Complex Mental Illness and Concurrent Addictions

Transcription

1 Complex Mental Illness and Concurrent Addictions Tony P. George, M.D., FRCPC Professor of Psychiatry Co Director, Division of Brain and Therapeutics Department of Psychiatry, University of Toronto Chief, Schizophrenia Division Medical Director, Complex Mental Illness Program Centre for Addiction and Mental Health (CAMH) Toronto, Ontario, Canada M5T 1R8

2 Disclosures: Dr. Tony P. George Advisory board or similar committee Novartis, Pfizer Honoraria or other fees Pfizer, Novartis, Janssen, ACNP (Deputy Editor, Neuropsychopharmacology) Research grants NIH/NIDA, NARSAD, CIHR, Canada Foundation for Innovation (CFI), Ontario Mental Health Foundation (OMHF), Pfizer Global Research

3 Learning objectives Discuss reasons for the high rates of substance use disorders among people with serious mental illness. Describe evidence-based treatments, including pharmacological and behavioural interventions. Describe an integrated treatment approach to concurrent addictions in serious mental illness.

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5 Addictions in the News

6 Concurrent Disorders = Heterogeneity Schizophrenia Alcohol Use Disorder Major Depression Cocaine Use Disorder Bipolar Disorder Tobacco Use Disorder PTSD Borderline Personality Disorder Cannabis Use Disorder Pathological Gambling

7 Case Review Mr. A., a 34 year old single Caucasian male diagnosed with schizophrenia, presented to a community mental health center for treatment of psychosis, and cocaine dependence. He was reportedly spending ~$2,000 per month, and driving more than 30 minutes from his home to obtain crack cocaine; he used cocaine in a binge pattern every 2 3 days. On several occasions, he had shown up at his mother s work place and harassed her for money, and security had to be called. The mother never pressed charges. He presented with increasing paranoia, command auditory hallucinations, and thought broadcasting. Mr. A reports severe cocaine cravings every 1 2 days when not using, and stated that he smokes crack cocaine (1 2 rocks/session) to make him feel normal and give him a sense of calmness. However, he admitted that using cocaine makes him more paranoid and irritable. He has intermittent thoughts of suicide.

8 Crack Pipe

9 Cocaine Misusing Schizophrenia Patients and Disability Income Shaner et al. (1995) from UCLA studied the relationship between disability payments and cocaine use, psychiatric symptoms and hospitalization rates at three day intervals during a month in male veteran cocaine addicts with schizophrenia in Los Angeles.

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13 Factors Associated with Addiction Vulnerability Genetic/Familial Stress Gender Personality Factors Cognitive Impulsivity, Executive Function Psychiatric Disorders Adverse Childhood Events (ACE; including, verbal, physical and sexual abuse, household drug use)

14 Cause of Disability in the United States, Canada, and Western Europe in 2000 Mental illnesses Alcohol and drug use disorders Alzheimer s disease and dementias Musculoskeletal diseases Respiratory diseases Cardiovascular diseases Sense organ diseases Injuries (disabling) Digestive diseases Communicable diseases Cancer (malignant neoplasms) Diabetes Migraine All other causes of disability >36% of disability attributed to mental illness plus addictions!! Proportion of Cases of Disability (%) Data are from the report by the President s New Freedom Commission on Mental Health (2003)

15 Co-morbidity of SUDs in Psychiatric Disorders (ECA Study) Any Alcohol/Drug AnyAlcohol Any Drug % Co-Morbidity Schizophrenia Depression Bipolar Disorder Phobias Panic Disorder ASPD Psychiatric Diagnosis Regier et al. (1990)

16 Prevalence of Smoking in Clinical Samples of Persons with Psychiatric and Substance Use Disorders Schizophrenia Bipolar Disorder Major Depression Panic Disorder Post-Traumatic Stress Disorder Alcohol Dependence Cocaine Dependence Opioid Dependence General U.S. Population General Canadian Population Mean Smoking Prevalence (%) PD SUD Non-PD Clinical Group From Morisano, D., Bacher, I. et al. (2009). Can. J. Psychiatry. 54:

17 SUDs in Schizophrenia Earlier onset of schizophrenia 1 2 Increased relapse 3 5 Treatment non compliance 6 1. Humbrecht, Häfner Biol Psychiatry, 1996;40: Tsuang et al. Arch Gen Psychiatry. 1982;39(2): Richard et al. J Clin Psychiatry. 1985;46(3): Gupta et al. Schizophr Res. 1996;20(1 2): Drake, Brunette. Recent Dev Alcohol. 1998;14: Owen et al. Psychiatr Serv. 1996;47(8):

18 SUDs in Schizophrenia (cont.) Poorer overall response to antipsychotic medication 1 More hospitalizations 2 3 Increased risk for violence 4 6 Increased medical costs 1. Bowers et.al. Schizophr Bull. 1990;16(1): Richard et.al. J Clin Psychiatry. 1985;46(3): Brady et.al. Am J Psychiatry. 1990;147(9): Swanson et.al. Hosp Comm Psychiatry. 1990;41(7): Dickey, Azeni. Am J Public Health. 1996;86(7): Fazel, S. JAMA. 2009; 301:

19 Schizophrenia, Substance Abuse and Violent Crime Fazel, S. et al. (2009). JAMA. 301:

20 Reasons to Explain Co-morbid SUDs in Schizophrenia Self-Medication Medication (e.g. to reduce psychiatric symptoms, medication side effects, boredom) Addiction Vulnerability Hypothesis - Shared genes or brain abnormalities which cause or make people vulnerable to mental illness and substance abuse Social and Environmental Factors poverty, drug availability, peer modeling Khantzian, 1997; Chambers et al., 2001; George, 2007; Bridgman et al., 2013

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22 Two Models of Addiction in Schizophrenia Chambers, R.A. et al. (2001). Biol. Psychiatry

23 Neurocircuits Involved In Drug Dependence VTA

24 History Taking 1 What substance(s)? frequent polysubstance misuse in psychosis NB: Drugs which fuel psychosis stimulants (cocaine), cannabis, psychedlics (LSD), arylcyclohexylamines (PCP, ketamine), alcohol Most common Tobacco and Cannabis Age of first use Amount taken during a use episode (dollars spent) Route of administration (oral, snorted, IV, smoked) Consequences associated with use Time taken to recover from acute use

25 History Taking 2 Abstinence periods associated factors History of treatment Relapse what factors associated with this? Onset of SUD in relation to MH symptoms Impact of abstinence/reduction on MH symptoms Collateral contacts Motivation to reduce or stop drug use

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27 Influence of adolescent-onset cannabis use on adult psychosis is moderated by allelic variations in the Catecholamine O-Methyltransferase (COMT) gene (Caspi et al., Biol. Psychiatry)

28 Behavioural Treatments

29 Psychosocial Therapies for CD Motivational Interviewing (Martino et al., 2000) Cognitive Behavioural Therapies (Barraclough et al., 2001; Weiss et al., 2007) Contingency Management (Roll et al., 2004) Mindfulness Based Therapies

30 Evidence-Based Treatment Using Motivational Interviewing for CD Patients Martino et al. (2000). Am. J. Addictions. A single MI session versus a standard interview in 23 CD/SPMI patients led to improved substance abuse outcomes, treatment participation and medication compliance.

31 Integrated Group Therapies (IGT) Bipolar Substance Abusers Weiss, R.D. et al. (2007). Am. J. Psychiatry. 164: IGT addresses both Bipolar Disorder symptoms and co morbid drug and alcohol misuse. 20 week trial of IGT (n=31) vs. Group DC (n=31) in bipolar drug abusers.

32 Integrated Group Therapies Bipolar Substance Abusers IGT superior to GDC on drug and alcohol use, use to intoxication, time to first month of abstinence.

33 Integrated Group Therapy versus Group Drug Counseling For Bipolar Substance Abusers

34 Pharmacological Treatments

35 Pharmacotherapies Used to Treat Addictive Disorders Addictive Substance or Potential for Addiction Heroin Alcohol Nicotine Cocaine c Potential for cannabinoid, cocaine or alcohol addiction Medication Naltrexone a, Methadone a, Buprenorphine a Naltrexone a, Acamprosate a, Disulfiram a, Topiramate b Bupropion a, NRT a, Varenicline a Disulfiram b, Topiramate b, Modafinil b, Propranolol b, Baclofen b Rimonabant, Ondansetron, Topiramate a Approved by the Food and Drug Administration (FDA) for this indication b Approved by the FDA for another indication. c No medication is currently approved by the FDA for this indication. Adapted from O Brien, CP. Am. J. Psychiatry, 2005

36 Two Empirical Approaches to Pharmacotherapy of SUDs in Schizophrenia 1) Adjunctive treatment with an agent with antiaddictive drug effects (e.g. naltrexone, disulfiram, acamprosate, topiramate) 2) Treatment of the co morbid psychiatric disorder with an agent that may secondarily target the drug of abuse (e.g. antidepressants, atypical antipsychotic drugs)

37 Evidence-Based Pharmacotherapies for SUDs in Schizophrenia Atypical Antipsychotic Drugs for alcohol and stimulant dependence in schizophrenia (e.g., Albanese et al., 1994; McEvoy McEvoy et al., 1995; Drake et al., 2000; George et al., 2000; 2002). Naltrexone for Alcohol Abuse in Schizophrenia (e.g., Petrakis et al., 2004) Varenicline for Smoking Cessation in Schizophrenia (Pachas Pachas et al., 2011; Williams et al., 2012)

38 Pharmacotherapy for Comorbid Substance Use Disorder in Patients with Schizophrenia Naturalistic longitudinal study (N=101) Dual diagnosis, treatmentrefractory patients 36 patients given clozapine on clinical basis All patients prospectively assessed Drake, R.E. et al. Schiz. Bull % remission of alcohol abuse 0 79% 33% Clozapine Typical neuroleptic

39 Naltrexone for Alcohol Abuse in Schizophrenia Double blind, placebo controlled, randomized 12 week trial of naltrexone (50 mg/d) in N=31 patients with schizophrenia and alcoholism maintained on antipsychotic therapy. Behavioural platform of CBT and skills training. Naltrexone (versus placebo) reduced # of drinking days, # heavy drinking days, and alcohol craving. No published studies with the glutamate/gaba agent acamprosate Petrakis, IL et al. (2004). Psychopharmacology

40 Williams, J.M. et al. (2012). J. Clin. Psychiatry. 73: Varenciline for Smoking Cessation in People with Schizophrenia

41 Problems in the Care of People with CMI and Concurrent Disorders Non adherence to treatment Clinicians trained in treatment of psychiatric or addictive disorders but not both Lack of integrated treatment (e.g. patients get psychiatric treatment separate from that for addictions) Little research to support empirically validated treatment in co morbid populations Most co morbid patients don t achieve drug abstinence

42 Integrated Treatment Programs

43 Concurrent Disorders (CD) Severity Grid High MH, Low SUD Severity (Psychiatric Treatment Setting) High MH, High SUD Severity (Specialized CD Treatment Setting) Mental Health Severity Low MH, Low SUD Severity (Community Treatment) Low MH, High SUD Severity (Addictions Treatment Setting) Addiction Severity

44 Characteristics of Integrated Treatment Programs for Concurrent Disorders Client participates in ONE program that treats both PD and SUD. Both the PD and SUD are treated by the same clinician, who is trained in psychopathology, assessment and treatment of both disorders Drake, R.E. et al., Schizophr. Bull.

45 Characteristics of Integrated Treatment Programs for Concurrent Disorders SUD Treatment is tailored to those with SPMI. There is an adaptation of traditional abstinenceoriented SUD treatment to include SUD reduction oriented approaches. Drake et al., Schizophr. Bull.

46 Conclusions High rates of SUD co morbidity in people with psychiatric disorders, leads to significant disability and poor outcomes. Biopsychosocial vulnerability factors may explain this co morbidity.

47 Conclusions Treatments for this co morbidity should take advantage of the pathophysiological relationships between drug addiction and mental illness. Integrated psychiatric and SUD treatment is the evidence based standard of care for people with concurrent disorders.

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