Male primary alcoholics with and without family histories of affective disorder

Treating patients with bipolar disorder and substance dependence: lessons learned

Although bipolar disorder is the Axis I psychiatric disorder associated with the highest rate of co-occurring substance use disorders, little research has focused on treatments specifically designed for these patients. The author and his colleagues have developed and studied Integrated Group Therapy (IGT) for this population. This paper describes common themes that have emerged in carrying out IGT for patients with bipolar disorder and substance dependence. These include the strong emphasis on depression, as opposed to mania; the predominance of hopelessness; specific patterns of medication noncompliance; and the implications of patients' labeling their substance use as self-medication. Therapeutic aspects involved in addressing these themes are discussed.

Impact of substance abuse on the course and treatment of bipolar disorder

OBJECTIVES

The objectives of this article are to review the prevalence, natural history, pathophysiology, and treatment of comorbid bipolar disorder with alcoholism and other psychoactive substance use disorders (PSUDs).

METHODS

All identified bibliographies through a literature search of all Medline files and bibliographies of selected articles focusing on the prevalence, natural history, course, prognosis, inter-relationship, and treatment of bipolar disorder with comorbid alcoholism and other PSUDs were reviewed.

RESULTS AND CONCLUSIONS

Comorbidity of bipolar disorder and alcoholism and other PSUDs is highly prevalent. The presence of this so called 'dual diagnoses' creates a serious challenge in terms of establishing an accurate diagnosis and providing appropriate treatment interventions. The inter-relationship between these disorders appears to be mutually detrimental. The course, manifestation, and treatment of each condition are significantly compounded by the presence of the other condition. Substance abuse and alcoholism appear to significantly complicate the course and prognosis of bipolar disorder resulting in increased suffering, disability, and costs. On the other hand, bipolar disorder may be a risk factor for developing PSUDs. Although, there are a number of hypotheses explaining the pathophysiological mechanism involved in such comorbidities, our understanding of the exact nature of such neurobiological mechanisms is still limited. While the antikindling agents and targeted psychotherapeutic techniques may be useful intervention strategies, there is still a significant lack of empirically based treatment options for these patients.

A relapse prevention group for patients with bipolar and substance use disorders

Although bipolar disorder is the Axis I disorder associated with the highest risk of having a coexisting substance use disorder, no specific treatment approaches for this dually diagnosed patient population have thus far been developed. This paper describes a 20-session relapse prevention group therapy that the authors have developed for the treatment of patients with coexisting bipolar disorder and substance use disorder. The treatment uses an integrated approach by discussing topics that are relevant to both disorders and by highlighting common aspects of recovery from and relapse to each disorder.

Depression and stimulant dependence: neurobiology and pharmacotherapy

Depressive disorder rates in stimulant-dependent individuals are substantially higher than community rates. Further, depressive symptoms are considered a major component of stimulant withdrawal. The comorbidity of these disorders may reflect shared neurochemical alterations in the function of serotonin, dopamine, and peptide systems, such as corticotropin releasing factor (CRF) and neuropeptide Y (NPY). These alterations are observed in patients, and in animal models of depression and stimulant dependence, particularly in limbic brain structures. This shared neurobiology does not seem to result from significant shared heritability or genetic linkage; stimulants may induce changes in neurobiology that are similar to those found in depression, and these changes might provide a therapeutic target. Stimulant-dependent patients with a depressive disorder may be a specific subpopulation for antidepressant trials, and they might reduce their stimulant abuse when treated with antidepressants. Nevertheless, concomitant dependence on alcohol or opioids may influence this response, and antidepressants appear to be more effective for depression in combined stimulant and opioid dependence than in combined stimulant and alcohol dependence.

Three clusters of male alcoholics

The study comprises 296 male alcoholics in whom detailed studies of family history, clinical factors, psychopathology of dependence as well as psychological and neurophysiological tests were made. On the basis of five clinical factors: age of onset of dependence, history of familial alcoholism, severity of alcohol-related problems and the prevalence of psychiatric and somatic diseases, K-means cluster analysis delineated three types of alcoholics. Type 1 was characterized by late onset of dependence, low prevalence of familial alcoholism and mild course. Type 2 was characterized by early onset of dependence, high familial alcoholism in fathers, frequent antisocial personality, severe intensity of alcohol-related problems. Type 3 was characterized by early onset of dependence, familial history of psychiatric diseases, severe intensity of alcohol-related problems and high prevalence of psychiatric disturbances and somatic diseases. Type 3 may be characterized as alcoholism associated with high predisposition and comorbidity. This may make a distinct type of male alcoholics.

Five-year course of major depression: effects of comorbid alcoholism

Some patients enter psychiatric treatment with clear cases of both major depression and alcoholism. While assumptions are often made about the relationships of these two conditions, little empirical evidence exists on the effects of sustained remissions in alcoholism on sustained remissions in depression. 127 patients with both disorders at treatment entry were studied over a 5-year period. Survival analyses with time-dependent covariates indicating alcoholism status were used to investigate remissions and relapses in major depression. Remission in alcoholism strongly and significantly increased the chances of remission in depression and were also related to reduced chances of depression relapse, although at a weaker level.

The effects of antecedent substance abuse on the development of first-episode psychotic mania

We examined associations of antecedent drug and alcohol abuse with age of onset of bipolar disorder and the time to hospitalization in a sample of 59 patients presenting with their first episode of psychotic mania. Patients with first-episode manic or mixed bipolar disorder with psychotic features were recruited from consecutive hospitalizations and evaluated using structured diagnostic instruments. Antecedent alcohol abuse was present in 12 patients (20%), and antecedent drug abuse in 19 (32%). Antecedent alcohol abuse was associated with a later age of onset of the bipolar disorder, although antecedent drug abuse was not associated with age of onset. Patients with antecedent drug or alcohol abuse required hospitalization sooner than those without. These preliminary findings suggest that patients with bipolar disorder and antecedent alcohol abuse may have a later onset of their affective illness, perhaps representing a subgroup of patients in whom previous alcohol abuse is necessary to precipitate an affective episode. Regardless, the presence of antecedent substance abuse leads to more rapid hospitalization in these patients. Our results should be considered preliminary, given the small sample size and the post-hoc design of the study. Additional prospective studies of patients with new onset bipolar disorder and antecedent substance abuse syndromes are needed to further clarify the complex relationships between substance abuse and bipolar disorder.

The depressed alcoholic. Clinical features and medical management

A relationship between depression and alcoholism has long been postulated. A review of prior research studies reveals that though patients with depression do not appear to develop alcoholism to any great extent, recently detoxified alcoholics have a depressive syndrome about 20% of the time. This cannot be accounted for readily from data on family studies or genetic studies, which generally suggest that alcoholism and depression are two independent illnesses, albeit both quite common. Clinically, depressed alcoholics resemble alcoholics more than they resemble depressives. The clinical course of depression when it coexists with alcoholism is generally benign and self-limited, with most patients becoming euthymic over the course of 2-4 weeks without specific antidepressant treatment. In some depressed alcoholics, however, a more chronic depression persists, and may predict a worse outcome for the alcoholism. Treatment of depression in alcoholics should be initially conservative. Tricyclic and other antidepressants should be used with extreme care as they may potentiate toxic effects of alcohol.