either underway or are planned to establish efficacy.