The Treatment of Patients with Mood Disorders and Substance

Use Disorders Roger D. Weiss, MD

Chief, Division of Alcohol and Drug Abuse, McLean Hospital

Professor of Psychiatry, Harvard Medical School

Belmont, MA, USA

Likelihood of SUDs in people with psychiatric diagnoses (ECA)

Diagnosis Odds ratio Bipolar disorder 6.6 Schizophrenia 4.6 Panic disorder 2.9 Major depression 1.9 Anxiety disorder 1.7

SUD in bipolar disorder

Lower medication adherence

■ More ■ Relapses ■ Hospitalizations ■ Homelessness ■ Suicide

Substance abuse in patients with psychiatric illness

Enhanced reinforcement Mood change Escape Hopelessness Poor judgment Inability to appreciate consequences

The Self-Medication HypothesisThe Self-Medication Hypothesis

Intolerance of specific emotions The importance of a “drug of

choice” More useful in describing substance

use rather than dependence

Diagnosing Psychiatric Disorders Diagnosing Psychiatric Disorders in Patients with SUDs in Patients with SUDs

How long should you wait until a How long should you wait until a patient has been off patient has been off all drugs and all drugs and alcoholalcohol before you can diagnose before you can diagnose anyany psychiatric disorder?psychiatric disorder?

How much does diagnosis or primary How much does diagnosis or primary vs. secondary depression vs. secondary depression mattermatter??

Treatment of patients with SUD and mood disorder

Pharmacotherapy

Psychosocial treatment

Pharmacotherapy

Co-occurring disorder pharmacotherapy

Typically focuses on treatment of the psychiatric disorder, though more recent studies have focused on SUD as well

Choice of medication is typically based on the usual considerations Side effect profile Family history of medication response Likelihood of medication adherence

McLean Hospital Study of McLean Hospital Study of Gender, Mood, and Recovery from Gender, Mood, and Recovery from

Alcohol Dependence Alcohol Dependence

(Greenfield et al., 1998)(Greenfield et al., 1998) Followed 101 patients (60 men, 41 women) Followed 101 patients (60 men, 41 women)

hospitalized for alcohol dependencehospitalized for alcohol dependence Monthly assessment visits x 1 yearMonthly assessment visits x 1 year SCID diagnoses of MDD were made a) SCID diagnoses of MDD were made a)

regardless of drinking and b) regardless of drinking and b) >> 3 mos. 3 mos. abstinentabstinent

Depression and Gender as Predictorsof Time to Relapse1.00

Days Since Study Entry

0 50 100 150 200 250 3000.00

0.25

0.50

0.75

Ch

ance

of

No

Rel

apse

Female, not dep

Male, not dep

Male, dep

Female, dep

Relation of Depression and Discharge Antidepressants to Time to First Drink1.00

Days Since Study Entry(Greenfield et al., Arch Gen. Psychiatry, 1998)

0 50 100 150 200 250 3000.00

0.25

0.50

0.75

Ch

ance

s of

Ab

stin

ence

No dep, discharge antidep

Dep, discharge antidep

Dep, no discharge antidep

No dep, no discharge antidep

Medication studies of Medication studies of co-occurring SUDs and mood disordersco-occurring SUDs and mood disorders All trials have compared medication vs. All trials have compared medication vs.

placeboplacebo No head-to-head studies of 2 active No head-to-head studies of 2 active

medicationsmedications

Placebo EffectPlacebo Effect

1.1. Very strong in substance dependent Very strong in substance dependent populationspopulations

2.2. Difficult to distinguish between Difficult to distinguish between placeboplacebo effect & study effect & study participation participation effect, particularly in disorders effect, particularly in disorders involving voluntary behavior such as involving voluntary behavior such as substance use disorderssubstance use disorders

15

Drinks Per Day (ITT)

0

2

4

6

8

10

12

14

16

B13 B12 B11 B10 B9 B8 B7 B6 B5 B4 B3 B2 B1 1 2 3 4 5 6 7 8 9 10 11 12

Study Week

Mea

n

Placebo

Treatment Start

In-Clinic Screen

Phone Call Initiation

Pharmacotherapy of SUD & Pharmacotherapy of SUD & Depression Depression

Most recent controlled studies show Most recent controlled studies show improvement in depressionimprovement in depression

Tricyclics have most robust effectTricyclics have most robust effect SSRIs most helpful in late-onset alcoholics, SSRIs most helpful in late-onset alcoholics,

may worsen early-onset alcoholicsmay worsen early-onset alcoholics Less improvement in substance use (often Less improvement in substance use (often

correlated with mood improvement), but not correlated with mood improvement), but not worsening (ie, not enabling)worsening (ie, not enabling)

Pneumonia model Pneumonia model

Valproate for Alcohol Dependence & BD

24-week trial of valproate vs. placebo in 59 pts on lithium

Valproate patients had Fewer heavy drinking days Less drinking on heavy drinking days No differences in manic, depressive sx

Salloum et al., 2005

Medication adherence in patients with BD & SUD

Patients with BD & SUD were asked about lifetime adherence to various medications

Answers ranged from “never” to “all the time”

We compared “all the time” to other responses

Weiss et al., 1998

Lifetime adherence 100 % adherence

Lithium* 22 % Valproate* 48 % Benzodiazepines 36 % Neuroleptics 37 % TCAs 63 % SSRIs 46 %

*Lithium vs. valproate p< .03

Reasons for med non-adherenceLithium ■ Physical effects

n=29 ■ Saw no need for meds

■ Wanted to use substances

Valproate ■ “Hassle” to take (lab tests)

n=13 ■ Forgot

■ Wanted to use

Benzodiazepines ■ Took more to get “high”

n=21 ■ Impatient, so took more

■ Couldn’t think clearly

Reasons for non-adherence (cont’d)Neuroleptics ■ Physical effects (EPS)

n=19 ■ Impatient, modify substance use, or get high

■ Saw no need

TCAs ■ Impatient, so took more

n=10 ■ Saw no need

■ Meds not working, so took less

SSRIs ■ Wanted to use

n=17 ■ Felt manic

■ Meds not working, so took less

Psychosocial Treatment

Models of dual diagnosis treatment

Sequential

Parallel

Integrated

Models of integrated treatment

Depends on the disorders & their

relationship

“Integrated” treatment means

different things to different

people

Integrated Group Therapy (IGT): Core principles

Cognitive-behavioral model focuses on parallels between the disorders in recovery/relapse thoughts and behaviors

Interaction between the disorders The single disorder paradigm: “bipolar

substance abuse” The central recovery rule

IGT structure Check-in: substance use, mood, med

adherence

Review last week’s group

Skill practice

Didactic/handout on integrated topic (e.g., dealing with depression without using alcohol and drugs)

Discussion

What is “integrated” about Integrated Group Therapy ?

Check-in focuses on mood, substance use,

and medication adherence Topics relevant to both disorders Patients seen as having a single disorder:

“bipolar substance abuse” Relationship & similarities between the

disorders & the recovery process stressed

Integrated Group Therapy: Sample topics

Dealing with depression without using alcohol or drugs

Denial, ambivalence, acceptance Taking medication Self-help groups (for both

SUD & BD) Identifying and fighting triggers Getting a good night’s sleep

The Central Recovery Rule

No matter what

Don’t drink Don’t use drugs Take your medication as prescribed

No matter what!

Findings of IGT research 3 studies funded by National Institute

on Drug Abuse

Compared IGT initially to either treatment as usual or standard manualized Group Drug Counseling (GDC)

All 3 studies showed significantly greater likelihood of abstinence in IGT patients

Fewer differences in mood outcomes

“Community-Friendly” Version of IGT vs.

Group Drug Counseling

Making IGT more “community-friendly”

IGT had had 2 successful studies, with 20 sessions led by therapists who had CBT and BD knowledge

However, many community treatment programs don’t have counselors with experience in either CBT or BD, and can’t be paid for 20-session treatments

These factors could reduce adoption of IGT in community treatment programs

Study of “Community-Friendly” version of IGT

Made IGT more “community-friendly” 12 sessions, instead of 20 Groups were run by front-line drug

counselors without formal CBT training or explicit BD knowledge

Compared IGT to GDC

Weiss et al., Drug and Alcohol Dependence, 2009

Patients

61 patients: 31 IGT & 30 GDC Current BD & substance dependence

Substance use in the past 60 days

A mood stabilizer regimen for ≥ 2 weeks

Results: Mood (p<.10)Results: Mood (p<.10)

IGT (n=31) GDC (n=30) Outcome Variables

Baseline End of

Tx 3-mo f/u

Baseline End of

tx 3-mo

f/u Mood episode (% yes)

52 20 27 57 30 37

Depressive episode

35 20 20 40 23 22

Manic episode

16 0 7 17 7 15

0

20

40

60

80

100

1 2 3 4 5 6

Time to first abstinent month by treatment (p<.04)

Month

Ab

stin

ent

(%)

Baseline

GDC

IGT

Abstinence: IGT vs. GDC

≥1 month abstinent: 71% vs. 40 %, p<.02 Abstinent throughout treatment (3 mos.):

36% vs. 13%, p<.05

“Good clinical outcome” by treatment condition:

Abstinent & no mood episodes in last month

0

10

20

30

40

50

End of treatment (p<.04)* 6 month follow-up

Goo

d o

utc

ome

(%) IGT

IGT

GDC GDC

Conducting an IGT Group

Structure of a 60-min. IGT sessionStructure of a 60-min. IGT session

Check-in/introductions (15’)Check-in/introductions (15’) Review of last week’s group (5’)Review of last week’s group (5’) Review of last week’s skill practice (5’)Review of last week’s skill practice (5’) Discuss session topic (20’)Discuss session topic (20’) Review session hand-out and wrap up (10’)Review session hand-out and wrap up (10’) Hand out and discuss skill practice for next Hand out and discuss skill practice for next

week (5’)week (5’)

Conducting the check-inConducting the check-in

Have you used drugs or alcohol during the past Have you used drugs or alcohol during the past week? If so, on how many days?week? If so, on how many days?

How was your overall mood during the past week?How was your overall mood during the past week? Did you take all of your medications as prescribed Did you take all of your medications as prescribed

during the past week? If no, why not?during the past week? If no, why not? Did you face any high-risk situations or triggers in Did you face any high-risk situations or triggers in

the past week? If yes, how did you deal with them?the past week? If yes, how did you deal with them?

Conducting the check-in (2)Conducting the check-in (2)

Asking about how many days of use is importantAsking about how many days of use is important

Allows for assessment of improvement vs. Allows for assessment of improvement vs. worseningworsening

Conducting the check-in (3)Conducting the check-in (3)

The check-in establishes the tone of the groupThe check-in establishes the tone of the group

It illustrates the “integrated” nature of IGTIt illustrates the “integrated” nature of IGT

Listen for the relevance of check-ins to the Listen for the relevance of check-ins to the session topicsession topic

Come back to check-ins to illustrate session Come back to check-ins to illustrate session topic themestopic themes

Key principles of IGTKey principles of IGT

Parallels between the two disorders in Parallels between the two disorders in the recovery and relapse processesthe recovery and relapse processes

Interactions between the two disordersInteractions between the two disorders The single disorder paradigm: The single disorder paradigm:

“bipolar substance abuse”“bipolar substance abuse” The central recovery ruleThe central recovery rule

Parallels in the recovery and Parallels in the recovery and relapse processesrelapse processes

The abstinence violation effect vs. stopping The abstinence violation effect vs. stopping medication when depressedmedication when depressed

Parallels in the recovery and Parallels in the recovery and relapse processesrelapse processes

Recovery vs. relapse thoughts and Recovery vs. relapse thoughts and behaviorsbehaviors

““May as well thinking” vs. “It matters May as well thinking” vs. “It matters what you do”what you do”

Medication non-adherence vs. staying Medication non-adherence vs. staying in bed all day vs. skipping AAin bed all day vs. skipping AA

Combating hopelessness: “It Combating hopelessness: “It matters what you do”matters what you do”

• Early sign of relapse to depression: not Early sign of relapse to depression: not returning phone callsreturning phone calls

• One more call vs. one less call to makeOne more call vs. one less call to make• Making concrete suggestions for taking one Making concrete suggestions for taking one

step at a time toward recoverystep at a time toward recovery• You’re always on the road to getting better You’re always on the road to getting better

or getting worse; therefore, or getting worse; therefore, it matters what it matters what you doyou do

Interactions between the two Interactions between the two disordersdisorders

Why use the term “bipolar substance Why use the term “bipolar substance abuse?”abuse?”

““Drinking is bad for your mood”Drinking is bad for your mood” ““Playing around with your medication is Playing around with your medication is

bad for your addiction”bad for your addiction”

General guidelines for conducting General guidelines for conducting IGTIGT

Go back and forth between mood issues Go back and forth between mood issues and substance use issuesand substance use issues

Think about parallels: if a patient is Think about parallels: if a patient is talking about drinking, think about mood talking about drinking, think about mood issues, and vice versaissues, and vice versa

Try to gently call on everyone, including Try to gently call on everyone, including people who are lost in their own thoughtspeople who are lost in their own thoughts

Be upbeatBe upbeat

General guidelines for conducting General guidelines for conducting IGT (cont)IGT (cont)

Focus on both successes and failures Focus on both successes and failures (“What did you do on the 4 days that you (“What did you do on the 4 days that you were sober that you didn’t do on the 3 days were sober that you didn’t do on the 3 days that you drank?)”that you drank?)”

Therapist characteristics for IGTTherapist characteristics for IGT

Familiarity with SUD, BD idealFamiliarity with SUD, BD ideal Can be successfully run by front-line Can be successfully run by front-line

substance abuse counselorssubstance abuse counselors Some knowledge of relapse prevention or Some knowledge of relapse prevention or

CBT is very helpfulCBT is very helpful EmpathicEmpathic Warm, friendly, non-confrontationalWarm, friendly, non-confrontational

Who should be in an IGT group?Who should be in an IGT group?

Willingness to enter a group that addresses Willingness to enter a group that addresses both problemsboth problems

Not acutely manicNot acutely manic Not intoxicatedNot intoxicated IGT is designed to be delivered with IGT is designed to be delivered with

pharmacotherapy as well; other pharmacotherapy as well; other psychosocial treatment is also encouragedpsychosocial treatment is also encouraged

Adapting IGT to other settings

Change the length of the sessions

Add items to the check-in (e.g., exercise, self-help meeting attendance)

Add a preparation group

Broaden the population

Recite the central recovery rule at the end of the group

Use IGT principles in individual Rx

Current status of IGT

Has been adapted for patients with psychotic illness as well

In use in multiple clinical settings at McLean Hospital

Currently in use in multiple clinical and research settings in U.S., Canada

Book published in 2011 by Guilford Press

Now available!Now available!