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The Treatment of Patients with
Mood Disorders and Substance
Use Disorders
Roger D. Weiss, MD
Chief, Division of Alcohol and
Drug Abuse, McLean Hospital
Professor of Psychiatry, Harvard
Medical School
Belmont, MA, USA
Likelihood of SUDs in people
with psychiatric diagnoses (ECA)
Diagnosis
 Bipolar disorder
 Schizophrenia
 Panic disorder
 Major depression
 Anxiety disorder
Odds ratio
6.6
4.6
2.9
1.9
1.7
SUD in bipolar disorder
 Lower
■ More
medication adherence
Relapses
■ Hospitalizations
■ Homelessness
■ Suicide
■
Substance abuse in patients with
psychiatric illness






Enhanced reinforcement
Mood change
Escape
Hopelessness
Poor judgment
Inability to appreciate consequences
The Self-Medication Hypothesis
Intolerance of specific emotions
 The importance of a “drug of
choice”
 More useful in describing substance
use rather than dependence

Diagnosing Psychiatric Disorders
in Patients with SUDs
 How long should you wait until a
patient has been off all drugs and
alcohol before you can diagnose any
psychiatric disorder?
 How much does diagnosis or primary
vs. secondary depression matter?
Treatment of patients with SUD
and mood disorder
 Pharmacotherapy
 Psychosocial
treatment
Pharmacotherapy
Co-occurring disorder
pharmacotherapy
 Typically
focuses on treatment of the
psychiatric disorder, though more recent
studies have focused on SUD as well
 Choice of medication is typically based on
the usual considerations
 Side effect profile
 Family history of medication response
 Likelihood of medication adherence
McLean Hospital Study of
Gender, Mood, and Recovery from
Alcohol Dependence
(Greenfield et al., 1998)
 Followed 101 patients (60 men, 41 women)
hospitalized for alcohol dependence
 Monthly assessment visits x 1 year
 SCID diagnoses of MDD were made a)
regardless of drinking and b) > 3 mos.
abstinent
Depression and Gender as Predictors
of Time to Relapse
Chance of No Relapse
1.00
0.75
0.50
Female, not dep
Male, not dep
0.25
0.00
Male, dep
Female, dep
0
50
100
150
200
Days Since Study Entry
250
300
Relation of Depression and Discharge
Antidepressants to Time to First Drink
Chances of Abstinence
1.00
0.75
No dep, no discharge antidep
0.50
No dep, discharge antidep
0.25
Dep, discharge antidep
Dep, no discharge antidep
0.00
0
50
100
150
200
Days Since Study Entry
(Greenfield
250
et al., Arch Gen. Psychiatry, 1998)
300
Medication studies of
co-occurring SUDs and mood disorders
All trials have compared medication vs.
placebo
 No head-to-head studies of 2 active medications

Placebo Effect
1.
2.
Very strong in substance dependent
populations
Difficult to distinguish between
placebo effect & study participation
effect, particularly in disorders
involving voluntary behavior such as
substance use disorders
Drinks Per Day (ITT)
Placebo
16
14
Mean
Phone Call Initiation
12
In-Clinic Screen
10
Treatment Start
8
6
4
2
0
B13 B12 B11 B10 B9 B8 B7 B6
B5 B4 B3 B2
B1
1
2
3
4
5
6
7
8
9
10
11
12
Study Week
15
Pharmacotherapy of SUD &
Depression
Most recent controlled studies show
improvement in depression
 Tricyclics have most robust effect
 SSRIs most helpful in late-onset alcoholics,
may worsen early-onset alcoholics
 Less improvement in substance use (often
correlated with mood improvement), but not
worsening (ie, not enabling)
 Pneumonia model

Valproate for Alcohol
Dependence & BD

24-week trial of valproate vs. placebo in 59
pts on lithium

Valproate patients had
 Fewer heavy drinking days
 Less drinking on heavy drinking days
 No differences in manic, depressive sx
Salloum et al., 2005
Medication adherence in
patients with BD & SUD
Patients with BD & SUD were asked
about lifetime adherence to various
medications
 Answers ranged from “never” to “all the
time”
 We compared “all the time” to other
responses

Weiss et al., 1998
Lifetime adherence
100 % adherence
Lithium*
Valproate*
Benzodiazepines
Neuroleptics
TCAs
SSRIs
22 %
48 %
36 %
37 %
63 %
46 %
*Lithium vs. valproate p< .03
Reasons for med non-adherence
Lithium
n=29
Physical effects
■ Saw no need for meds
■ Wanted to use substances
Valproate
■ “Hassle” to take (lab tests)
n=13
■ Forgot
■ Wanted to use
Benzodiazepines ■ Took more to get “high”
n=21
■ Impatient, so took more
■ Couldn’t think clearly
■
Reasons for non-adherence (cont’d)
Neuroleptics ■ Physical effects (EPS)
n=19
TCAs
n=10
SSRIs
n=17
■
Impatient, modify substance use,
or get high
■
Saw no need
■
Impatient, so took more
■
Saw no need
■
Meds not working, so took less
■
Wanted to use
■
Felt manic
■
Meds not working, so took less
Psychosocial
Treatment
Models of
dual diagnosis treatment
 Sequential

Parallel

Integrated
Models of
integrated treatment
 Depends on the disorders & their
relationship
 “Integrated” treatment means
different things to different
people
Integrated Group Therapy
(IGT): Core principles
Cognitive-behavioral model focuses on
parallels between the disorders in
recovery/relapse thoughts and behaviors
 Interaction between the disorders
 The single disorder paradigm: “bipolar
substance abuse”
 The central recovery rule

IGT structure

Check-in: substance use, mood, med
adherence

Review last week’s group

Skill practice

Didactic/handout on integrated topic
(e.g., dealing with depression without
using alcohol and drugs)

Discussion
What is “integrated” about
Integrated Group Therapy ?
 Check-in
focuses on mood, substance use,
and medication adherence
 Topics relevant to both disorders
 Patients seen as having a single disorder:
“bipolar substance abuse”
 Relationship & similarities between the
disorders & the recovery process stressed
Integrated Group Therapy:
Sample topics
Dealing with depression without
using alcohol or drugs
 Denial, ambivalence, acceptance
 Taking medication
 Self-help groups (for both
SUD & BD)
 Identifying and fighting triggers
 Getting a good night’s sleep

The Central Recovery Rule
No matter what
 Don’t
drink
 Don’t use drugs
 Take your medication as prescribed
No matter what!
Findings of IGT research

3 studies funded by National Institute
on Drug Abuse

Compared IGT initially to either
treatment as usual or standard
manualized Group Drug Counseling
(GDC)

All 3 studies showed significantly
greater likelihood of abstinence in IGT
patients

Fewer differences in mood outcomes
“Community-Friendly”
Version of IGT vs.
Group Drug Counseling
Making IGT more
“community-friendly”
 IGT
had had 2 successful studies, with 20
sessions led by therapists who had CBT
and BD knowledge
 However, many community treatment
programs don’t have counselors with
experience in either CBT or BD, and can’t
be paid for 20-session treatments
 These factors could reduce adoption of
IGT in community treatment programs
Study of “Community-Friendly”
version of IGT

Made IGT more “community-friendly”
 12 sessions, instead of 20
 Groups were run by front-line drug
counselors without formal CBT training
or explicit BD knowledge

Compared IGT to GDC
Weiss et al., Drug and Alcohol Dependence, 2009
Patients
 61
patients: 31 IGT & 30 GDC
 Current
BD & substance dependence
 Substance
A
use in the past 60 days
mood stabilizer regimen for ≥ 2 weeks
Results: Mood (p<.10)
Outcome
Variables
IGT (n=31)
End of 3-mo
Baseline
Tx
f/u
GDC (n=30)
End of 3-mo
Baseline
tx
f/u
Mood
episode (%
yes)
52
20
27
57
30
37
Depressive
episode
35
20
20
40
23
22
Manic
episode
16
0
7
17
7
15
Time to first abstinent month
by treatment (p<.04)
Abstinent (%)
100
80
IGT
60
40
GDC
20
0
Baseline
1
2
3
Month
4
5
6
Abstinence: IGT vs. GDC
 ≥1
month abstinent: 71% vs. 40 %, p<.02
 Abstinent throughout treatment (3 mos.):
36% vs. 13%, p<.05
“Good clinical outcome”
by treatment condition:
Abstinent & no mood episodes in last month
Good outcome (%)
50
40
IGT
30
IGT
20
GDC
GDC
10
0
End of treatment (p<.04)*
6 month follow-up
Conducting an IGT Group
Structure of a 60-min. IGT session
(15’)
 Review of last week’s group (5’)
 Review of last week’s skill practice (5’)
 Discuss session topic (20’)
 Review session hand-out and wrap up (10’)
 Hand out and discuss skill practice for next
week (5’)
 Check-in/introductions
Conducting the check-in
Have you used drugs or alcohol during the past
week? If so, on how many days?
 How was your overall mood during the past
week?
 Did you take all of your medications as
prescribed during the past week? If no, why
not?
 Did you face any high-risk situations or triggers
in the past week? If yes, how did you deal with
them?

Conducting the check-in (2)

Asking about how many days of use is important

Allows for assessment of improvement vs.
worsening
Conducting the check-in (3)

The check-in establishes the tone of the group

It illustrates the “integrated” nature of IGT

Listen for the relevance of check-ins to the
session topic

Come back to check-ins to illustrate session
topic themes
Key principles of IGT
 Parallels
between the two disorders in
the recovery and relapse processes
 Interactions between the two disorders
 The single disorder paradigm:
“bipolar substance abuse”
 The central recovery rule
Parallels in the recovery and
relapse processes
 The
abstinence violation effect vs. stopping
medication when depressed
Parallels in the recovery and
relapse processes
 Recovery
vs. relapse thoughts and
behaviors
 “May as well thinking” vs. “It matters
what you do”
 Medication non-adherence vs. staying
in bed all day vs. skipping AA
Combating hopelessness: “It
matters what you do”
•
•
•
•
Early sign of relapse to depression: not
returning phone calls
One more call vs. one less call to make
Making concrete suggestions for taking
one step at a time toward recovery
You’re always on the road to getting better
or getting worse; therefore, it matters what
you do
Interactions between the two
disorders
 Why
use the term “bipolar substance
abuse?”
 “Drinking is bad for your mood”
 “Playing around with your medication is
bad for your addiction”
General guidelines for conducting
IGT
 Go
back and forth between mood issues
and substance use issues
 Think about parallels: if a patient is
talking about drinking, think about mood
issues, and vice versa
 Try to gently call on everyone, including
people who are lost in their own thoughts
 Be upbeat
General guidelines for conducting
IGT (cont)
 Focus
on both successes and failures
(“What did you do on the 4 days that you
were sober that you didn’t do on the 3 days
that you drank?)”
Therapist characteristics for IGT
 Familiarity
with SUD, BD ideal
 Can be successfully run by front-line
substance abuse counselors
 Some knowledge of relapse prevention or
CBT is very helpful
 Empathic
 Warm, friendly, non-confrontational
Who should be in an IGT group?
 Willingness
to enter a group that addresses
both problems
 Not acutely manic
 Not intoxicated
 IGT is designed to be delivered with
pharmacotherapy as well; other
psychosocial treatment is also encouraged
Adapting IGT to other settings

Change the length of the sessions

Add items to the check-in (e.g., exercise,
self-help meeting attendance)

Add a preparation group

Broaden the population

Recite the central recovery rule at the
end of the group

Use IGT principles in individual Rx
Current status of IGT
 Has
been adapted for patients with
psychotic illness as well
 In use in multiple clinical settings at
McLean Hospital
 Currently in use in multiple clinical
and research settings in U.S.,
Canada
 Book published in 2011 by Guilford
Press
Now available!