Alcohol And Mood Disorders. L.E. Smit, MD, FRCPC. Objectives. February 8, 2007

Transcription

1 Alcohol And Mood Disorders L.E. Smit, MD, FRCPC February 8, Objectives To provide an overview of mood and anxiety disorders and alcohol use disorders. Their prevalence co-morbidity and treatment. 2 Substance use disorders and mood and anxiety disorder that develop independently of intoxication and withdrawal are among the most prevalent psychiatric disorders in North America. Association between them are overwhelmingly positive and significant. Treatment should not favour one at the expense of the other. 3 1

2 Alcohol intoxication and withdrawal do not entirely account for the association between them. Many symptoms of intoxication and withdrawal resemble the symptoms of mood and anxiety disorders. 4 Correct diagnosis is essential in understanding the relationship between alcohol use disorders and mood and anxiety disorders. DSM IV First to place emphasis on the substance use disorders. Independent mood and anxiety disorders and Substance induced distinction and the clarity and specificity of the guidelines for making the distinction. 5 DSM IV Criteria For Major Depression A five or more of 1. Depressed mood most of the day nearly daily. 2. Diminished interest or pleasure. 3. Significant weight loss or gain. 4. Insomnia or hypersomnia. 5. Psychomotor agitation or retardation. 6. Fatigue or loss of energy. 7. Feelings of worthlessness or guilt. 8. Diminished ability to think or concentrate. 9. Recurrent thoughts of death or suicide. D Not due to direct physiological effect of a substance or general medical condition. 6 2

3 Independent Mood And Anxiety Disorders Are Diagnosed In Substance Use Disorder Individuals 1. If full syndrome is established before substance use. 2. If their onset is mainly associated with sobriety. 3. If they persist for more than four weeks after the cessation of intoxication or withdrawal. 7 Substance Induced Mood Disorder A.Prominent and persistent disturbance in mood predominates. 1. Depressed or decreased interest or pleasure and/or 2. Elevated expansive irritable. B. 1. Develop within a month of substance intoxication or withdrawal or 2. Medication use is etiologically related C. Not better accounted for by an (independent) Mood Disorder D. Not exclusively during delirium. Diagnose only if mood symptoms are in excess of those usually associated with intoxication or withdrawal. 8 Substance Induced mood and anxiety disorders. 1. Occur only during periods of substance/alcohol use. 2. Remit shortly after cessation of intoxication or withdrawal. (within four weeks). 9 3

4 One Year Prevalence of Mood and Anxiety Disorders Independent mood and anxiety disorders 9.21%. Substance induced mood and anxiety disorders less than 1%. With one current mood or anxiety disorder. 7.35% reported independent disorders 2.95% reported substance induced disorders 10 One Year Prevalence of Substance Use Disorders Any substance 9.35% Alcohol 8.46% Any other Drug 2.00% Rates for abuse exceed dependence regardless of substance. 11 One Year Prevalence of Independent Mood and Anxiety Disorders In Individuals With Substance Use Disorders 19.6% had at least one mood disorder % had at least one anxiety disorder. 12 4

5 One year prevalence of substance abuse disorder in individuals with independent mood and anxiety disorder With mood disorder 19.9% had at least one substance use disorder. With anxiety disorder 14.96% has at least one substance use disorder. 13 One Year Prevalence of DSM IV Independent Mood and Anxiety Disorders and DSM IV Substance Use Disorders Who Sought. Treatment 5.8% has alcohol use disorders 13.10% has drug use disorders Treatment for alcohol use disorder 40.64% has at least one mood disorder 33.38% has at least one anxiety disorder 33.05% has at least one other drug disorder Treatment for any drug use disorder 60.31% has at least one mood disorder 42.63% has at least one anxiety disorder 55.16% has a co-morbid alcohol use disorder 14 Alcohol and substance induced mood and anxiety disorders are important and serious conditions with poor outcome of substance use disorder and high lifetime number of suicide attempts and suicides. 15 5

6 Bipolar Spectrum Disorders Rates of lifetime substance abuse disorder or dependence. Bipolar Type I Bipolar Type II For any Drug 60.7% 48.1% For Alcohol 46.2% 39.9% For Cocaine 11.00% 8.6% For Marijuana 20.00% 5.6% National co-mobidity survey found lifetime history of mania in 6.5% of alcoholic males and 10.00% of alcoholic females. 16 Why So High: Overlapping symptoms Self medication of mood symptoms Substances causing bipolar illness Common genetic vulnerability Increased impulsivity in both conditions (more than either alone) 17 Complications of Alcohol (and drug) Abuse in Bipolar Disorder Patients Increased hospitalizations Increased rates of mixed and rapid cycling Increased recovery time Increased prevalence of medical disorders Increased suicide attempts Increased suicides Increased violence Increased psychopathology with increased impulsivity Lifetime rate of suicide attempts 38.4% while 21.7% in absence of alcoholism. 18 6

7 Highest level of unmet treatment needs in Bipolar patients with co-morbid alcohol (and other substance use) disorders. treatment non compliance diagnostic difficulties reluctance to abstain service provision issues 19 Treatment In co-morbid Bipolar and Alcohol Use Disorders Carbamazepine - cocaine less depressive/manic symptoms less abuse Lithium Carbonate alcohol and marijuana less symptoms less positive screens Valproate - alcohol less drinking days less drinks per day Topiramate - alcohol less craving less relapse Lamotrigine alcohol and cocaine less mood symptoms less alcohol (and cocaine) use 20 Atypical antipsychotics Quetiapine cocaine less mood symptoms less cravings less relapse Aripiprazole, Alcohol and Cocaine less mood symptoms less use 21 7

8 Psychosocial Treatment Comprehensive Treatment for both disorders. Case Management Vocational Rehab Services Housing Medications Motivational Strategies Group and if necessary one to one counseling AA/NA AADAC Mental Health Support Groups 22 Major Depression Independent and Substance Induced Depressive Disorder 1. Abstinence 2. Antidepressants Wait one week after cessation of intoxication and withdrawal symptoms and still depressed or prior history of independent mood or anxiety disorder SSRI s TCA in adequate dosage reduces mood symptoms but not alcohol use disorders or relapse NaSSRI DNRI 3. Ondansetron 5-HT3 antagonist (for nausea) reduces drinking in early onset alcoholics 4. Acamprosate 23 Alcohol Dependence or Abuse Comorbid with Major Depression Worse outcome for depression and recovery Increased risk of relapse Increased suicide and death risk Decreased social functioning Increased health care utilization 24 8

9 Seasonal Affective Disorder (SAD) 4.3 to 10% of Population Link between alcoholism and SAD (family study) Eg. 41% with SAD has first degree relative with alcoholism compared to 18% without SAD Iceland Carbohydrate craving Treatment Light Therapy Antidepressants 25 SOCIAL ANXIETY DISORDER Lifetime Prevalence Males Females Alcohol Dependence 20.1% 8.2% Alcohol Abuse 12.5% 6.4% SAD 11% 15% High rates of co-morbidity SAD has 24% lifetime prevalence of alcohol dependence 26 Social Anxiety Disorder (Phobia) A. Marked and persistent fear of social or performance situations. B. Individual fears, scrutiny, negative evaluation, humiliation, or embarrassment. C. Exposure to (or anticipation of) social or performance situation provoke anxiety. D. Avoidance of social or performance situations. E. Significant impairment in social and occupational functioning. F. Not due to direct physiological effects of a substance or medical condition. 27 9

10 SAD often the primary disorder Existed prior to the AUD (While Panic Disorder More Co-Morbid) AUD individuals seeking treatment 23% has SAD compared to 7% in population AUD more common in interactional rather than performance SAD. Highest with both 28 Theoretical Models Explaining Co-morbidity Tension reduction theory 1. Stress response dampening model 2. Self-medication hypothesis Moderating Variables 1. Alcohol expectations 2. Other eg. Gender Situational factors 29 Self Medication Hypothesis assumes that distressing psychological symptoms predate AUD the alcohol does relief the symptoms the symptom relief leads to continued and excessive alcohol consumption. Thus: Alcohol will decrease anxiety in anxious individuals this decreased anxiety would be associated with preference for alcohol

11 Note: Unlikely that alcohol reduce social anxiety generally a rather superficial relationship between expectancy of social anxiety reduction and alcohol consumption Except in alcoholics 50-90% of alcoholics with phobias ingested alcohol to reduce anxiety only 43% of non alcoholics with phobias will have some similar expectancy but these alcoholics appear to have worse anxiety than non alcoholic phobics. 31 Conclusion: 1. Increased co-morbidity between AUD and SAD. 2. Alcohol use depends on individuals expectations positive and negative - and availability of alternative coping responses. 32 Treatment of co-morbid SAD and AUD 1. Psychosocial TSF (twelve step facilitation program) CBT (Cognitive Behavioral Therapy) MET (Motivational Enhancement Therapy) 2. Pharmacological treatment SSRI s 3. Combined treatment CBT, TSF, and SSRI s Demand may overwhelm the client so adjust treatment Severity of each disorder to be assessed In or outpatient 33 11

12 Hyperanxiety In Early Sobriety This is anxiety below threshold for panic but intensely uncomfortable may occur in early sobriety regardless of adequate medical supervision. More common in alcoholics with a co-morbid independent anxiety disorders. Untreated has a high rate of relapse for alcoholism. In part, due to dysregulation in specific brain reward and stress circuits. 34 Treatment: 1. Benzodiazepines Clonazepam 2. Buspirone 3. Antidepressants Mirtazepine (Remeron) (superior to Paxil and Celexa) 4. Quetiapine 5. Combine Quetiapine and Buspirone 6. Decrease Caffeine 35 Mechanisms of Anxiety and Anhedonia Dysregulation in specific brain reward and stress circuits partly to blame for anxiety and anhedonia. Alcohol dependence cause disruption of neurotransmitter systems converging on the amygdala. eg. GABA Serotonin Dopamine Which overlap with neurotransmitters significant in anxiety. eg. GABA Opioid Peptides Glutamate Serotonin Dopamine 36 12

13 Dopamine Acute alcohol ingestion increases dopamine which stimulates the reward pathway. Chronic alcohol ingestion cause endogenous dopamine levels to drop below normal. To attain normal DA levels alcohol blood/brain levels must increase. Response weakens but drinkers still feel less anxious than with abstinence. 37 Neuropeptide Y Chronic alcoholism changes brain stress response. Corticotropin Releasing factor increases causes altered neuropeptide Y brain antistress mechanism. 38 Beta Endorphins Reduces pain sensation by binding to opioid receptors in the CNS causing a sense of well being. Alcohol abstinence leads to lowered betaendorphin levels which persists through at least first 14 days of abstinence

14 Co-morbid Substance Use Disorders and Psychiatric Disorders 1. Two or more distinct disorders each likely to run the clinical course unique to that disorder. Due to 1. Chance alone 2. same predisposing factors Treat both comprehensively. 2. First disorder influences development of second disorder which then runs an independent course. 1. Unmask existing predisposition. 2. Cause long term physiological changes resulting in long-term syndromes. Treat both comprehensively. 40 Co-morbid Substance Use Disorders and Psychiatric Disorders Cont d 3. Second condition develop by selfmedication of patient to treat the first condition. 4. Second condition closely related to use or recent use of substance. 41 Focus still on substance/alcohol use and AXIS I disorders. More research will reveal its relationship to AXIS II. (personality) disorders

15 Specific substances more associated with specific conditions. Alcohol more related to depression and anxiety. Is the full diagnostic criteria needed or only some symptoms. Is the first sadness the onset of Major Depression? 43 Do Alcohol Induced Disorders Exist Closely Associated To Use In A Clear Sensorium SSAGA The semi-structured assessment for the genetics of alcoholism. More than 40% of (drinking) alcoholics fulfill criteria for Major Depression with 70% of the depressions being alcohol induced. 44 Do Alcohol Induced Disorders Exist Closely Associated To Use In A Clear Sensorium..Cont d In alcohol induced depression 1. The proportion with marked depressive symptoms decrease from 42% to 6% by four weeks abstinence. 2. Un-medicated male alcoholics with HAMD score of 16 by one week abstinence decrease to score of 4 by four weeks abstinence. 3. Drinking alcoholics of whom 67% had major depressive like symptoms reduced to 13% by one month of abstinence

16 Not so for those with independent major depressive disorders. Look for family history of major mood or anxiety disorders if unsure. More often absent with alcohol induced disorder. Alcohol induced disorders closely resemble the independent disorders but 85% or more improve rapidly with abstinence in days to one month to at least sub diagnostic syndromes. 46 Acute Phase of Alcohol Withdrawal Mostly followed by abstinence syndrome lasting months or more with insomnia, irritability, poor concentration and some anxiety or depressive symptoms. Not fulfilling the diagnostic criteria for the syndrome. 47 Neurochemical and Clincial Aspects Of Craving In Alcohol Addiction Craving - strong desire - psychological and physical suffering accompanied by dysphoria, anxiety, insomnia, and anorexia 48 16

17 Endogenous Opioids Important Role In Alcohol Re-Enforcement GABA Mediates effects of Alcohol Reward Deficiency Syndrome Genetic Variant In Dysfunctions: In brain reward cascade, especially in the DA system. They need a DA fix and leads to drug seeking behaviors. 49 Endogenous Opioids Important Role In Alcohol Re-Enforcement Cont d In part explains familial alcoholism 2 types of genetic predisposition to alcoholism. Type I Environment limited alcoholism more common Males more than females. Genetics and environment. Type II Genetically sex limited alcoholism only in males nine times higher in children of alcoholics regardless of environment raised in. 50 Abstinence Related Craving GABA Glutamine (Relief craving or to reduce tension) ( Reactive drinking) Cognitively in response to withdrawal symptoms. Treatment: Psychosocial Baclofen GHB (Gamma hydroxy butyrate) Acamprosate 51 17

18 Craving Related To Memory Of Reward Effects of Alcohol Dopamine Glutamine Opioid Reward Craving: In response to lack of pleasure and hedonic desires. Treatment: Psychosocial Naltrexone GHB 52 Stress Induced Craving Serotonin And all of above Systems (Obsessive Craving) In conditioned response to drug cues, etc: Treatment: SSRI s Baclofen Topiramate Ondansetrine Acamprosate 53 Treatment of Mood and Anxiety Disorders and Alcohol Abuse Treat both Treat depression or anxiety vigorously to remission. Partially treated or relapsing mood or anxiety disorders increases relapse rate of alcoholism and failure of abstinence can worsen mood and anxiety disorders. Long term medication may be necessary. Be aware of abstinence syndrome. Usually temporarily but can be life long with phases of dysphoria or anxiety, insomnia and craving. Treat craving appropriately. Ensure sleep is adequate. Use a crisis as a positive motivator for change. Empathy and support. Education

19 Questions/Discussion Grant BF et al. Prevalence and co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders. Archives General Psychiatry Vol 61 No. 8 August Krishnan K.R.R. Psychiatric and Medical Comorbidalities of Bipolar Disorder. Psychosomatic Medicine (2005). 3. Vornik L.A. Management of Comorbid Bipolar Disorder and Substance Abuse. J. Clin, Psychiatry suppl Pettinati H.M. Antidepressant Treatment of Cooccurring Depression and Alcohol Dependence Biological Psychiatry 2004; 56: Sullivan L.E. The Prevalence and Impact of Alcohol Problems In Major Depression: A Systematic Review. AM Med : Sher C. Alcoholism and Seasonal Affective Disorder. Compr Psychiatry Volume 5, No. 1 (Jan/Feb) 2004: Morris E.P. et al. The Relationship Between Social Anxiety Disorder And Alcohol Use Disorders: A critical Review, Clin. Psychology Review 25 (2005) Carrigan M.H. et al. Self-Medication in Social Phobia. A review of the Alcohol Literature Addictive Behaviors 28 (2003) McGuinness T.M. Hyperanxiety in Early Sobriety J. Psychosocial Nursing 44;1: Schuckit M.A. Comorbidity Between Substance Use Disorders and Psychiatric Conditions A.P.A.J Addiction 101 (suppl) Addolorato G. et al. Neurobiochemical and Clinic Aspects of Craving in Alcohol Addiction: A Review. Addictive Behaviors 30(2005)

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