Psychiatric Comorbidity in SUDs

Psychiatric Comorbidity in SUDs

• The occurrence of psychiatric illness in an individual with a SUD– In most settings, refers to occurrence of a

diagnosable psychiatric disorder

• Comorbidity of SUDs and diagnosed psychiatric disorders is substantial– SUD individuals with comorbid psychiatric

illness are referred to as: ‘Dual Diagnosis’

Psychiatric Comorbidity in NativeHawaiian & Pacific Islanders Compared to Other Populations: Measurement & Clinical

Issues

George Fein Ph.D. President and Senior Scientist, Neurobehavioral Research, Inc

Victoria Di Sclafani Ph.D.John A. Burns School of Medicine,

University of Hawaii at Manoa

Myths Regarding Psychiatric Comorbidity and SUDs

Myth #1: It is very difficult for dual diagnosis individuals to achieve abstinence.

Myth #2: It is very difficult for an abstinent individual to maintain abstinence with a current psychiatric diagnosis, especially if psychiatric medication management is needed.

Psychiatric Comorbidity

• We will present illustrative data from three studies of alcoholics:1. Long-Term (avg > 6 yrs) Abstinent Alcoholics

2. Treatment Naïve Actively Drinking Alcohol

Dependent Sample

3. Older Long-Term (avg > 14 yrs) Abstinent Alcoholics

Each group vs. its own age and gender comparable controls.

Psychiatric Diagnosis:Lifetime and Current

• Long-term Abstinent Alcoholics– minimum 6 months, average 6.3 years abstinence– alcohol dependent sample 34-58 years old (n=52)

• Age and gender comparable controls (n=48)

Lifetime Psychiatric Diagnoses

Significant: * p<.05, ** p<.01, *** p<.001. Duration of abstinence was not associated with the presence of a lifetime diagnosis

Abstinent Alcoholics Non-Alcoholic Controls

Female Male Female Male

(n=24) (n=28) (n=23) (n=25)

Odds Ratio: Alcoholic vs.

Control

Any Lifetime Diagnosis 20 25 14 10 6.4***

Mood Disorder 14 21 14 5 12.0*** (males only)

Anxiety Disorder 9 10 4 3 3.4*

Externalizing Disorder 3 11 0 4 3.7*

Lifetime psychiatric diagnoses do not militate against achieving long-term abstinence; in fact, lifetime psychiatric diagnoses are the norm.

LTAA vs Controls

Current Psychiatric Diagnoses

a Abstinent alcoholics with abstinence duration of 18 months or greater (5 females and 7 males excluded) Significant: * p<.05, ** p<.01, *** p<.001. Duration of abstinence was not associated with the presence of a current diagnosis.

Abstinent Alcoholics Non-Alcoholic Controls


(n=19)a (n=21)a (n=23) (n=25)

Odds Ratio: Alcoholic vs. Control

Any Current Diagnoses 9 5 3 0 8.1

Mood Disorder 6 4 3 0 5.0*

Anxiety Disorder 4 3 0 0 ***

Externalizing Disorder 0 0 0 0 N/A (no diagnoses)

Current psychiatric diagnoses (even those treated with medication) do not militate against maintaining long-term abstinence.

LTAA vs Controls


Significant: * p<.05, ** p<.01, *** p<.001.

Treatment Naïve Alcoholics

Non-Alcoholic Controls


(n=37) (n=49) (n=30) (n=40)


Control

Any Lifetime Diagnosis 21 30 18 15 1.6

Mood Disorder 19 23 15 9 1.8 (p = 0.075)

Anxiety Disorder 3 6 7 3 0.7

Externalizing Disorder 4 12 0 5 3.0 (p = 0.057)

Treatment Naïve Alcoholics vs Controls

Treatment Naïve Alcoholics do not evidence more Lifetime diagnoses than Controls.


Significant: * p<.05, ** p<.01, *** p<.001.

Treatment Naïve Alcoholics Non-Alcoholic Controls


(n=37) (n=49)a (n=30) (n=40)


Any Current Diagnoses 8 11 4 4 2.2 (p = 0.092)

Mood Disorder 7 8 3 3 2.3


Externalizing Disorder 2 3 0 1 4.3

Treatment Naïve Alcoholics vs Controls

There is no difference between Treatment Naïve Alcoholics and Controls in current psychiatric diagnoses.


Significant: * p<.05, ** p<.01, *** p<.001. Duration of abstinence was not associated with the presence of a lifetime diagnosis

Older Abstinent Alcoholics

Non-Alcoholic Controls


(n=40) (n=49) (n=29) (n=24)


Control

Any Lifetime Diagnosis 26 20 10 6 3.9*

Mood Disorder 25 15 9 6 3.2 (p = 0.053)


Externalizing Disorder 1 4 0 1 4.3

Older LTAA vs Controls

Older Long-Term Abstinent Alcoholics tend to have somewhat more psychiatric morbidity than Controls but less than seen in Middle-Aged Alcoholics.


Significant: * p<.05, ** p<.01, *** p<.001. Duration of abstinence was not associated with the presence of a current diagnosis.

Older Abstinent Alcoholics Non-Alcoholic Controls


(n=40) (n=49) (n=29) (n=24)


Any Current Diagnoses 1 3 2 0 1.7

Mood Disorder 0 2 1 0 1.6


Externalizing Disorder 0 0 0 0 N/A (no diagnoses)

Older LTAA vs Controls

Virtually no current psychiatric morbidity is found in Older Abstinent Alcoholics.

Tentative Conclusions

• Middle-aged LTAA have major psychiatric morbidity.

• Older LTAA have minimally more psychiatric morbidity than controls.

• Treatment naïve alcoholics have comparable psychiatric morbidity to controls.

Sub-Diagnostic Psychiatric Comorbidity

• Most studies ignore psychiatric symptoms that do not meet criteria for a diagnosis.

• Subthreshold psychiatric disorder data (i.e., Sx LT the diagnostic threshold) are not presented, implying that Dx completely addresses the presence & severity of psychiatric morbidity.

• Dx results in great loss of sensitivity, examining only tail of Sx distribution, leaving the bulk of the Sx distribution unexplored.

•Currency of symptoms is usually not assessed unless diagnosis is met.

•Thus, diagnostic thinking is reflected even in the psychological measures we use.


Mood Disorder Symptom Counts: LTAA

Mood Disorder Symptom Counts: OAA

Mood Disorder Symptom Counts: TxN

Anxiety Disorder Symptom Counts: LTAA

Anxiety Disorder Symptom Counts: OAA

Anxiety Disorder Symptom Counts: TxN

Externalizing Disorder Symptom Counts: LTAA

Externalizing Disorder Symptom Counts: OAA

Externalizing Disorder Symptom Counts: TxN


• Psychological measures of attitudes, beliefs, reactions and thoughts also reflect psychiatric illness (e.g., depressive thinking, poor self-esteem, etc.)

• Such measures and scales are usually not part of an assessment of psychiatric comorbidity, but often represent the psychological substrate for illness (e.g., socialized thinking is antithetical to antisocial behaviors).

Mood Psychological Measures: LTAA

Mood Psychological Measures: OAA

Mood Psychological Measures: TxN

Anxiety Psychological Measures: LTAA

Anxiety Psychological Measures: OAA

Anxiety Psychological Measures: TxN

Externalizing Psychological Measures: LTAA

Externalizing Psychological Measures: OAA

Externalizing Psychological Measures: TxN

Conclusions

• Sub-diagnostic psychopathology carries the bulk of the difference between LTAA and NAC in psychiatric illness.

• Continuous measures of psychiatric illness yield a more accurate picture of psychiatric comorbidity than the limited view that is provided by using only symptomatology that meets criteria for a diagnosis.

NRI Current Procedures: c-Dis Follow Up Questions

• In the last 12 months, have you had [symptom]?

• How old were you the first time you EVER had [symptom]?

• When you first felt/experienced this [symptom], was it in the context of seeking/using/withdrawing from alcohol/drugs?

• What percent of the time that you had [symptom] was it in association with seeking/using/withdrawing from drugs or alcohol?

• Older Abstinent Alcoholics (OAA)– 49 men, 40 women– age: 60-85 years (mean = 67.5 years)– abstinent 6 mos – 44 yrs (mean = 14.8 yrs)

• Older Non-Alcoholic Controls (ONC)– 24 men, 29 women– age: 60-85 years (mean = 69.3 yrs)

Diagnoses

• 51.7% of OAA vs. 30.2% of ONC had a lifetime psychiatric Dx (χ2 = 5.40, p < .02).

• 44.9% of OAA vs. 28.3% of ONC had a lifetime mood Dx (χ2 = 3.21, p = .07).

• No differences in anxiety and externalizing diagnoses: p’s > 0.30

• Essentially NO current Diagnoses.– 4.5% of OAA and 3.8% of ONC

Symptoms and Psych Measures

• Total Psychiatric Sx: 77% ↑ in OAA– 50% ↑ Anxiety Sx in OAA vs. ONC– 50% ↑ Mood Sx in OAA vs. ONC– 250% ↑ Externalizing Sx in OAA vs. ONC

• Psychological Measures– OAA vs. ONC ↑ ASI, no diff STAI- T or S– OAA vs. ONC ↑ MMPI-Hy, no diff MMPI-D– OAA vs. ONC ↑ MMPI pD, ↓ CPI Soc Scale

Conclusions

• Psychiatric disorder is more prevalent in OAA than ONC.

• Psychiatric comorbidity is less in OAA compared with ONC compared to MAA vs. MNC.

• Largest effects in externalizing domain.• Differences from middle-age study:

– Cohort effects– Selective survivorship– Selection bias for participating is greater in older

samples

Sensation Seeking Scales

Scale

Abstinent Alcoholics Controls Effect Size (%)

Male(n=28)

Female (n=24)

Male(n=25)

Female(n=23)

Group SexGroup x

Sex

Disinhibition4.36 ± 1.393

3.04 ± 1.756

3.68 ± 1.574

3.13 ± 1.180

1.0 9.2 ** 1.7

Boredom Susceptibility

4.32 ± 2.212

2.50 ± 1.414

4.24 ± 2.026

3.26 ± 1.657

0.8 12.6 *** 1.3

Thrill/ Adventure Seeking

7.39 ± 2.470

5.46 ± 2.570

6.12 ± 2.774

5.22 ± 2.907

2.0 6.8 ** 1.0

Experience Seeking

5.04 ± 1.527

5.00 ± 1.103

4.76 ± 1.640

5.30 ± 1.396

0.0 0.8 1.0

Measures are reported as mean ± standard deviation.Effect is significant: * p ≤ 0.05, ** p ≤ 0.01, ***p ≤ 0.001.

Conclusions

• The propensity towards sensation seeking normalizes with long-term abstinence.– The measures are sensitive enough to detect

gender differences within LTAA and NC.– We see increased sensation seeking in

treatment naïve actively drinking alcoholics (after removing items associated with substance use).

Cognitive Function

• Rey-Osterrieth Complex Figure (copy, immediate, and 20 minute delayed), Trail Making Test A and B, Symbol Digit Modalities Test, American version of the Nelson Adult Reading Test, Short Category Test, Controlled Oral Word Association Test, Paced Auditory Serial Addition Test, Block Design Stroop Color and Word Test

• MicroCog (MC) Assessment of Cognitive Functioning• Global Clinical Impairment Score (GCIS)

– 1 for each domain scoring 5-15th %ile– 2 for each domain scoring < 5th %ile– Summed across 9 domains

Cognitive Profiles

Conclusions

Very long-term abstinence resolves most neuro-cognitive deficits associated with alcoholism, except for the suggestion of lingering deficits in spatial processing.

Cognitive Function in Older Long-Term Abstinent Alcoholics• 91 older (>60 years of age) abstinent

alcoholics in 3 subgroups– OAA1: abstinence before age 50 (n=39)– OAA2: abstinence achieved 50-60 (n = 26)– OAA3: abstinence after 60 (n=26)

• 39 older controls

Results

• EAA were comparabe to controls, except those abstinent before 50 were worse than controls on auditory working memory

• EAA had larger craniums than controls– effect was strongest for those who drank the

longest and had shortest abstinence– Such individuals also performed better

cognitively

Conclusions

• Older alcoholics who drank late into life, but with than six months abstinence can exhibit normal cognitive functioning.

• Selective survivorship and selection bias likely play a part in these findings.

• Cognitively healthier alcoholics, with more brain reserve capacity, may be more likely to live into their 60’s – 80’s with relatively intact cognition, and to volunteer for studies such as ours.

• Our results do not imply that all elderly alcoholics with long-term abstinence will attain normal cognition

Decision-Making

• Iowa Gambling Task (IGT)– Task performance– Voxel-based morphometry

• Balloon Analogue Risk Task– Preliminary error-related negativity (ERN)

data from treatment-naïve drinking alcoholics

IGT

The views on the right (B.) show the region of interest (ROI) to which the analysis was restricted [the amygdala (blue) and the ventromedial prefrontal cortex (magenta)]. The views on the left (A.) show the SPM2 areas of significantly reduced gray matter (orange; SPM2 family wise error corrected p< 0.05), and the spatial uncertainty of that area (green).

ROI Restricted VBM Shows Amygdala Volume Reductions

Conclusions

• Alcoholics can achieve long-term abstinence in spite of persistent deficits in decision- making.

• These deficits are associated with reduced gray matter in regions implicated in similar impairments in neurological samples.

• May result from long-term alcohol dependence, or may reflect a pre-existing factor that predisposes one to severe alcoholism.

ERNs during the BART

• Brain activity during risk-assessment tasks can provide insights into the mechanisms underlying impaired behavior on these tasks.

• The feedback error-related negativity (F-ERN) is hypothesized to reflect the valence attached to the negative consequences of behavior.

F-ERN during BART Task

Results & Conclusions

• Within treatment-naïve alcoholics, smaller F-ERN amplitudes were associated with a greater FHD of alcohol problems (r = -0.567, p = 0.007).

• Results suggest a possible link between the genetic vulnerability toward developing alcoholism and the brain’s response to the negative consequences of behavior.

Region of Interest Analysis

• Most studies measure cortical gray matter volumes using masks from a common space, ignoring the variations in cortical folding between subjects.

• Our approach accounts for these variations.

• Middle-aged long-term abstinent alcoholics– 48 NAC, 52 LTAA, 34.4 – 59.8 years old

Frontal: ↓ 2.77%, NSPrimary Sensory: ↓ 9.3%, p = 0.009

Parietal: ↓ 6.9%, p = 0.014 Lateral Parietal: ↓ 7.4%, p = 0.006

Occipital: ↓ 6.2%, p = 0.015Visual Assn: ↓ 7.3%, p = 0.007Ant Occipital: ↓ 3.3%, p = 0.007

Temporal: ↓ 1.9%, NS

Limbic: ↓ 0.9%, NSAnt Cingulate: ↓ 4.7%,p = 0.015

Volume Reductions in LTAA

Conclusions

• Reduced visual association and lateral parietal gray matter is consistent with reduced spatial processing scores in LTAA.

• Absence of reduced temporal lobe gray matter (which has been linked to alcohol-related damage) suggests recovery with abstinence, consistent with intact memory function in this sample.

Documents

Psychiatric Comorbidity in SUDs