Behavioral Medicine:
CD, Anxiety, and
Depression
Michael G. Kavan, Ph.D.
Associate Dean for Student Affairs
Creighton University School of Medicine
Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Age: 2006 (SAMHSA, 2006)
Past Month Use of Specific Illicit Drugs
Among Persons Aged 12 or Older: 2006
How Do You Know if a Patient Has
a Problem?
Appearance
History
Relationships
Mood disorders
Employment/school difficulties
Medical problems
Problems with law
Use
DSM-IV-TR/AUDIT/CAGE/NIAAA criteria
Assessment of Substance Abuse:
DSM-IV
Substance Abuse
Maladaptive pattern of substance use leading to
significant impairment/distress as manifested by one
(or more) of the following within a 12-month
period:
Recurrent use resulting in work, school, or home
problems
Recurrent use in physically hazardous situations
Driving while intoxicated
Operating heavy machinery
Recurrent substance-related legal problems (e.g.,
substance-related disorderly conduct)
Continued use despite persistent/recurrent social or
interpersonal problems (e.g., arguments with spouse
associated with substance use)
Substance Dependency
Maladaptive pattern of substance use leading to
significant impairment/distress as manifested by
three (or more) of the following within the same
12-month time period:
Tolerance
Withdrawal
Substance taken in larger amount or for longer
period than intended
Persistent desire or unsuccessful efforts to cut down
or control substance use
Great deal of time spent to obtain, use, or recover
from its effects
Important social, occupational, or recreational
activities are given up or reduced due to use
Substance use continues despite knowledge of
having a persistent or recurrent physical or
psychological problem related to substance use
AUDIT – Alcohol Use Disorders
Identification Test: Interview Version
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a
typical day when you are drinking?
How often to you have six or more drinks on one
occasion?
How often during the last year have you found that you
were not able to stop drinking once you had started?
How often during the last year have you failed to do
what was normally expected from you because of
drinking?
How often during the last year have you needed
a first drink in the morning to get yourself going
after a heavy drinking session?
How often during the last year have you had a
feeling of guild or remorse after drinking?
How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
Have you or someone else been injured as a result of
your drinking?
Has a relative or friend or a doctor or another health
worker been concerned about your drinking or
suggested you cut down?
Scoring is 0-4 points for each item
Total scores of 8 or more (4 or more in women) are
recommended as indicators of hazardous and harmful alcohol
use
See full AUDIT for details
Alcohol Abuse
CAGE Questionnaire (Ewing, 1984)
Have you ever felt like you ought to Cut down on your
drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover? (Eye-opener)
NIAAA Criteria
Men: > 14 drinks per week or > 4 drinks/day more than
once/wk
Women: > 7 drinks per week or > 3 drinks/day more than
once/wk
What is a Drink?
12 ounces of beer
10 ounces of wine cooler
5 ounces of wine
1.5 ounces of 80-proof hard liquor
Pharmacologic Management
Disulfiram
An aversion-based treatment that acts by blocking
aldehyde dehydrogenase (ALDH) and induces
negative effects with drinking including dizziness,
flushing, nausea, vomiting, hypotension, arrhythmia,
convulsions, respiratory depression, and myocardial
infarction
Conflicting evidence on efficacy
Naltrexone
A competitive opioid antagonist
Naltrexone reduces cravings and also is likely to
minimize the “high” that individuals experience
from alcohol intake
Side-effects include headache, dizziness, anxiety, and
decreased appetite
Conflicting evidence on efficacy
IM Naltrexone appears to be more effective (since it
is thought nonadherence may impact Naltrexone’s
efficacy)
Acamprosate
Restores GABA and glutamate imbalances cuased by
alcohol intake (and may effect N-methyl-D-aspartic
acid receptors)
Side-effects include diarrhea, headache, insomnia,
anxiety, and muscle weakness
Questionable efficacy in U.S. studies, whereas
European studies suggest higher continuous
abstinence rates at 6 months as well as decreased
drinking frequency and rate of relapse
Treatment
Outpatient
AA – 402-556-1880
Al-Anon – 402-553-5033
Inpatient
Comorbid psychiatric problems
Comorbid medical problems (e.g., withdrawal)
Repeated outpatient treatment failures
Poor social support system
Follow-up!!!
Anxiety
Most common anxiety disorders seen in Family
Medicine and presentation?
GAD
Panic disorder (w/wo agoraphobia)
OCD
PTSD
Social anxiety
Simple phobia
Rule Out Nonpsychiatric
Conditions
Endocrine (e.g., thyroid)
Cardiovascular (e.g., arrhythmia, MVP)
Respiratory (e.g., COPD)
Intoxication/withdrawal
Nutritional deficiencies (e.g., B12, folate)
Medications (e.g., Ginseng, SSRIs, theophylline)
Management
Psychologic
REST
Pharmacologic
SSRIs
Benzodiazepines
Nonbenzodiazepines
SNRIs
Depression
Typical presentation?
Mood
Appearance
Physical complaints
Major Depressive Disorder:
SIG E CAPS + Mood
Sleep Appetite
Interests Psychomotor
Guilt Retardation or Agitation
Energy Suicide
Concentration Depressed Mood
Interview Questions
“Over the past two weeks, have you felt down,
depressed, or hopeless?”
“Have you felt little interest or pleasure in doing
things?”
Sensitivity of 97%; specificity of 67%
Arroll B, Khin N, Kerse N. Screening for depression in primary
care with two verbally asked questions: Cross sectional study.
BMJ 2003;327:1144-1146.
Assessment of Suicide
Okay to bring up topic
How to ask about it:
Incorrect – “You haven’t had any thoughts of suicide, have you?”
Correct – “Have you recently had any thoughts of death or suicide?”
Seek clarification
Major risk factors/red flags
Psychiatric illness (e.g., depression, schizophrenia)
Hopelessness
Previous attempt
Psychosocial stressors
Protective factors
Children, religious beliefs, good social support
SAD PERSONS (SAD PERSONAS) Scale
Rule Out Nonpsychiatric
Conditions
Endocrine (e.g., thyroid)
Neoplasias (e.g., pancreatic cancer)
Medications (e.g., steroids, beta blockers)
Intoxication/withdrawal
Management
Psychologic
Behavioral
Cognitive
Cognitive Behavior Therapy
Pharmacologic
SSRIs
SNRIs
TCAs
Counseling on side-effects and length of tx