A number of years ago, a recovering alcoholic was referred for treatment of depression. He had been sober for about a year but was depressed and afraid that it would precipitate a relapse. He was doing well in many ways, being steadily employed and attending weekly meetings at two different Alcoholics Anonymous (AA) groups. He thought that antidepressant medication might help but had noticed that most members of one AA group were opposed to taking medication, while the other group accepted its use. He wanted to continue in each group but was concerned that one would ostracize him if he took medication. After some discussion, we decided to begin antidepressant medication and simply not mention it in the one group. His depression resolved over the next several months, he continued to participate in both groups, and he remained sober until he left treatment about two years later. He continued in AA but discontinued medication after a period of remission from depression.
Then there was the patient with alcohol dependence who was drinking heavily and had signs and symptoms of major depression but no history of depression prior to the development of alcohol dependence or during periods of sobriety. He had been prescribed an antidepressant in hopes it would treat the depression and alcoholism but it was not helping. He was admitted for inpatient treatment where his depressive symptoms began to remit as he was detoxified. The antidepressant was stopped, and the patient did well with counseling and participation in AA.
These two anecdotes illustrate some of the issues that emerge when treating people with psychiatric symptoms and substance-use disorders. On the one hand are patients who need both psychiatric and substance-abuse treatment over an extended period of time. On the other hand are people whose psychiatric symptoms are substance-induced and will remit with abstinence. Implicit in these two vignettes are issues of attitudinal and informational barriers to use of psychiatric treatment (especially medication), differential diagnosis, and the benefits of combining psychiatric and substance-abuse treatment for some patients.
Attitudinal and informational barriers were common in the early 1970s when patients were typically diagnosed as having either a substance-use or psychiatric disorder and then assigned to a treatment where only one disorder was addressed. However, as the number of psychiatrically trained clinicians in substance-abuse treatment expanded, the prevalence of comorbidity was noted by authors such as Khantzian (1985) and documented by other studies (Kessler et al., 1997; Regier et al., 1990). At about the same time, guidelines were developed for differentiating substance-induced from nonsubstance-induced disorders; these were formalized in DSM-IV.
A key feature of the DSM guidelines is the relationship between psychiatric symptoms and the drug(s) of abuse. In the first vignette, the guidelines indicate that the patient needed antidepressant and substance-abuse treatment. In the second vignette, the guidelines indicate that the depression was substance-induced, and, thus, treatment should focus mainly on that problem. Other cases are not so simple: for example, when the history is unclear or not available, when the psychiatric disorder begins after substance use, or when substance use magnifies a pre-existing psychiatric disorder.
Studies combining medication and/or psychotherapy for people with substance-use disorders have addressed patients with varying types of substance-use and other psychiatric disorders. Many studies used random assignment to a psychiatric treatment plus a substance-focused treatment or to a substance-focused treatment alone.
One of the first studies in a methadone (Dolaphine) maintenance program randomly assigned 35 patients with mild/moderate depressive symptoms at treatment admission to 12 weeks of doxepin (Sinequan) or placebo. Doxepin patients had more improvement in depression and a suggestion of a decrease in substance use (Woody et al., 1975). A later study by Nunes et al. (1998) randomized 137 methadone maintenance patients who had been chronically depressed for an average of six months, in spite of receiving adequate methadone doses and regular counseling, to a 12-week course of imipramine (Tofranil) or placebo. Results showed that depression improved in the imipramine group, with a trend toward less drug use as compared to placebo. No serious adverse effects attributable to medication were seen in either study, although side effects accounted for nine (12%) early dropouts in the imipramine group and only three (5%) placebo patients. Two psychotherapy studies examined the efficacy of psychotherapy when combined with methadone maintenance and drug counseling (Woody et al., 1995, 1983). These studies found that patients with high levels of psychiatric symptoms--mainly anxiety and depression--showed decreased substance use and improvement in other areas of adjustment if they received additional psychotherapy.
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