OVERVIEW OF PSYCHIATRIC COMORBIDITY

OVERVIEW OF PSYCHIATRIC COMORBIDITY

ADDICTIVE DISORDERS 0193-953X/99 $8.00 + .OO OVERVIEW OF PSYCHIATRIC COMORBIDITY Practical and Theoretic Considerations R. Jeffrey Goldsmith, MD P...

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ADDICTIVE DISORDERS

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OVERVIEW OF PSYCHIATRIC COMORBIDITY Practical and Theoretic Considerations R. Jeffrey Goldsmith, MD

Psychiatric comorbidity in the addictions is a major challenge for addiction specialists and general psychiatrists. It involves at least two axis I diagnoses, one a substance use diagnosis and the other a nonsubstance use diagnosis. It is also called dual diagnosis. Multiple substanceuse diagnoses, withdrawal diagnoses, and nonsubstance axis I diagnoses may be made. Although axis I1 diagnoses are common, they do not usually constitute the other, comorbid, psychiatric condition. Psychiatric comorbidity is sometimes difficult to identify accurately and often difficult to manage clinically. It affects men and women differently at times, and it alters outcome for addiction treatment. This article reviews the epidemiology of addictions and psychiatric comorbidity, describing some of the gender differences. The diagnostic criteria are reviewed and diagnostic challenges discussed. The clinical management of dualdiagnosis patients is discussed and the dynamics of collaboration between psychiatrists and primary therapists addressed. Finally, cost-effectiveness and outcome results are presented. EPIDEMIOLOGY

The most common psychiatric disorders in the United States among adults are alcoholism and other addictions, which affect almost 20% of the population, according to the Epidemiologic Catchment Area (ECA) From the Department of Psychiatry, University of Cincinnati College of Medicine; and the Veterans Affairs Medical Center, Cincinnati, Ohio

THE PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 22 * NUMBER 2 * JUNE 1999

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study.32Alcohol dependence and abuse is the largest subgroup in this population, 13%, with drug dependence and abuse amounting to approximately 6%. S c h u ~ k i reported t~~ that 40% to 50% of the men in the United States had alcohol problems sometime during their lives and that 20% or more met some diagnostic scheme for alcoholism. Among young adults, alcohol and marijuana are the most commonly used drugs (90.7% and 53.8%, respectively, for lifetime use), followed by hallucinogens (16.8% ever used), inhalants (14.1% ever used), stimulants (14.6% ever used), cocaine (12.1% ever used), and other opiates (9.2% ever Heroin has increased 133% among high school seniors and marijuana approximately 35% among high school seniors from 1991 to 1997.30 Cigarettes and smokeless tobacco have been used by 65% and 2.570, respectively, of the high school seniors and are a major health epidemic which kills and disables hundreds of thousands yearly.30Although drug use seemed to be leveling off for high school seniors, they increased their use of hallucinogens and LSD, PCP, MDMA (ecstasy), cocaine, heroin and other opiates, sedatives or hypnotics, alcohol, and cigarettes from 1991 to 1997.30 Approximately 25% of the adult population in the ECA study were identified with other axis I diagnoses.32Phobias were a problem for 12.6%, major depression for 5%, and panic disorder or obsessive-compulsive disorder for 4%, while psychotic disorders, bipolar disorder, and other disorders comprised approximately 5%. These disorders are generally chronic or relapsing in course, and many patients require lifelong treatment. Approximately one third of the addictions have comorbid axis I disorders; some of these are drug abuse or dependen~e.'~ Miller2*reported that more than 80% of the alcoholics under 30 years old were coaddicted to another drug and that 50% to 75% of a general psychiatric population had a comorbid substance-use disorders. Almost half (47%) of the alcoholics in the National Comorbidity Survey (NCS) had a comorbid second psychiatric diagnosis.19McLellan et alZ6reported that psychiatric severity affects treatment outcome regardless of diagnosis. In the psychiatric inpatient setting, the occurrence of comorbid substance dependence is much more likely, with risk ratios ranging from 1.7 to 62.0 compared with a nonclinical setting2*

Homeless Population Dual-diagnosis patients who are also homeless offer a special challenge. Engagement into treatment is particularly difficult. Studies show considerable variation in alcohol and drug dependence among homeless patients, ranging from a low of 4% alcohol or drug dependence to a high of 71% lifetime alcohol or drug d e p e n d e n ~ eWhen . ~ ~ drug or alcohol use (not abuse or dependence) is reported, the results range from 1%to 58%. Studies of homeless, mentally ill patients report that 18% had a secondary diagnosis of alcoholism or other drug addiction.27

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In one study of 414 homeless people who visited a shelter in Washington, DC, 87% were black, approximately two thirds were men, 81% were over 25 years old, and 65% were high school graduates (190/, had attended Of the black homeless adults, 26% were currently using drugs (17% marijuana, 16% cocaine) and 59% were currently using alcohol. Analysis showed that the younger cohorts used drugs to a greater degree than did the older adults, with the 18- to 35-year-olds using much more than those older than 35 years. The over-35-year group was more likely than the younger homeless blacks to be drinking alcohol and more likely to be drinking than their nonhomeless counterparts in the general population. Other factors associated with higher use rates among homeless people in this study included male gender and higher income. Marital status, education, prior psychiatric hospitalization, history of psychosis, and history of depressive symptoms were not related to increased use. Intermittent homelessness was more related to drug use than was new homelessness or long-term homelessness. Medical Comorbidity

Medical illnesses are another common comorbidity for alcohol- and other drug-dependent patients. In some cities, such as New York, the needle-using population has a seropositive rate of 55% to 60% for HIV.27 Intravenous drug users represent 30% of the AIDS cases in the United States despite the fact that only 1%of the general population are IV drug users. High-risk behaviors, such as using needles, going to a shooting gallery, or going to a crackhouse, are twofold or threefold more likely for addicts not in treatment programs compared with those in treatment programs.26Other illnesses, such as hepatitis C, tuberculosis, sexually transmitted diseases, cancers, heart disease, and hypertension, are also more prevalent among the addicted p0pulation.3~Trauma, accidents, and assaults while under the influence are common among this p~pulation.~~ Gender Issues

Addictive disorders are predominantly male illnesses; most epidemiologic studies find that among heavy drinkers, men outnumber The NCS more recently showed two or three times women by 4 to 1?fZ9 the lifetime prevalence rate of alcohol abuse and alcohol dependence in men compared with women.23The gender difference for drug dependence is 2 to 1 and close to 1 to 1 for some drugs.4 Among alcoholics, women begin heavy drinking later, and the illness progresses faster, than among men. This may not be true with drug addiction. In the general population, women outnumber men regarding most psychiatric diagnoses. Women outnumber men 3 to 1 in the prevalence

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of depressive disorder~.~’ The ratio is similar for bipolar disorders and anxiety disorders, whereas it may be closer to 1 to 1 for schizophrenia.” Antisocial personality disorder is the only common psychiatric disorder that is more prevalent among men than women (14.6% compared with 10.1%).28More recently, the NCS showed similar results, with women having twofold to threefold the rate of comorbidity compared with men with regard to most anxiety and affective disorders.23When stratified by gender, 64% of the women in the NCS had a second psychiatric diagnosis compared with 44% of the men. In women, phobias (30% simple, 30% social) and depression (21.O% dysthymia, 48.5% major depression) were the most common other diagnosis with alcohol dependence, whereas for men, antisocial personality disorder (17%), phobias (19% social phobia, 14%simple phobia), and depression (24% major depression, 11%dysthymia) were the most common comorbid diagnoses. Addicted women were more frequently victims of violent crimes than controls (nonaddicted women in the general population)-61% versus 20%, including rape-32% versus 8%.* Women reported that they entered treatment because of mental or physical health problems or problems with family members, whereas men were more frequently motivated by job and legal problems.’ Genetic Issues The genetic studies of alcoholism suggest that sons of alcoholic fathers have threefold to fourfold the lifetime prevalence of alcoholism than do sons of nonalcoholic fathers.29Some researchers think that women inherit alcoholism differentl~.~ Several studies have shown little difference among female adoptees compared with nonadopted; however, when both inheritied and environmental risks were present, the prevalence of adult alcoholism in the adopted daughters increased threefold, from 2.3% to 7.770.’’ Recent studies have shown a higher rate of alcoholism and drug addiction for adoptees than in the general population and have identified genetic and environmental factors in the development of drug addi~tion.~ Specific Disorders Anxiety and Depression

Anxiety disorders and affective disorders are common in the general US population. Approximately 8% to 10% of Americans develop anxiety disorders and 10% to 15%, affective disorders. If co-occurrence were random, the addiction population should have co-occurring problems of similar magnitude, but the frequency of anxiety and depression in the dual-diagnosis population is higher than the general p~pulation.’~ Men in this study reported the onset of alcoholism before the comorbid

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psychiatric illness (depression or anxiety), whereas women reported that their psychiatric illnesses began the same year or before the alcoholism. The authors concluded that an association exists between the primary onset of an anxiety disorder and the subsequent development of alcoholi~m.2~ Affective disorders have been associated with addictions for several reasons. Mania is strongly associated with excessive behaviors of all sorts, including alcohol and drug intake. Depressed patients do not show the same marked increase in their use of alcohol and drugs. The self-medication hypothesis suggests the opposite-that depressed patients use to feel better and that manic patients do not need this boost in mood. Because of the confounding nature of substance-induced symptoms, how many patients with an affective disorders are comorbid for addictions is not clear. The ECA study showed that 30% to 50% of alcoholics were comorbid with major depression; however, several studies have found the occurrence of depressive symptoms dropped by half after 2 or 3 weeks of abstinence.6Of alcoholics in the NCS, 28% of men and 53% of women had co-occurring major depressive disorder.36 Schizophrenia Schizophrenia is an illness that affects men and women about equally; however, men with schizophrenia are more likely than women to have a substance-dependence disorder.40Among schizophrenics in an inner city psychiatric emergency service, 47% qualified for a lifetime alcohol-use disorder of some kind, 69% reported use of some nonalcoholic drug to intoxication, and 37% reported daily use of a nonalcohol intoxicant for the past 2 weeks or more.4oAmong young patients with chronic schizophrenia, 52% qualified as having a substance-use disorder on admission to the hospital. In this sample, patients with schizophrenia and schizoaffective disorder were more likely to report polydrug use than alcohol use only.43An inpatient Veterans Administration study published in 1991 reported that of those admitted with schizophrenia, 60% had a current or past history of drug abuse (half during the previous 30 days).35A study from Eastern Pennsylvania Psychiatric Institute published in 1990 reported that among schizophrenics admitted to Eastern Pennsylvania Psychiatric Institute, 47% abused alcohol; 42%, cannabis; 25%, stimulants; and 18%, hallucinogen^.^^ Among schizophrenic patients, both cocaine and alcohol dependence were associated with more hospitalizations and more psychosocial symptoms. Diagnosis

The American Psychiatric Association's fourth edition of the Diagnostic and Statistical Manual (DSM-IV) uses the concept of substancerelated disorders and describes substance use and substance-induced disorders for each of the major categories of addictive substances.' Use disorders are divided into two categories: (1)abuse and (2) dependence.

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Dependence may be with or without physiologic dependence and may be modified in “full” or ”partial” remission. Opiate dependence has a further qualifier, ”on agonist therapy,” which applies to those receiving methadone or L-a-acetylmethadol (LAAM) maintenance. Other classes of drugs, such as nicotine, have the potential for this qualifier. The diagnosis of substance-dependence disorder requires three of seven criteria, including tolerance, physiologic withdrawal symptoms, loss of control, narrowing of lifestyle, and use despite reasons not to use within the same 12-month period. The specifier, with physiologic dependence, is intended to be used if tolerance or withdrawal occurs. Course specifiers are designated to describe the stage of recovery-full or partial remission, agonist therapy, or the context of a controlled environment. Substance-abuse disorder is a diagnosis that includes a maladaptive pattern of use that leads to impairment or distress and that does not meet the criteria for dependence. The evidence for this maladaptive pattern of use must have occurred within a 12-month period. Substance-induced disorders include a wide variety of diagnoses: intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, persisting perception disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. Most of these can be diagnosed as occurring during intoxication or during withdrawal. Woody et a142described three guidelines for these diagnoses: (1)identify according to the most prominent symptom; (2) be sure the disorder developed within 1 month of intoxication or withdrawal, as long as the symptoms are consistent with the drug and not better explained by another disorder; and (3) use a non-substance-induced disorder diagnosis if it has been present during abstinence longer than 1 month, if it developed before the substance use, or if it is better explained as a non-substance-induced disorder. MANAGEMENT OF DUAL DISORDERS

Clinical management of addictive disorders is always affected by the attitude of the clinician. Attitudes are shaped by the cultural matrix that transmits values, stigmas, and moral judgments. Addictive illnesses still carry considerable stigma, and the nouns alcoholic and addict are still derogatory when used in a public discussion, suggesting moral degeneracy. Because of the prevalence of the addictions, many clinicians grew up with alcoholic or addicted family members who had a painful impact on their lives. Many people still believe that addiction is selfinflicted, irresponsible, and pleasure driven. When addicted individuals do not wish to give up the drugs, even friends and family often are disgusted and enraged, feel powerless, and eventually become resigned to the ”badness” of the addict. If a previous period of abstinence from drugs or alcohol occurred, people may feel betrayed or angry when relapse occurs. These are common culturally determined responses. If a

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person grew up with an alcoholic or addicted family member, the reaction in the here and now may be much more intense, even overwhelming or paralyzing. ImhoP2 refers to two types of codependence: (1) primary codependence, that is, growing up in a family with an adult alcoholic, and (2) secondary codependence, that is, living with an adult alcoholic as an adult.22Management of the addictions is best handled from a nonjudgmental, understanding position. Increased efforts are being made to include education about addictive illness as part of the preclinical and clinical training in medical schools. Terms such as dirtball are less commonly heard these days when referring to patients with advanced addictive illness, but judgmental approaches to these patients are still common among physicians at all levels of training and experience. Recent cutbacks in Medicare and Medicaid financing for the treatment of patients with addictive illnesses show that acceptance of the illness model of addiction is still limited, with a strong bias toward a punitive approach to both addictive and other forms of mental illness. Chronic mental illness has its own stigma and cultural stereotypes that must be overcome for effective clinical work. Friends and colleagues still tell depressed people to ”snap out of it,” expecting that to overcome some superficial inertia. Unfortunately, some addiction counselors still ascribe to that view and prescribe a “boot camp” approach toward getting schizophrenics out of bed in the morning. Family and friends become tired of the chronic anxiety and dysphoria of people with panic attacks or posttraumatic stress disorder, wanting them to relax, have a good time, and forget the past. As with addictive illness, friends and family may become disgusted or enraged, feel powerless, and eventually cut off contact. These attitudes become barriers to empathic connection and, as a result, are important obstacles to growth and recovery. SUBSTANCE-INDUCED DISORDERS

Assessment Assessment is the most important and challenging aspect of work with dually disordered patients. It is important because the treatment depends on the presumptive diagnosis. Substance-induced disorders mimic much of the criteria in DSM-IV,’ and their treatment primarily involves abstinence and rehabilitation therapy when the immediate crisis is over. In contrast, treatment of patients with other axis I disorders is often best managed using a combination of approaches, including medications, psychotherapy, milieu treatment, and community casemanagement services. To address the diagnostic issues of comorbidity, Anthenelli3described the following algorithim. The first decision is whether the patient is alcohol or drug dependent. The next challenge is to explore the relationship between drug use and the prominent psychiatric symptom. Was a drug used just before or while the symptoms became prominent? Was a long-term and habitual

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pattern of use stopped suddenly, which might have caused a withdrawal syndrome? This assessment requires knowledge of the acute and longterm effects of the drugs of abuse, as well as their withdrawal syndromes. Depression and anxiety can be symptoms of intoxication states and withdrawal states. The same is true for hallucinations and delusions. At this point, the clinician can make a decision on the diagnosis and recommend treatment; however, clinicians should be aware that denial of addiction or denial of mental illness can distort the history and lead the clinician astray. Also important is to be willing to change the diagnosis if new symptoms arise or if new information is gathered from collateral sources. Furthermore, the patient may reveal information more honestly to the physician as trust begins to develop. Some clinicians find the distinction between primary and secondary disorders useful in this assessment. A primary disorder is one that precedes chronologically the other disorder. A secondary disorder began after the primary disorder; however, they both may be independent and not causally connected. S c h u ~ k i treported ~~ that patients with primary depression or secondary depression, in combination with alcoholism, both remained depressed without treatment of depression in a hospital setting, where drinking was prohibited. This distinction is not to be confused with diagnosing substance-induced disorders. Stabilization

When the dual disorders have been diagnosed, psychiatric stabilization and abstinence are essential. Addictive disorders and psychiatric illness, when acutely decompensated, cause severe cognitive and behavioral disruption. Stabilization of both illnesses is essential to restore clear thinking, develop a cooperative (or more cooperative, at least) attitude, improve physical health, and stop the cycle of addictive relapse and noncompliance. Long-term abstinence is essential for stabilization, and residential placement in an environment supportive of abstinence is sometimes necessary. This phase may last a few days or several weeks in highly motivated patients. For some dually ill patients who do not wish to stop using drugs, frequent relapses often extend this phase for years. When this occurs, progression of the disability and mortality associated with both disorders is likely. The Patient Placement Criteriu of the American Society of Addiction Medicine uses six dimensions of the patient to make decisions about the level of intensity of care? The first dimension is the level of intoxication or potential for withdrawal. This includes the potential for medically severe withdrawal. The second dimension is medical comorbidity: Is medical illness present that could be severely destabilized by withdrawal or continued use? Emotional or behavioral comorbidity is the third dimension. Only these three dimensions can be used to determine the need for inpatient, medically managed treatment as opposed to residential, medically monitored treatment. The other three dimensions are (1)

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acceptance or rejection of treatment, (2) relapse potential, and (3) supportive environment. These are important in deciding between residential and outpatient care, as are the first three. The second edition of the Patient Placement Criteria describes a spectrum of services separate from the programmatic approach? For dual-diagnosis patients, a new revision is underway that will integrate psychiatric severity with addiction severity in the decision-making process. Although a continuum of care concept is appealing, each community has preexisting formulas of care and a limited amount of resources that can be used for dually diagnosed patients. Three models of treatment for dual-diagnosis patients have been described: (1)sequential, (2) parallel, and ( 3 ) integrated.28Although integrated treatment-treatment delivered by staff trained in both psychiatric and addictions treatmentis the most desirable, it is not often available. Parallel treatment occurs when a patient is in two different types of treatment programs simultaneously. This could be inpatient, outpatient, or both. Sequential treatment refers to situations in which one illness is treated before the other, that is, a psychotic decompensation is stabilized before enrolling the patient in a rehabilitation treatment program for patients with alcohol dependence. The parallel and sequential treatment programs may be more programmatic and less individualized than integrated treatment programs. They also have the potential for confusing the patients with different explanatory approaches and facilitating splitting in patients with significant character pathology. The long-term outcome of dual-diagnosis patients is not yet well studied. Although outcome studies over 6 months and 1 year have been reported, stabilization of the addictive and other psychiatric illnesses may take years. Often dual-diagnosis patients come to treatment in the throes of addiction, homeless, unfunded, actively psychotic, depressed or manic, socially isolated, suicidal, medically compromised, and unemployed. The therapeutic challenge is to prevent relapse and to treat symptoms long enough to allow stabilization and engagement in longterm outpatient or residential treatment, which in turn supports sobriety, stabilizes patients financially, and allows for treatment and rehabilitation of the medical comorbidity (e.g., dental, nutritional or cardiovascular problems; hepatitis B and C; or chronic pain). Longer-term sobriety allows for further resolution of the substance-induced psychiatric syndromes. Subsequently, the nonaddictive psychiatric illness can be treated more effectively. A further period of stability is needed to make amends and clean up the shambles from the past, including legal problems, divorces, custody battles, alienation of family and friends, bankruptcy and past debts, guilt, shame, and self-loathing. Self-care, mood stability, and self-esteem begin to emerge now, and with them, confidence and the feeling of self-efficacy. This is the beginning of growth. Although this is a challenging process for single-diagnosis patients, it is daunting and formidable for dually disordered patients. Until initial stabilization occurs, treatment outcomes may be measured more appropriately in preventing further deterioration in functioning and adverse outcomes,

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such as incarceration or death. For patients with treatment-resistant illness, this is challenging and resource intensive. A naturalistic study of service use and outcomes at the Cincinnati Veterans Affairs (VA) Medical Center Dual Diagnosis Clinic34found that patients who completed an initial 60-day assessment period had fewer psychiatric emergency room visits than did those who dropped out of the assessment process ( P < 0.000001). In addition, completers had equal or more hospitalizations on detoxification, rehabilitation (28-day residential), and medicine but with shorter lengths of stay. Those who dropped out had fewer hospitalizations and stays that were longer. In this study, to measure services received outside of the VA was not possible. The completers of the assessment phase seemed to become more engaged in the VA for multiple problems that had been neglected by them as a consequence of their dual illnesses. Shorter lengths of stay may have been possible because of the stability obtained from the Dual Diagnosis Clinic. Dropouts from assessment seemed to become disengaged from essential services and required more acute hospital days to stabilize emergent problems. The early phase of engagement and stabilization may be associated with increased service utilization. Further study is required to determine whether and when service costs begin to decrease. Practical Medication Guidelines

Although medication is often essential for the treatment of dualdiagnosis patients, abstinence remains a critical pathway to recovery for both psychiatric illnesses. There are several reasons for this, but the primary reason is that alcohol and drug use confuse the clinical picture, distorting the phenomenology. Depression can be alcohol induced, cocaine withdrawal induced, long-term opiate induced, or independently determined. When antidepressants are started immediately, improvement can be deceiving because abstinence clears up drug-induced depression. Although toxicology screens are critical in identifying covert drug use, they are not foolproof. A user may be missed because the drug is already metabolized (common with alcohol), the drug level is too low to be detected (alprazolam or clonazepam), the drug was not tested for (drug-abuse screens often test for a few specified drugs only), or the sample was obtained too late to identify the drug. Although psychiatric symptoms may be prominent for many alcohol- and other drug-dependent patients, abstinence is still the foundation of treatment in most cases. Studies with alcoholics have shown little propensity for patients in treatment to resume and sustain controlled drinking3*This does not mean that no benefit or harm reduction occurs with reduced use or intermittent periods of abstinence. Quite the contrary, gain can occur with reduced drinking in alcoholism, reduced heroin use, the concomitant reduction of needle use, or regulating the use of potentially habituating medications in the treatment of chronic

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i l l n e s ~ e sFamilies, .~~ friends, and work colleagues may notice a marked improvement before full abstinence is achieved. The critical therapy issue is loss of control. Patients who have loss of control are likely to suffer from it again. Controlled use is not predictable, and loss of control may have dangerous, irreversible sequelae. The attempts to control use may reflect the final struggle to justify continued drinking or drug use. Realizing this loss of control often helps patients accept the necessity of abstinence-based treatment. Treatment of withdrawal is important for the engagement of many patients. Some need pharmacologic interventions, and many do not. Alcohol and sedatives have severe withdrawal complications that can include delirium, seizures, and death. The vast majority of alcoholics do not need medical intervention for detoxification. Opiate withdrawal is often safe but uncomfortable, which may lead to termination of detoxification efforts by the patient. Nicotine withdrawal is uncomfortable and frequently leads to relapse even though it is not medically dangerous. Pharmacologic interventions for withdrawal are important to prevent life-threatening events, such as seizures, premature labor, or exacerbation of medical conditions, to prevent immediate relapse, injury, self-poisoning, suicide, or homicide. For the most part, agonists are used for detoxification: benzodiazepines for alcohol and sedatives, methadone or LAAM for opiates, and nicotine for tobacco; however, alternative ways to detoxify may be important for different patients and different settings. Clonidine, an a,-agonist, is useful for withdrawal syndromes that have adrenergic hyperactivity, including alcohol, opiates, and nicotine. Because the effects of clonidine are mediated through the locus coeruleus, it does not block the seizures or hallucinations that come from the limbic system during alcohol withdrawal. Because it lowers blood pressure, monitoring vital signs are important during clonidine detoxification. Antiepileptics, such as carbamazepine and valproic acid, have been used successfully for alcohol and benzodiazepine withdrawal. Some concern exists that untreated alcohol withdrawal may kindle the CNS for withdrawal symptoms in the future. This topic requires further research before its clinical impact can be understood. Many alcoholics detoxify on their own, and this is not always strongly discouraged by physicians. If kindling occurs, a strong argument could be made to engage routinely all alcoholic patients in a medically managed detoxification program. Treating the psychiatric illness that remains after detoxification is important for engagement, relapse prevention, and rehabilitation. Some physicians have debated about how soon to treat a significant depression or anxiety disorder. The old clinical wisdom recommended waiting 6 months; however, research by Brown et a16have suggested that the vast majority of alcohol- and drug-induced syndromes are clear within a few days to weeks. Thus, reasonable clinicians can observe the change in mood with sobriety without ignoring the possibility of a substanceinduced disorder. At the same time, reasonable clinicians can take action

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after 2 weeks of unremitting symptoms with some confidence that an independent disorder is present and requires treatment. The use of benzodiazepines with alcoholics and drug addicts has been controversial for decades because of the high risk for cross-addiction. Whenever safe, nonaddictive alternatives can be used, they should be. Patients with anxiety and panic disorders can usually be managed with antidepressants and buspirone. Some clinicians use hydroxyzine, diphenhydramine, trazodone, nefazodone, or doxepin for anxious patients who insist on having something to take when overwhelmed by anxiety or agitation. The tricyclic antidepressants carry a significant risk for accidental overdose when patients are drinking alcohol or when a risk for intentional overdose exists. A fine line exists between drugseeking and panic-avoidant behavior; obviously, they can coexist. In the human self-administration research, only the alcoholics, not the normal subjects or the anxious subjects, wanted more benzodiazepines.16Relief of anxiety is wonderful, but it does not lead to a desire for more benzodiazepines under research conditions in nonaddicted individuals. Overdose in dually ill patients can occur in both intoxicated and nonintoxicated states, Patients with anxiety and panic disorders may administer repeated doses of prescribed agents with or without a drug of abuse leading to severe toxicity and death in some cases. Bipolar disorder; schizoaffective disorder; and impulse-control disorders, such as intermittent explosive disorder, are common in the dualdiagnosis population. Use of mood stabilizers, which include several of the antiepileptics, are common. Mixed bipolar disorders are sometimes hard to distinguish from alcohol-exaggerated axis I1 disorders. Observation over time may be needed to see some of the affective patterns emerge. Management of patients with craving is an important aspect of addiction treatment.16 Craving has been described as a function of withdrawal and as an urge to use when not in withdrawal. With addicted patients, agonists seem to stimulate craving for more drug, even as they satisfy the urge to use momentarily. With dual-diagnosis patients, the relapse triggers may be related to mood swings, boredom and lassitude, familial crises, and peer pressure more than pure craving. Even so, the anticraving medications, such as naltrexone, selective serotonin reuptake inhibitors, acamprosate (not yet available in the United States), methadone, LAAM, buprenorphine (not yet available in the United States), and nicotine, can have a significant impact on prevention of relapse. Researchers found that subjects drank as often while taking naltrexone compared with placebo; however, they also found that subjects had a relapse to heavy drinking much less often with naltrexone compared with placebo. Some think of craving as a conscious sensation; however, empiric models suggest that craving may be a subconscious, physiologic drive. Diminishing such a drive could help patients with compromised impulse control or depression-weakened motivation to stay sober. Attendance of Alcoholics Anonymous (AA) is an important aspect of recovery that must be considered for every dual-diagnosis patient.

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Follow-up studies of abstinence rates have found that those attending AA have much higher rates.25aAlthough these studies did not stratify for comorbid psychiatric illness, dual-diagnosis patients should not be assumed to fare poorly at AA meetings. Kurtz et aP4 found that dualdiagnosis patients could be regular attenders at AA meetings (either regular AA meetings or special dual-recovery AA meetings) (87.5% continued in AA meetings), could be active in AA, and could feel supported in AA groups.” Furthermore, they found that level of impairment, locus of control, effect balance (well-being and happiness), and first meeting experience did not correlate with any of the involvement measures (i.e., participation in meetings, identification with others in AA, and involvement with members outside of the meetings). Although the dropout rate from AA is high during the first year,31athe research with dual-diagnosis patients suggests that they can gain significant benefit from the meetings and that professionals should encourage attendance.

ISSUES IN PHARMACOTHERAPY COLLABORATION

Collaboration is ubiquitous today for psychiatrists in clinical practice.15 Collaboration means the sharing of responsibility for a patient’s outcome among health care professionals. It requires articulating what responsibility each professional has and how the clinical work will be coordinated so as to benefit the patient. The potential strengths of collaboration include the mix of skills available to treat the patient, the support that each clinician provides for the patient and the others involved in the care, and the creative ideas that can emerge from the collaborative dialogue. Its potential weaknesses include the undermining of one treatment approach by the other professional, the abandonment of the patient by one professional, and the creation of confusion or anxiety for the patient by conflicting styles. Medicolegally, the courts may conceptualize this clinical situation more as supervision, in which the psychiatrist is ultimately responsible. This tendency of the courts may influence physicians’ styles and lead to conflicts when the psychiatrist insists on having overall authority or control of clinical care. One of the most important aspects of collaboration is its triangular dynamics. Although some people want to see collaboration as a “double dyad,” in which each professional has a dyadic relationship with the patient, this ignores the crucial relationship between the professionals. Effort and attention are required to maintain this relationship-this takes more time and costs more; however, failure to maintain this collaborative relationship often leads to misunderstandings that require even more time to correct and may lead to blame, resignation, guilt, self-pity, and c~nfusion.’~ When collaboration is not occurring effectively, the patient often suffers. With a dual-diagnosis population, this may mean missed appointments, appointments spaced further apart, medications not

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taken, return to drinking, continuation of marijuana smoking, increase in psychiatric symptoms, and increased need for crisis intervention. Maintaining the triangular relationship requires time for the professionals to get together and time for each professional with the patient, sometimes conjointly. Physicians should communicate contact with the patient to the collaborating professional soon after the session to keep each other up to date, pick up on discrepancies, and avoid splitting. The collaborating psychiatrist depends on the therapist for information and understanding of the intrapsychic and home life to prescribe medications responsibly. Without this additional information, the psychiatrist can be misled by patients. With increasing pressure for psychiatrists to see patients only for medications and not psychotherapy too, the collaborating therapist is essential for the intrapsychic understanding of the patient. To optimize collaborative treatment, the collaborators are recommended to meet and discuss their roles in the collaboration, how communication will occur (i.e., when, where, by what route, and how frequently), the need for conjoint sessions (and how to bill for them), treatment approaches and styles, management of emergencies, how to handle questions about medications, and vacation coverage. Some lawyers are recommending that psychiatrists collaborate only with therapists who have equivalent amounts of malpractice coverage so that the psychiatrist is not singled out as the person with “deep pockets” in a suit. Malpractice insurance may stipulate how many collaborators the insurance policy covers. Collaboration is likely to go more smoothly and collaborators are likely to feel more satisfied if the collaborators know each other well professionally. When the inevitable surprises occur, a solid foundation will exist for the collaboration to rest on. Identifying the patient-therapist relationship as the primary dyad clarifies the role of the pharmacologist as one in which the psychiatrist provides medication so as to enhance this primary relationship. Because medication is more effective in conjunction with psychotherapy, physicians should remember that the medication works optimally within the context of a therapeutic relationship. COST-EFFECTIVENESS AND OUTCOME OBSERVATIONS

With addictive disorders is considerable leverage for money saved compared with money spent. Studies across the United States have shown savings in social costs and medical costs for every treatment dollar spent. In California, the Department of Alcohol and Drug Programs launched an initiative in 1992 to study the cost-effectiveness of alcohol and drug treatment.*They found that for every treatment dollar spent, they saved an average of $7. The residential care had a return of 4 to 1, whereas the return for outpatient care was 10 to 1. Furthermore, the program spent approximately $209 million on 150,000 people, and it

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saved approximately $1.4 billion in the first year alone, with emergency room visits reduced by 38%, hospital admissions reduced by 33%, physical health hospitalizations reduced by 36%, and the mental health hospitalizations reduced by 44y0.~Ohio found similar benefits within 1 year, with a 66% reduction of hospital admissions and a 41% reduction in emergency room use.8 Minnesota saved $22 million in 1 year after alcohol and drug treatment for 18,000 patients.8 Reductions also occur for criminal recidivism and improved employment status. At an estimated $25,900 per year for incarceration, reduced recidivism could save millions of dollars. A program for second drug felony offenders in Brooklyn, New York, reported a fivefold reduction in recidivism (8% versus 40%) after treatment compared with incarceration with no treatment.8 Georgia’s program for adjudicated youths with multiple past offenses, Project Adventure, reported 28% recidivism after treatment compared with 55% for youthful offenders not in the program.8 United Airlines estimated an almost $17 return on every dollar spent on a drug-free workplace ~ r o g r a m Despite .~ these savings, Drug Strategies in 1995 found that health coverage for alcohol and drug dependence declined over the previous decade, resulting in fewer workers and their families having access to privately funded treatment.9 An estimated $100 billion annually is lost in health impairment and the fruitless treatment of ”surrogate diagnoses” for alcohol abuse a10ne.’~ In all, the government estimates that the total economic costs in the United States for alcohol and drug dependence was $246 billion in 1992.31Several studies have found inpatient and outpatient alcohol and drug treatment in large populations to be significantly cost20* a effecti~e.’~, Among chronically mentally ill patients, substance-use disorders have been associated with negative outcomes, including relapse, rehospitalization, violence, incarceration, inability to manage finances, unstable housing, noncompliance with medications and other treatments, increased vulnerability to HIV infection, and higher service use.13Drake et all3 thought that the poorer outcomes were, in part, related to the poor coordination of services between the mental health and substanceabuse systems. They supported the idea of integrated treatment when they reported that assertive community treatment (ACT) and standard case management (SCM) improved the substance-use disorders in a group of dual-diagnosis patients only when the ACT team or case manager provided the addiction services and the mental-illness treatment. For both ACT and SCM, days in the hospital and Brief Psychiatric Rating Scale total scores were reduced, and substance-use remission occurred. In a similar study with a chronically mentally ill population (two thirds were dual-diagnosis patients), Essock et all4 reported that ACT reduced the number of days in the hospital more than the SCM subgroup for patients who had begun the study in the hospital. Those who began as outpatients were affected equally by ACT and SCM. As reflected in the cost-benefit analysis, the ACT group averaged significantly less ”societal cost” than did the SCM group.

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With affective disorders and substance-use disorders, a mixture of outcomes can occur. Some studies report that outcome is worse for substance users with a comorbid psychiatric illness, whereas other studies have found that comorbid depression predicts a better outcome for alcoholic women, longer treatment retention for cocaine-addicted men, and more individual counseling sessions for methadone-maintained patients." Charney et al" found that all groups of substance-dependent patients (i.e., those with primary depression, substance-induced depression, and no depression) improved in substance consumption and depressive symptoms; however, those with substance-induced depression had more abstinence and a greater improvement in the global assessment scale than did the other two groups. Other studies have found that dual-diagnosis patients are hospitalized (i.e., for psychiatric care, detoxification, and rehabilitation) more frequently after engagement into integrated treatment services, suggesting that they were more engaged than those who were unserved in the community.34These patients had a shorter length of stay than did the dropouts, which could mean they were "sicker" and left the hospital sooner or were engaged in an outpatient clinic and had follow-up care already in place. Furthermore, the engaged patients had many fewer psychiatric emergency room visits than did the dropouts. A large-scale study of more than 85,000 alcoholic veterans found that alcoholics hospitalized for alcoholism treatment at the VA had increased total inpatient days and outpatient visits but had fewer inpatient medical days.5 The most likely explanation is that the dual-diagnosis population has two or more disorders that interfere with engagement in the medical care system. As a result, these patients stop taking their psychiatric medications during binges, miss outpatient appointments because of drug use and disorganization, and develop more psychotic symptoms because of their drug and alcohol use. Moreover, this population generally has the same problem with the real world: they tend not to pay bills and their gas, electric, and telephones are shut off; they tend to lose their driver's licenses to suspension and cannot drive to appointments or AA meetings; they tend to be too symptomatic to manage buses or sustain supportive family and friend relationships; and they tend to get impatient and demanding, offending or frightening potential helpers. When recovery is going well, this population is often dependent and easily overwhelmed, often in need of social services for rides, housing, financial aid and requiring monitoring for other important appointments (e.g., medical appointments, court dates, vocational training, or disability hearings). With abstinence and support, patients with dual disorders can stabilize and make gains. Removing support in the first few years of treatment often leads to a rapid decrease in functioning. Being consistent, patient, limit setting, insistent on regular contacts, and supportive pays off in the long run. The realities of limited resources and the success of "levels of care" for the treatment of singly diagnosed patients makes applying this model to dually ill patients tempting. This model may be

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appropriate for patients who obtain stable abstinence and who suffer minimal residual or negative symptoms. For many patients, the reality is that they have not sustained abstinence and that they suffer from positive and negative symptoms that result in ongoing disability. Significant opportunities exist to develop new models or to apply existing models of care to this challenging but rewarding population of patients.

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TK (eds): Principles of Addiction Medicine, ed 2. Chevy Chase, MD, American Society of Addiction Medicine, 1998, pp 731-740 Westermeyer J: Schizophrenia and substance abuse. In Tasman A, Riba MB (eds): Review of Psychiatry, vol 11. Washington, DC, American Psychiatric Press, 1992, pp 379-401 Wodak A: Harm reduction as an approach to treatment. In Graham AW, Schultz TZ (eds): Principles of Addiction Medicine, ed 2. Chevy Chase, American Society of Addiction Medicine, 1998, pp 395404 Woody G, Schuckit M, Weinrieb R, et al: A review of the substance use disorders section of the DSM-IV. Psychiatr Clin North Am 16:21-32, 1993 Woody GE, McLellan AT, Bedrick J: Dual diagnosis. In Oldham JM, Riba MB (eds): Review of Psychiatry, vol 14. Washington, DC, American Psychiatric Press, 1995, pp 83-104 Address reprint requests to R. Jeffrey Goldsmith, MD Veterans Affairs Medical Center, 7 East 3200 Vine Street Cincinnati, OH 45220 e-mail: Goldsmith.Richard JOcincinnati.va.gov