Schizophrenia and comorbid substance abuse

Research suggests that nearly half of all patients with schizophrenia concurrently abuse substances. However, despite the prevalence of substance abuse among persons with schizophrenia, the effective treatment of these comorbid conditions has eluded mental health professionals for decades. Apart from the obvious problems associated with schizophrenia and alcohol or drug abuse, schizophrenic persons who abuse substances also experience increased rates of depression, suicide, homelessness, unemployment, and illegal activity. These diverse problems necessitate interventions that address the special needs of this population. Research indicates that the use of atypical antipsychotic agents with persons who have a dual diagnosis may prove to be efficacious with treatment, overall. This article reviews the current literature pertaining to the potential expanded therapeutic benefits of enhanced efficacy of atypical antipsychotic medication in association with decreased substance use and craving.     

Characteristics of Cocaine Users Presenting to an Emergency Department Chest Pain Observation Unit

Objectives: This report examines the sociodemographic and substance use characteristics, co-occurring psychological status, substance abuse consequences, and prior experiences with substance abuse treatment among patients with cocaine-associated chest pain presenting to an emergency department chest pain observation unit. Methods: This was a consecutive cohort of patients in the emergency department chest pain observation unit aged 18–60 years with low to moderate risk for acute coronary syndrome and recent cocaine use. Responses on standardized and validated instruments were used to examine demographic and clinical characteristics of the sample and to compare patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for past three-month substance abuse or substance dependence with patients who did not. Results: Of 145 eligible patients identified between June 1, 2002, and February 29, 2004, 86% met criteria for a lifetime DSM-IV substance use disorder and 50% met past three-month criteria. Approximately one half of the total sample reported substantial symptoms of depression. Substance use frequency and consequences, depression, and psychological distress were significantly more severe among those with past three-month substance use diagnoses; however, most sociodemographic characteristics were not associated with substance use diagnoses. Interest in treatment services and treatment history was also significantly associated with the presence of a substance use disorder diagnosis. Conclusions: Findings regarding diversity in alcohol and drug involvement, current level of psychological functioning, depressive symptomatology, and interest in treatment services provide useful information for designing emergency department–based interventions for this population.     

Adult ADHD: evaluation and treatment in family medicine

Attention-deficit/hyperactivity disorder (ADHD) affects 30 to 50 percent of adults who had ADHD in childhood. Accurate diagnosis of ADHD in adults is challenging and requires attention to early development and symptoms of inattention, distractibility, impulsivity and emotional lability. Diagnosis is further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions such as depression and substance abuse. While stimulants are a common treatment for adult patients with ADHD, antidepressants may also be effective. Cognitive-behavioral skills training and psychotherapy are useful adjuncts to pharmacotherapy.     

Depression and HIV disease.

Depressive disorders are common among 20% to 32% of people with HIV disease but are frequently unrecognized. Major depression is a recurring and disabling illness that typically responds to medications, cognitive psychotherapy, education, and social support. A large percentage of the emotional distress and major depression associated with HIV disease results from immunosuppression, treatment, and neuropsychiatric aspects of the disease. People with a history of intravenous drug use also have increased rates of depressive disorders. Untreated depression along with other comorbid conditions may increase costly clinic visits, hospitalizations, substance abuse, and risky behaviors and may reduce adherence to treatment and quality of life. HIV clinicians need not have psychiatric expertise to play a major role in depression. Screening tools improve case finding and encourage early treatment. Effective treatments can reduce major depression in 80% to 90% of patients. Clinicians who mistake depressive signs and symptoms for those of HIV disease make a common error that increases morbidity and mortality.     

The many faces of bipolar disorder. How to tell them apart

Bipolar disorder is a chronic disease characterized by depressive, manic or hypomanic, and mixed episodes. Bipolar disorder may be confused with unipolar depression, because patients with bipolar disorder are usually symptomatic with depression rather than mania. Bipolar disorder may also be misdiagnosed as schizophrenia, since both disorders can present with psychotic symptoms. For children, the principal differential diagnostic consideration is ADHD. Making the correct diagnosis has important prognostic and treatment implications. Comorbidities with personality disorders, substance and alcohol abuse or dependence, and anxiety disorders complicate assessment, treatment, and recovery. Effective pharmacotherapy and maintenance monitoring are critical in order to minimize the risk of relapse and associated disability, morbidity, and mortality.     

A longitudinal study of major and minor depression following traumatic brain injury

Hart T, Hoffman JM, Pretz C, Kennedy R, Clark AN, Brenner LA. A longitudinal study of major and minor depression following traumatic brain injury.ObjectiveTo examine patterns of change and factors associated with change in depression, both major (major depressive disorder [MDD]) and minor, between 1 and 2 years after traumatic brain injury (TBI).DesignObservational prospective longitudinal study.SettingInpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone.ParticipantsPersons with TBI (N=1089) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years postinjury.InterventionsNot applicable.Main Outcome MeasurePatient Health Questionnaire-9.ResultsAmong participants not depressed at 1 year, close to three fourths remained so at 2-year follow-up. However, 26% developed MDD or minor depression between the first and second years postinjury. Over half of participants with MDD at year 1 also reported MDD the following year, with another 22% reporting minor depression; thus three fourths of those with MDD at year 1 experienced clinically significant symptoms at year 2. Almost one third of those with minor depression at year 1 traversed to MDD at year 2. Polytomous logistic regression confirmed that worse depression at year 1 was associated with higher odds of depression a year later. For those without depression at year 1, symptom worsening over time was related to year 2 problematic substance use and lower FIM motor and cognitive scores. For those with depression at year 1, worsening was associated with lower cognitive FIM, poor social support, and preinjury mental health issues including substance abuse.ConclusionsMajor and minor depression exist on a continuum along which individuals with TBI may traverse over time. Predictors of change differ according to symptom onset. Results highlight importance of long-term monitoring for depression, treating minor as well as major depression, and developing interventions for comorbid depression and substance abuse.     

The utility of DSM‐IV criteria in diagnosing substance abuse/dependence in adolescents

The purpose of this study was to explore the utility of DSM‐IV criteria in diagnosing alcohol and marijuana abuse/dependence in adolescents. A modified version of the Structured Clinical Interview for DSM‐IV (SCID) was administered to assess substance abuse/dependence symptoms in 127 inpatient, treatment‐seeking adolescents with substance‐use disorders. The proportion of individuals with clinically relevant symptoms was examined separately for individuals classified with either abuse or dependence. Chi‐square tests of independence between the abusive/dependent classification and the presence/absence of a given symptom were also performed. Rates of DSM‐IV current substance use diagnoses were alcohol abuse 21 (16%), alcohol dependence 44 (35%), marijuana abuse 27 (21%) and marijuana dependence 72 (57%). A diagnosis of marijuana dependence was significantly more likely when tolerance symptoms were present but was not significantly dependent on the presence of withdrawal symptoms. By contrast, the presence of both tolerance and withdrawal symptoms were indicative of alcohol dependence. There was a high degree of heterogeneity of DSM‐IV dependence symptoms for both alcohol and marijuana dependence. Our study suggests that the DSM‐IV criteria have limitations in diagnosing substance‐use disorders in adolescents. A modified version of the SCID may be useful in the adolescent substance use population.     

难治性抑郁症患者临床特征对照研究

目的探讨难治性抑郁症的临床特征,为临床诊断与治疗提供依据。方法将67例难治性抑郁症患者设为研究组,67例非难治性抑郁症患者设为对照组,对两组一般资料、临床表现、精神病性症状、药物治疗等临床资料进行回顾性分析。结果研究组嗜酒、物质滥用史及伴有躯体疾病发生率,以及自责自罪、疑病妄想、疲乏、自杀观念、自杀行为、社会功能下降、自知力缺乏等表现发生率均显著高于对照组（P〈0．01）;精神运动性迟滞、焦虑激越发生率则显著低于对照组（P〈0．05或0．01）;被害妄想、牵连观念、幻听等精神病性症状发生率均显著高于对照组（P〈0．01）;联合应用≥2种不同类型抗抑郁剂、联合情绪稳定剂及联合电休克治疗、联合抗精神病药治疗率,以及利培酮、碳酸锂的应用率均显著高于对照组（P〈0．05或0．01）。结论难治性抑郁症患者自责自罪、自杀观念、自杀行为、社会功能缺损、自知力缺损、伴随精神病性症状发生率以及联合用药治疗率显著增加,表明难治性抑郁症具有其精神病理特征。     

The effects of spiritual practices on recovery from substance abuse

Twelve-step programs have stressed the importance of spiritual practices for over four decades. The spiritual principles embodied in the twelve-step programs may be key in their success of recovering addicts/alcoholics with an overall recovery rate of 34%. A literature search revealed little available data on spiritual principles and practices and their effects on long-term recovery from substance abuse. This study compared two groups of recovering addicts, those with one year of recovery and those with less than one year and a history of relapse. Spiritual practices were measured using a five-point Likert scale questionnaire. The results of the study indicated a relationship between spiritual practices and long-term recovery from substance abuse.     

Health issues in men: Part II. Common psychosocial disorders

During screening examinations and, when appropriate, other health-related visits, family physicians should be alert for signs and symptoms of common psychosocial disorders in men. Health issues of concern include alcohol and substance abuse, domestic violence, midlife crisis and depression. Alcohol remains the most abused drug in America. The highest rates of alcohol abuse are in men 25 to 39 years of age, although alcoholism is also a considerable problem after 65 years of age. Disulfiram and the opioid antagonist naltrexone are the two medications currently labeled by the U.S. Food and Drug Administration for the treatment of chronic alcohol dependence. Like alcohol abuse, domestic violence is a sign of psychosocial distress in men. Domestic violence may be a problem in up to 16 percent of marriages. Most men move through the midlife period without difficulty. Major depressive illness occurs in about 1 percent of elderly men, whereas minor depression or subsyndromal depression affects 13 to 27 percent of older men. Selective serotonin reuptake inhibitors have become first-line therapy for depression.     

Anxiety and depression in substance abuse: clinical implications

Accurate diagnosis in patients presenting with anxiety and/or depressive symptoms requires that the contribution of substance abuse be carefully considered. When chemical dependence is identified, detoxification may be all that is necessary. However, if indicated, specific treatment of the mood or anxiety disorder may reduce substance use as well.     

Depressive disorders in older medical inpatients

Symptoms of depression that are temporary or caused by physical illness can be difficult to differentiate from those that represent a depressive disorder. A diagnosis of depressive disorder depends on the underlying cause, and on the nature, severity and duration of symptoms. Management involves accurate diagnosis and treatment of medical illness, practical interventions to resolve concurrent family, social and economic stressors, and emotional support. Cognitive, behavioral and brief psychodynamic therapies may be helpful in selected cases. Antidepressants and electroconvulsive therapy have a role in the treatment of severe or persistent depression associated with suicidal behavior, marked psychomotor retardation, starvation or other life-threatening symptoms. Suicidal thoughts are frequent in older patients with concurrent major depression and chronic illness, and measures to ensure patient safety are a priority.     

Role of ethnicity in social anxiety disorder: A cross-sectional survey among health science students

AIM: To investigate the influence of ethnicity in social anxiety disorder (SAD), and the relationship with symptom severity, depression and substance use or abuse, in health sciences'' students .METHODS: This was a cross-sectional survey of 112 1^st, 2^nd and 3^rd year students from the Faculty of Medicine and Health Sciences at Stellenbosch University, Cape Town, South Africa. The self-reported Social Anxiety Spectrum questionnaire was used to assess for SAD. The Social Phobia Inventory (SPIN) was adapted to a version called the E-SPIN (Ethnic-SPIN) in order to evaluate the effects of ethnicity. Two sub-questions per stem question were included to assess whether SAD symptoms in social interactions were ethnicity dependent. Substance use was assessed with the Alcohol Use Disorders Identification Test and Drug Use Disorders Identification Test, and depression with the Centre for Epidemiological Studies Depression Scale.RESULTS: Of 112 students who completed the E-SPIN questionnaire, 54.4% (n = 61) met criteria for SAD, with significantly more females than males meeting criteria. Ethnicity had a significant effect on SAD symptomatology, but there was no effect of ethnicity on the rates of drug and alcohol abuse in students with and without SAD. Overall significantly more students with SAD met criteria for depression compared with students without the disorder.CONCLUSION: Among university students, SAD is prevalent regardless of whether interactions are with individuals of the same or different ethnic group. However, ethnicity may be an important determinant of social anxiety for some ethnic groups. SAD was significantly associated with major depression but not significantly associated with drug or alcohol abuse.     

Adolescent substance use and abuse: recognition and management

Substance abuse in adolescents is undertreated in the United States. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attention-deficit/ hyperactivity disorder. Office-, home-, and school-based drug testing is not routinely recommended. Screening tools for adolescent substance abuse include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance use disorders. Although family physicians may be able to treat adolescents with substance use disorders in the office setting, it is often necessary and prudent to refer patients to one or more appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance abuse clinics, day treatment programs, and inpatient and residential programs. Working within community and family contexts, family physicians can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents.     

Managing somatization disorder

Somatization disorder (SD), a chronic psychiatric illness that affects about 1% of adult women, is characterized by multiple somatic complaints. It should be suspected in any woman who presents with a vague or complicated history; unaccountable non-responsiveness to therapy; dramatic, seductive or demanding personality style; family history of personality disorder; sexual abuse as a child; substance abuse; or depression with atypical features. Its cause is unknown, although both genetic and environmental factors have been implicated. At follow-up, patients with SD continue to have somatic symptoms, but many improve with therapy. Nearly two thirds of patients with SD attempt suicide, but few complete it; however, completions may be more common than formerly realized. There is no specific treatment for SD, but management can be organized around the following ABCs: Accommodate initially to forge rapport; Behavior modification (ignore symptoms, praise for improved behavior); Confrontation later about effects of behavior style; Decrease drugs gradually, with praise for reduction; Educate about course and meaning of illness; Family involvement to give information and help with treatment; Guilt should be assuaged in physicians, who may blame themselves when patients do not improve; Hospitalize (closed psychiatric unit) only for serious suicide risk, substance abuse, or other extreme behavior; and Intercurrent depression should be treated conservatively.     

The stigma of a psychiatric diagnosis: prevalence, implications and nursing interventions in clinical care settings

The stigma associated with psychiatric and substance abuse disorders is a formidable barrier to the achievement of health and well-being for persons who carry such a diagnosis or who exhibit symptoms. Attitudes of nurses and treatment providers toward patients with comorbid psychiatric and substance abuse disorders can be influenced by stigma, which can have a negative impact on the therapeutic process and development of trust necessary to support good patient outcomes. Understanding the interrelated components of stigma, including labeling, stereotypes, and discrimination, can help nurses to reduce its impact in clinical care settings to improve the care experience for patients and nurses. Implementing interventions based on the core values of the nurse-patient relationship to enhance understanding, mutual trust, and acceptance of differences can contribute to improved communication and patient assessments in an effort to improve patient outcomes.     

Drug treatment, health, and social service utilization by substance abusing women from a community-based sample

BACKGROUND: Substance abuse is an escalating problem among poor urban Latina women; little is known about their access to drug treatment and to needed social and health services. OBJECTIVE: Our objectives were to (1) examine the need and use of substance abuse treatment, health services, government entitlement programs, and social service programs among cocaine and heroin using Puerto Rican women and (2) identify whether service use predicts their prospective entry into drug treatment. RESEARCH DESIGN: This was a 3-wave longitudinal study of community substance abusing women evaluated on substance abuse and dependence using diagnostic measures, and hair and urine toxicological screens. Information was collected on self-reported need and receipt of substance abuse treatment, social services, general health services, and government entitlement programs. SUBJECTS: A community sample of cocaine-, crack-, and/or heroin-using women from copping areas in low-income urban centers of Puerto Rico were interviewed in 1997-1998 with 2 follow-up periods. RESULTS: Drug treatment, health, and social service utilization were low relative to need for services throughout all data waves. Social service utilization predicted prospective entry into drug treatment but not contacts with general health services or government entitlement programs. CONCLUSION: Drug-abusing women in low-income urban areas in Puerto Rico have substantial unmet substance abuse treatment, health, and social service needs. Mandated treatment by social service agencies may explain their clients' higher likelihood of entering drug treatment. Building linkages between service sectors to augment entry into drug treatment is essential for meeting the complex needs of this underserved population.     

Childhood sexual abuse and substance abuse in relation to depression and coping

Objectives: To examine relationships between childhood sexual abuse (CSA), substance abuse, substance abuse relapse, depression and coping styles in an Australian sample. Methods: Participants were 79 adults actively seeking treatment for substance abuse or CSA. CSA and substance use history were assessed using a purpose built questionnaire. Depression was assessed using the Beck Depression Inventory Second Edition (BDI‐II), and coping styles were evaluated using the Coping Scale for Adults.

Results: Among substance abusers, self‐reported CSA history was associated with (1) severe depression; (2) less optimistic coping; (3) longer duration of substance abuse; and (4) the use of drugs to alleviate negative moods. A non‐substance‐abusing CSA group was remarkably similar to the CSA substance‐abusing group on all measures. Penetrative abuse, younger age at CSA onset, and lack of confidence in dealing with CSA were associated with more severe depression in CSA victims.

Conclusions: Despite several limitations of the present study, these findings have implications for treatment of substance abusing CSA victims and suggest directions for future research on the CSA‐substance disorder relationship.     

Screening for depression across the lifespan: a review of measures for use in primary care settings

Depression is a common psychiatric disorder in children, adolescents, adults, and the elderly. Primary care physicians, not mental health professionals, treat the majority of patients with symptoms of depression. Persons who are depressed have feelings of sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt that may be accompanied by an array of physical symptoms. A diagnosis of major depression requires that symptoms be present for two weeks or longer. Identifying patients with depression can be difficult in busy primary care settings where time is limited, but certain depression screening measures may help physicians diagnose the disorder. Patients who score above the predetermined cut-off levels on the screening measures should be interviewed more specifically for a diagnosis of a depressive disorder and treated within the primary care physician's scope of practice or referred to a mental health subspecialist as clinically indicated. Targeted screening in high-risk patients such as those with chronic diseases, pain, unexplained symptoms, stressful home environments, or social isolation, and those who are postnatal or elderly may provide an alternative approach to identifying patients with depression.     

Management of chronic noncancer pain in depressed patients

Many patients with chronic noncancer pain present with comorbid depression, which can greatly complicate the treatment of pain. Chronic pain and depression each increase the risk of licit and illicit substance abuse, including the abuse of opioids, and of suicide. Patients attempting suicide may overdose on opioids, which are commonly perceived as potentially harmful, or acetaminophen, an agent that is believed to be safe but is actually the leading cause of liver failure in the United States. Opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) have the potential to interact with antidepressants, and their adverse effects may be exacerbated by alcohol use, which is also common in patients with depression. Topical NSAIDs, capsaicin, and lidocaine provide effective analgesia for several pain conditions. These agents limit systemic drug exposure, reducing the risk of systemic adverse events without risk of accidental or deliberate overdose. However, use of topical agents is generally limited to localized pain syndromes and therefore does not substantially eliminate the need for systemic analgesics in those patients with diffuse persistent pain, central sensitization, and opioid-responsive pain. This review will discuss the challenges associated with treating chronic pain in depressed patients and will provide recommendations for optimizing treatment.