Drug and Alcohol Dependence, 25 (1990) 121Elsevier Scientific Publishers Ireland Ltd.
121
123
Research on psychopathology and addiction: treatment implications George E. Woody, A. Thomas McLellan Addiction
Treatment
and Research
Center,
University Philadelphia
of Pennsylvania and PA 19104 (U.S.A.1
The relationship between psychopathology and addiction has long been discussed in the psychiatric literature, but only recently has this topic been the subject of formal research. Though few in number, recent studies on psychopathology and addiction have provided information that can be used to guide treatment decisions. Some of these studies will be discussed in this brief review, with the aim of demonstrating how research has been able to inform clinical decisions. One group of studies has shown that drug use can cause psychiatric disorders, and that stopping drugs can result in significant reductions in psychopathology. Some of the first such studies examined the relationship between depression and alcoholism. For example, Mendelson [l] evaluated psychiatric symptoms in alcoholics who were allowed to self-administer alcohol while living on an inpatient unit. He showed that levels of depression increased during the period of alcohol self-administration and decreased following abstinence. Other studies have shown that symptoms of depression are common among alcoholics at the beginning of treatment, but that most depressive symptoms disappear after 3-4 weeks of abstinence [2]. These studies are consistent with the impressions of many clinicians that much of the depression that is seen in alcoholics results from toxic effects of alcohol on the central nervous system. The treatment implication is that specific antidepressant therapy for alcoholics should be reserved until after depressive symptoms have been given the opportunity to 0376.8716/90/$03.50 0 1990 Elsevier Printed and Published in Ireland
Scientific
Publishers
and Charles Veterans
P. O’Brien
Administration
Medical
Center,
resolve through abstinence and drug-focused therapy. A related study of the long-term effects of dependence on a variety of illicit drugs [3] examined psychiatric symptoms in a group of patients who were readmitted to a substance abuse treatment unit at least once every 6 months over a period of 6 years [3]. Due to their history of repeated admissions, the patients studied were some of the most refractory and chronic among those treated at the institution where the work was performed during the years 19’72-19’78. The patients were grouped into three categories based upon the class of drugs used: stimulants (mainly amphetamines); depressants (barbiturates, methaqualone, glutethimide, benzodiazepinesl; and narcotics (heroin, hydromorphone, methadone). All subjects had a psychiatric interview upon admission and were administered the MMPI approximately 2 weeks after hospitalization. This two-week interval was selected as being sufficient for most acute drug effects to have disappeared, since it followed a 7- to lo-day period of detoxification, thus minimizing the chances for acute withdrawal effects to interfere with the MMPI scores or psychiatric assessments. Demographic variables and MMPI scores were similar for all subjects at the first admission. They differed only in respect of the drugs that they typically abused at this early stage in their drug-taking careers. A much different picture emerged over the period of study. The stimulant developed significant group increases in schizophrenic-like symptoms, espe-
Ireland Ltd.
122
cially paranoia and mania. The sedative abusers developed increases in depressive symptoms, cognitive impairment and anxiety. The narcotic addicts had elevations in depression and sociopathy upon admission, and these symptoms remained unchanged over the 6-year period. The results were interpreted as indicating that prolonged use of stimulants can be associated with the emergence of schizophrenia-like symptoms; depressants can be associated with depression; and narcotic addiction results in no new psychiatric symptoms. These conclusions must remain tentative due to the retrospective nature of the design. Since the patients were only observed after drug abuse had started, it was impossible to be certain that the effects were due only to the drug and not to an underlying, non-drug condition that would have emerged even in the absence of drug abuse and dependence. Though not conclusive, these data are sufficiently indicative of possible drug toxicity to include in presentations to health care professionals about adverse drug effects, and to consider these effects in differential diagnoses of psychiatrically impaired substance abusers. A treatment implication is that long-term abstinence may be associated with symptomatic improvement, such as reported in alcoholics suffering from cognitive impairment [4]. A third area of research concerns the observation that most opiate addicts have diagnosable psychiatric disorders in addition to their addiction. These findings emerged from three studies that were supported by the National Institute on Drug Abuse during the early 1980s. Each found that 80-85% of methadonemaintained addicts had a range of psychiatric disorders in addition to opiate dependence, either currently or in the past [5-771. The most common disorders were depression, occurring in 50 - 60% of the samples; antisocial personality disorder, found in 20-50% depending on whether the RDC or DSM-III criteria were used; alcohol dependence, either current or past, found in 20- 25%; anxiety disorders in 10 -20%; and an assortment of other problems,
often reflecting disorders of mood such as labile personality or bipolar II disorder, found in 210%. One of these studies also evaluated a group of addicts who were not in treatment and found the same types of problems as seen in the treated sample, however the out-of-treatment subjects had less psychopathology than the intreatment group [8]. One interpretation of this finding was that co-existing psychiatric problems may have contributed to the decision to enter treatment. Many of these psychiatric disorders appear to have prognostic significance for the outcome of drug treatment. This was shown in a study which demonstrated that a global rating of psychiatric severity is a good predictor of 6-month post-treatment outcome for both opiate addicts and alcoholics [9]. This work showed that patients with few additional psychiatric symptoms (termed low severity patients1 generally did well regardless of the type of treatment or whether the setting was programme inpatient or outpatient. Patients with high symptom levels did poorly in all forms of standard substance abuse treatment programmes although outpatient treatments generally and outpatient drug free treatments specifically, were particularly ineffective. The ‘mid psychiatric severity’ patients, i.e., those with mild symptoms of depression and anxiety, usually situational or temporary, had generally intermediate outcomes but these outcomes could be improved with patientlprogramme matching strategies using other types of information about them collected at the time of treatment admission, e.g., the severity of their employment and family/social problems. The treatment implications of these findings are first, that the psychiatric problems and symptoms of substance abusers are important predictors of outcome from standard substance abuse treatments. Second, that if professional psychiatric treatments could be delivered as adjuncts to the standard drug-focused therapies, that these extra therapies might provide additional gains for those patients who are psychiatrically impaired, the so-called ‘dual diagnosis’ patients.
123
This prediction, based on the results of prior outcome studies was tested in one study which compared drug counseling plus supportive expressive therapy (SE) or cognitive behavioral therapy (CB), with paraprofessional counseling alone (DC) in methadone-maintained opiate addicts. The data from this study were analyzed, looking especially for interactions between psychiatric severity, outcome, and treatment condition. It was found that there were few outcome differences among the three treatment conditions (SE, CB and DC) in low psychiatric severity patients, confirming the common clinical impression that not all substance abuse patients need professional therapy. In contrast, high psychiatric severity patients showed few gains, and little progress if they received drug counseling alone. However, these patients showed both a range of significant improvements and better outcomes when either form of professional therapy was added to the traditional methadone maintenance and counseling. The conclusion for this group of patients was that the addition of psychotherapy altered the traditional relationship between high psychiatric severity and poor outcome. Psychotherapy gave this group of more disturbed patients a better chance to benefit from methadone treatment [lo]. This finding pointed toward a possible costeffective use of psychotherapy. High severity patients are a very difficult group to treat. They usually demand more staff time than their less disturbed counterparts, and make little progress. The study results imply that these patients, when identified early in treatment and provided with additional psychotherapy concurrent with their substance abuse treatment, are thereby given a better chance to improve. This plan seems to also reduce the strain and time demands that these patients place on drug counselors, and thus has a positive effect on the overall program staff as well. Another finding from this series of studies was that opiate dependent patients with a diagnosis of antisocial personality disorder (ASP), but no other psychiatric disorders, showed min-
imal gains and no special benefits from the additional psychotherapy. However, if the ASP was accompanied by diagnosable depression these opiate dependent patients made a number of gains in measures of drug use, employment and psychiatric symptoms [ll]. The treatment implication of this work is that opiate addicts with ASP plus an accompanying psychiatric condition may have a better prognosis than many therapists expect, and thus additional treatments for this group may be helpful. In contrast, opiate dependent (and perhaps other substance dependent1 patients who show no diagnoses other than substance dependence and antisocial personality, may have the poor prognoses that are traditionally associated with this diagnosis. In closing, it should be emphasized that none of these studies has shown that treating psychiatric disorders in dually-diagnosed patients is a cure for drug abuse or addiction. The major finding is that some psychiatric disorders are best left to resolve with abstinence, while others remain and have prognostic significance. Making the proper diagnosis is as important here as in other areas of medicine, and patients with underlying or persistent psychiatric disorders will have a better chance to progress in their substance abuse treatment if attention is given concurrently to both conditions. References 1 2 3 4 5 6 7 8 9 10 11
J.H. Mendelson, Q.J. Stud. Alcohol., Suppl. 2, (1964). M. Schuckit. Am. J. Psychiat., 140 (1983) 711. A.T. McLellan, G.E. Woody and C.P. O’Brien, New Eng. J. Med., 301(1979) 1310. J. Brandt et al., Arch. Gen. Psychiat., 40 (1983) 435. B.J. Rounsaville et al., Arch. Gen. Psychiat., 39 (1982) 161. G.E. Woody et al., Arch. Gen. Psychiat.. 40 (1983) 639. E.J. Khantzian and C. Treece, Arch. Gen. Psychiat., 42 (1985) 1067. B.J. Rounsaville and H.D. Kleber, Arch. Gen. Psychiat., 42 (1985) 1072. A.T. McLellan et al., Arch. Gen. Psychiat., 40 (1983) 620. G.E. Woody G.E. Woody
et al.. Am. J. Psychiat.. 141(1984) 1172. et al., Arch. Gen. Psychiat., 42 (1985) 1081.
121
123
Research on psychopathology and addiction: treatment implications George E. Woody, A. Thomas McLellan Addiction
Treatment
and Research
Center,
University Philadelphia
of Pennsylvania and PA 19104 (U.S.A.1
The relationship between psychopathology and addiction has long been discussed in the psychiatric literature, but only recently has this topic been the subject of formal research. Though few in number, recent studies on psychopathology and addiction have provided information that can be used to guide treatment decisions. Some of these studies will be discussed in this brief review, with the aim of demonstrating how research has been able to inform clinical decisions. One group of studies has shown that drug use can cause psychiatric disorders, and that stopping drugs can result in significant reductions in psychopathology. Some of the first such studies examined the relationship between depression and alcoholism. For example, Mendelson [l] evaluated psychiatric symptoms in alcoholics who were allowed to self-administer alcohol while living on an inpatient unit. He showed that levels of depression increased during the period of alcohol self-administration and decreased following abstinence. Other studies have shown that symptoms of depression are common among alcoholics at the beginning of treatment, but that most depressive symptoms disappear after 3-4 weeks of abstinence [2]. These studies are consistent with the impressions of many clinicians that much of the depression that is seen in alcoholics results from toxic effects of alcohol on the central nervous system. The treatment implication is that specific antidepressant therapy for alcoholics should be reserved until after depressive symptoms have been given the opportunity to 0376.8716/90/$03.50 0 1990 Elsevier Printed and Published in Ireland
Scientific
Publishers
and Charles Veterans
P. O’Brien
Administration
Medical
Center,
resolve through abstinence and drug-focused therapy. A related study of the long-term effects of dependence on a variety of illicit drugs [3] examined psychiatric symptoms in a group of patients who were readmitted to a substance abuse treatment unit at least once every 6 months over a period of 6 years [3]. Due to their history of repeated admissions, the patients studied were some of the most refractory and chronic among those treated at the institution where the work was performed during the years 19’72-19’78. The patients were grouped into three categories based upon the class of drugs used: stimulants (mainly amphetamines); depressants (barbiturates, methaqualone, glutethimide, benzodiazepinesl; and narcotics (heroin, hydromorphone, methadone). All subjects had a psychiatric interview upon admission and were administered the MMPI approximately 2 weeks after hospitalization. This two-week interval was selected as being sufficient for most acute drug effects to have disappeared, since it followed a 7- to lo-day period of detoxification, thus minimizing the chances for acute withdrawal effects to interfere with the MMPI scores or psychiatric assessments. Demographic variables and MMPI scores were similar for all subjects at the first admission. They differed only in respect of the drugs that they typically abused at this early stage in their drug-taking careers. A much different picture emerged over the period of study. The stimulant developed significant group increases in schizophrenic-like symptoms, espe-
Ireland Ltd.
122
cially paranoia and mania. The sedative abusers developed increases in depressive symptoms, cognitive impairment and anxiety. The narcotic addicts had elevations in depression and sociopathy upon admission, and these symptoms remained unchanged over the 6-year period. The results were interpreted as indicating that prolonged use of stimulants can be associated with the emergence of schizophrenia-like symptoms; depressants can be associated with depression; and narcotic addiction results in no new psychiatric symptoms. These conclusions must remain tentative due to the retrospective nature of the design. Since the patients were only observed after drug abuse had started, it was impossible to be certain that the effects were due only to the drug and not to an underlying, non-drug condition that would have emerged even in the absence of drug abuse and dependence. Though not conclusive, these data are sufficiently indicative of possible drug toxicity to include in presentations to health care professionals about adverse drug effects, and to consider these effects in differential diagnoses of psychiatrically impaired substance abusers. A treatment implication is that long-term abstinence may be associated with symptomatic improvement, such as reported in alcoholics suffering from cognitive impairment [4]. A third area of research concerns the observation that most opiate addicts have diagnosable psychiatric disorders in addition to their addiction. These findings emerged from three studies that were supported by the National Institute on Drug Abuse during the early 1980s. Each found that 80-85% of methadonemaintained addicts had a range of psychiatric disorders in addition to opiate dependence, either currently or in the past [5-771. The most common disorders were depression, occurring in 50 - 60% of the samples; antisocial personality disorder, found in 20-50% depending on whether the RDC or DSM-III criteria were used; alcohol dependence, either current or past, found in 20- 25%; anxiety disorders in 10 -20%; and an assortment of other problems,
often reflecting disorders of mood such as labile personality or bipolar II disorder, found in 210%. One of these studies also evaluated a group of addicts who were not in treatment and found the same types of problems as seen in the treated sample, however the out-of-treatment subjects had less psychopathology than the intreatment group [8]. One interpretation of this finding was that co-existing psychiatric problems may have contributed to the decision to enter treatment. Many of these psychiatric disorders appear to have prognostic significance for the outcome of drug treatment. This was shown in a study which demonstrated that a global rating of psychiatric severity is a good predictor of 6-month post-treatment outcome for both opiate addicts and alcoholics [9]. This work showed that patients with few additional psychiatric symptoms (termed low severity patients1 generally did well regardless of the type of treatment or whether the setting was programme inpatient or outpatient. Patients with high symptom levels did poorly in all forms of standard substance abuse treatment programmes although outpatient treatments generally and outpatient drug free treatments specifically, were particularly ineffective. The ‘mid psychiatric severity’ patients, i.e., those with mild symptoms of depression and anxiety, usually situational or temporary, had generally intermediate outcomes but these outcomes could be improved with patientlprogramme matching strategies using other types of information about them collected at the time of treatment admission, e.g., the severity of their employment and family/social problems. The treatment implications of these findings are first, that the psychiatric problems and symptoms of substance abusers are important predictors of outcome from standard substance abuse treatments. Second, that if professional psychiatric treatments could be delivered as adjuncts to the standard drug-focused therapies, that these extra therapies might provide additional gains for those patients who are psychiatrically impaired, the so-called ‘dual diagnosis’ patients.
123
This prediction, based on the results of prior outcome studies was tested in one study which compared drug counseling plus supportive expressive therapy (SE) or cognitive behavioral therapy (CB), with paraprofessional counseling alone (DC) in methadone-maintained opiate addicts. The data from this study were analyzed, looking especially for interactions between psychiatric severity, outcome, and treatment condition. It was found that there were few outcome differences among the three treatment conditions (SE, CB and DC) in low psychiatric severity patients, confirming the common clinical impression that not all substance abuse patients need professional therapy. In contrast, high psychiatric severity patients showed few gains, and little progress if they received drug counseling alone. However, these patients showed both a range of significant improvements and better outcomes when either form of professional therapy was added to the traditional methadone maintenance and counseling. The conclusion for this group of patients was that the addition of psychotherapy altered the traditional relationship between high psychiatric severity and poor outcome. Psychotherapy gave this group of more disturbed patients a better chance to benefit from methadone treatment [lo]. This finding pointed toward a possible costeffective use of psychotherapy. High severity patients are a very difficult group to treat. They usually demand more staff time than their less disturbed counterparts, and make little progress. The study results imply that these patients, when identified early in treatment and provided with additional psychotherapy concurrent with their substance abuse treatment, are thereby given a better chance to improve. This plan seems to also reduce the strain and time demands that these patients place on drug counselors, and thus has a positive effect on the overall program staff as well. Another finding from this series of studies was that opiate dependent patients with a diagnosis of antisocial personality disorder (ASP), but no other psychiatric disorders, showed min-
imal gains and no special benefits from the additional psychotherapy. However, if the ASP was accompanied by diagnosable depression these opiate dependent patients made a number of gains in measures of drug use, employment and psychiatric symptoms [ll]. The treatment implication of this work is that opiate addicts with ASP plus an accompanying psychiatric condition may have a better prognosis than many therapists expect, and thus additional treatments for this group may be helpful. In contrast, opiate dependent (and perhaps other substance dependent1 patients who show no diagnoses other than substance dependence and antisocial personality, may have the poor prognoses that are traditionally associated with this diagnosis. In closing, it should be emphasized that none of these studies has shown that treating psychiatric disorders in dually-diagnosed patients is a cure for drug abuse or addiction. The major finding is that some psychiatric disorders are best left to resolve with abstinence, while others remain and have prognostic significance. Making the proper diagnosis is as important here as in other areas of medicine, and patients with underlying or persistent psychiatric disorders will have a better chance to progress in their substance abuse treatment if attention is given concurrently to both conditions. References 1 2 3 4 5 6 7 8 9 10 11
J.H. Mendelson, Q.J. Stud. Alcohol., Suppl. 2, (1964). M. Schuckit. Am. J. Psychiat., 140 (1983) 711. A.T. McLellan, G.E. Woody and C.P. O’Brien, New Eng. J. Med., 301(1979) 1310. J. Brandt et al., Arch. Gen. Psychiat., 40 (1983) 435. B.J. Rounsaville et al., Arch. Gen. Psychiat., 39 (1982) 161. G.E. Woody et al., Arch. Gen. Psychiat.. 40 (1983) 639. E.J. Khantzian and C. Treece, Arch. Gen. Psychiat., 42 (1985) 1067. B.J. Rounsaville and H.D. Kleber, Arch. Gen. Psychiat., 42 (1985) 1072. A.T. McLellan et al., Arch. Gen. Psychiat., 40 (1983) 620. G.E. Woody G.E. Woody
et al.. Am. J. Psychiat.. 141(1984) 1172. et al., Arch. Gen. Psychiat., 42 (1985) 1081.
