Diagnosis and Treatment of Alcohol Dependent Patients With Comorbid Psychiatric

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					                      Diagnosis and Treatment
                       of Alcohol-Dependent
                      Patients With Comorbid
                        Psychiatric Disorders
                    Vania Modesto-Lowe, M.D., M.P.H., and Henry R. Kranzler, M.D.

           Psychiatric disorders occur more often among alcoholics than among the general population.
           The psychiatric disorders that alcoholics most frequently experience include mood disorders
           (e.g., depression), anxiety disorders, and antisocial personality disorder. The evaluation of
           psychiatric symptoms in alcoholic patients is complicated by the multiple relationships that
           exist among heavy drinking, psychiatric symptoms, and personality factors. For example,
           alcoholics with co-occurring depression may be at greater risk of psychosocial problems,
           relapse, and suicide. Conversely, heavy drinking may produce or worsen symptoms of
           depression or anxiety. Although clinical experience provides general guidance for treating
           these patients, further research is needed to develop effective psychosocial and
           pharmacological therapies aimed at specific combinations of psychiatric and addictive
           disorders. KEY WORDS: diagnosis; treatment; AODD (alcohol and other drug dependence);
           behavioral and mental disorder; dual diagnosis; comorbidity; epidemiology; drug therapy;
           psychotherapy; literature review

        pidemiologic and clinical studies       For instance, alcoholics with comorbid      psychiatric assessment. Conversely,
        suggest that an alcoholic involved      depression may be at greater risk of        patients seen in psychiatric settings
        in treatment is statistically at high   psychosocial and interpersonal problems,
risk for a psychiatric disorder compared        treatment noncompliance, alcoholic
with the general population. Conversely,        relapse, and attempted and completed        VANIA MODESTO-LOWE, M.D., M.P.H.,
certain psychiatric disorders are often         suicide (Kranzler et al. 1998). Addition-   is an assistant professor of psychiatry and
accompanied by alcohol abuse or alco-           ally, heavy drinking may produce or         HENRY R. KRANZLER, M.D., is a professor of
hol dependence (Meyer 1986). The psy-           worsen depressive or anxiety symptoms.      psychiatry in the Department of Psychiatry
chiatric disorders that occur most fre-         Research also indicates that alcoholics     at the University of Connecticut School of
quently and that have been studied              with ASPD start drinking at an earlier      Medicine, Farmington, Connecticut.
most in alcoholics are mood disorders           age and develop symptoms of depen-
(e.g., depression), anxiety disorders, and      dence sooner than alcoholics without        The work in this article was supported
antisocial personality disorder (ASPD).         ASPD (Hesselbrock et al. 1992).             by National Institute on Alcohol Abuse
    The presence of comorbid psychi-                Together, these findings suggest that   and Alcoholism (NIAAA) grants P50-
atric disorders in alcoholic patients has       patients diagnosed with an alcohol-use      AA03510, T32-AA07290, and K02-
clinical and prognostic implications.           disorder should undergo thorough            AA00239 (to Henry R. Kranzler).

144                                                                                                       Alcohol Research & Health
                                                    Treatment of Patients With Comorbid Psychiatric Disorders

should be routinely evaluated for the         63 percent of 565 male inpatient alcoholic    are also commonly found during alco-
presence of an alcohol-use disorder.          veterans met lifetime criteria for a comor-   hol withdrawal, which further compli-
However, the evaluation of psychiatric        bid psychiatric diagnosis. The most com-      cates the diagnosis of bipolar disorder
symptoms in alcoholic patients can pre-       mon comorbid diagnosis was depression         in alcoholics.
sent a challenge to the clinician because     (42 percent), followed by mania (20 per-          The relationship between drinking
of the complexity of the relationships        cent) and ASPD (20 percent). Similarly,       and anxiety disorders is also complicated.
between heavy drinking, psychiatric           in a study of 321 inpatient alcoholics,       Alcoholics often report intense, but
symptoms, and personality factors.            Hesselbrock and colleagues (1985) found       transient, alcohol-induced anxiety symp-
    This article explores the extent of       that 75 percent of men and 80 percent         toms (i.e., palpitations, sweatiness,
comorbidity between psychiatric disor-        of women received one or more lifetime        lightheadedness, and fear of objects or
ders and alcohol-use disorders, describes     comorbid diagnoses. Drug abuse was the        social situations), which often abate
research on the nature of comorbid rela-      most prevalent lifetime diagnosis (45 per-    with abstinence from alcohol. On the
tionships, and suggests general treatment     cent), followed by ASPD (41 percent),         other hand, individuals with agorapho-
considerations as well as treatment strate-   major depression (38 percent), phobia         bia or social phobia may drink to self-
gies aimed at specific comorbidities. The     (27 percent), obsessive-compulsive            medicate anxiety symptoms; those with
article also considers pharmacological        disorder (12 percent), panic disorder         panic disorder and generalized anxiety
and psychosocial approaches, both sepa-       (10 percent), mania (4 percent), and          disorder may experience these symptoms
rately and in combination.                    schizophrenia (2 percent).                    as a consequence of heavy drinking
                                                                                            (Kranzler 1996).
                                                                                                Significant overlap also exists for
Epidemiology                                  The Relationship Between                      symptoms of alcohol dependence and
                                              Alcoholism and                                personality disorders. This finding is
Of the various epidemiologic studies          Psychiatric Disorders                         particularly true for ASPD, because
that have examined comorbidity among                                                        alcoholics often exhibit antisocial behav-
alcoholics sampled from the general           Alcoholics often report that they drink       ior associated with their heavy drinking
population, the National Comorbidity          to relieve a dysphoric mood, which has        (e.g., lying, impulsive aggression, and
Survey (NCS) provides a representative        been termed “self-medication.” This           breaking the law). Clinicians should work
sample and covers psychiatric disorders       hypothesis embodies a view of alco-           with patients to differentiate between
comprehensively (Kessler et al. 1994).        holism in which psychiatric symptoms          symptoms that are attributable to alco-
This community survey of more than            are primary, with drinking occurring in       hol dependence and symptoms that are
8,000 respondents showed that among           response to those symptoms. It has            attributable to ASPD. However, this
women, 72.4 percent of those who abused       been shown, however, that both chronic        task may be difficult, because although
alcohol and 86.0 percent of those who         heavy drinking and alcohol withdrawal         patients may be able to distinguish
were alcohol dependent had a comor-           can exacerbate negative mood states.          whether anxiety symptoms are related
bid lifetime psychiatric or drug-use dis-     This intensification of symptoms may          to substance intoxication or withdrawal,
order (Kessler et al. 1997). Among            result from the pharmacological effects       they may have greater difficulty differ-
men, the comparable figures for alcohol       of alcohol or from psychosocial prob-         entiating between antisocial behaviors
abuse and alcohol dependence were             lems (e.g., family, work, or legal prob-      that are alcohol-related (e.g., disorderly
56.8 percent and 78.3 percent, respec-        lems) that can stem from chronic heavy        conduct caused from intoxication) from
tively (Kessler et al. 1997). The NCS         drinking (Kranzler et al. 1998). Because      those that are not (e.g., chronic lying).
also shows that anxiety and mood disorder     depressive symptoms have been shown
were the most common comorbid dis-            to be both a cause and a consequence of
orders among female alcoholics, whereas       heavy drinking, a careful history is          Treatment of Patients
drug-use disorders and ASPD were the          required to guide treatment decisions.        With Comorbid Alcoholism
most common comorbid psychiatric                  Patients with bipolar disorder may        and Psychiatric Disorders:
disorders among male alcoholics (Kessler      drink to alleviate both manic and             General Considerations
et al. 1997). Despite some gender dif-        depressive symptoms, though evidence
ferences, NCS shows that for both             indicates that the greatest risk for heavy    Initial treatment for alcohol dependence
sexes, the association between alcohol        drinking occurs during the manic phase        consists primarily of detoxification (i.e.,
dependence and anxiety disorders,             of their illness (Kranzler et al. 1998).      treatment of acute physical withdrawal
mood disorders, and ASPD was signifi-         Conversely, alcohol intoxication in           symptoms) and psychosocial strategies
cantly elevated over what might be            persons without bipolar disorder may          aimed at maintaining abstinence. The
expected by chance.                           produce symptoms similar to those             added presence of a comorbid psychiatric
    High rates of comorbid lifetime psy-      associated with hypomania or mania.           disorder can substantially complicate
chiatric disorders also have been observed    Such symptoms may include elevated            this approach. For instance, depressive
in alcoholic patients in clinical settings.   mood, grandiosity, irritability, or physi-    symptoms (e.g., decreased energy and
Powell and colleagues (1982) found that       cal agitation. Some of these symptoms         interest) can interfere with a person’s

Vol. 23, No. 2, 1999                                                                                                              145
attendance at Alcoholics Anonymous                 Insofar as these goals can be achieved   ship meetings. For example, a person
(AA) meetings or group psychotherapy           using psychosocial or pharmacological        may need to attend several AA groups
sessions, two widely used psychosocial         treatments, or a combination of the          before choosing the one with which he
interventions for alcoholism. Similarly,       two, clinicians must consider the opti-      or she feels most comfortable. Dual-
patients with anxiety symptoms (e.g.,          mal sequence of interventions. Efforts       diagnosis patients also may have diffi-
panic attacks, social phobia) may find         to enhance motivation for recovery can       culty relating to other AA members
it difficult to attend AA meetings or to       be initiated during the first contact with   whose lives may improve more rapidly
learn skills for coping with situations        the patient, which for some patients may     than theirs as a consequence of absti-
that represent a high risk for alcoholic       be during detoxification. This can be        nence from alcohol. Patient education,
relapse. Alcoholics with ASPD, on the          accomplished by providing nonjudgmen-        an important aspect of treatment, should
other hand, may show manipulative or           tal feedback to the patient concerning       include a discussion of how psychiatric
aggressive behaviors, which can cause          the specific medical, social, interper-      symptoms and drinking may affect one
significant interpersonal problems for         sonal, or psychiatric effects of that per-   another. For instance, chronic heavy
themselves and for others in treatment.        son’s drinking on his or her life. Relapse   drinking may produce depressive symp-
    The diversity of alcoholics with           prevention strategies can be added after     toms. On the other hand, untreated
comorbid disorders means that individ-         detoxification is complete, assuming         depression can precipitate relapse, which
ualized treatment approaches may more          that the patient is adequately motivated     in turn can augment feelings of worth-
effectively address the comorbidity.           for such treatment.                          lessness, hopelessness, and guilt.
However, with the exception of studies             The focus of CBT is on the acquisi-          Frequently, recovering alcoholics
of antidepressant therapy for depressed        tion of skills, which may be used to         believe that recovery requires a medica-
alcoholics, little research exists on how      manage high-risk drinking situations, or     tion-free state. Although this view is not
best to treat alcoholics with comorbid         to reduce anxiety or depressive symptoms.    a formal position of AA, some members
psychiatric disorders. Although cogni-         Consequently, it makes conceptual            hold this view. Unfortunately, this belief
tive behavioral therapy (CBT) has been         sense to mix and match CBT techniques        may reduce medication compliance in
shown to be useful in treating patients        that are used both for relapse prevention    alcoholic patients with comorbid psy-
with alcohol dependence, as well as those      and to treat anxiety or depressive disor-    chiatric disorders. Therefore, the pre-
with certain depressive and anxiety disor-     ders. The varying combinations make          scribing physician should discuss the
ders, limited research exists on the utility   it possible to tailor a program accord-      possible benefits and adverse effects of
of integrated psychotherapeutic inter-         ing to the specific needs of the patient.    prescribed medications to treat psychi-
ventions that address the particular needs     For instance, since dysphoria is often a     atric symptoms and any potential inter-
of alcoholics with comorbid disorders.         cue for drinking, teaching patients to       actions they may have with alcohol.
    Despite the lack of systematic study,      avoid high-risk drinking situations can          After treatment is initiated, the clin-
some basic principles may be helpful in        go hand in hand with teaching patients       ician must monitor both drinking behav-
approaching patients with comorbid             how to manage their depressed moods.         ior and psychiatric symptoms, because
alcohol use and mood or anxiety disor-             Because many psychiatric symptoms        alcohol dependence, anxiety, and
ders. The clinician’s first objective is to    subside with abstinence, the use of med-     depressive disorders all tend to have a
establish both an alliance with the patient    ications to alleviate such symptoms          relapsing course. Objective methods
and a common goal for treatment. The           should generally be postponed until at       to assess drinking include the use of
goal in treating a patient with major          least 1 or 2 weeks of abstinence have        breath-alcohol testing as well as mea-
depression is to reduce the depressive         been achieved. However, under certain        surement of liver enzyme levels, such
symptoms and return the individual to          clinical circumstances (e.g., severe         as gamma-glutamyl transpeptidase
a normal level of function. Similarly, in      symptoms and a clear history of a pri-       (GGTP). GGTP, although nonspecific,
treating a patient with alcohol depen-         mary psychiatric disorder that was           is often elevated in heavy drinkers,
dence, the goal is usually abstinence, in      medication responsive), more immedi-         making it of potential value as an indi-
order to restore normal function.              ate action may be required. In other         cator of drinking status. With comor-
    Although it may be obvious that the        cases, the assessment of symptoms at         bid depression or anxiety disorders,
appropriate treatment goal for patients        regular intervals throughout treatment       symptoms also should also be assessed
with dual diagnosis is to address both the     will help to determine whether medica-       on a regular basis, preferably with a
substance use and the psychiatric symp-        tions are indicated. Meanwhile, the          semi-structured interview, such as
toms, this simple fact is often overlooked.    patient can begin to learn skills to han-    the Hamilton Anxiety Rating Scale
Thus, it is important to emphasize that        dle high-risk situations and craving         (Hamilton 1959), or a self-report ques-
treatment of such patients requires dual       along with techniques for managing           tionnaire, such as the Beck Depression
goals: namely, abstinence from alcohol         anxiety or depression, as indicated.         Inventory (Beck et al. 1961). Particular
and stabilization of comorbid symptoms,            Although alcoholics with comorbid        attention should be given to the risk
both of which can be expected (and may         disorders may find AA useful, these alco-    for suicide, as it may be particularly
be required) to improve the person’s           holics often require extra encouragement     high in depressed alcoholics (Kranzler
health and psychosocial functioning.           to initiate and continue to attend fellow-   et al. 1998). In addition, any pharma-

146                                                                                                       Alcohol Research & Health
                                                    Treatment of Patients With Comorbid Psychiatric Disorders

cotherapy targeting either alcohol depen-     effects on drinking outcomes. Further-         ment of mania, limited evidence suggests
dence or a comorbid psychiatric disor-        more, despite the availability of low-cost     that substance abusers tend to have sub-
der should be monitored regularly. In         generic forms of these medications, their      types of bipolar disorder (i.e., mixed and
so doing, it is important to consider         use in depressed alcoholics is problem-        rapid cycling) that are less responsive to
how biochemical changes in the liver          atic given the potential for a lethal over-    lithium (Donovan and Nunes 1998).
and medical disorders associated with         dose associated with TCAs.                     This possibility, coupled with the poten-
long-term alcohol misuse may influ-               Although not as well studied in            tial toxicity of lithium in overdose, has
ence medication effects.                      depressed alcoholics, SSRIs and other          led clinicians to preferentially employ
    In summary, interventions aimed at        serotonergic antidepressants have a good       anticonvulsants in the treatment of bipo-
alcoholics with comorbid psychiatric          safety profile. One study of severely          lar alcoholics.
disorders should address both the alco-       depressed alcoholics showed that fluox-
hol dependence and the comorbid psy-          etine is efficacious in reducing both
chiatric disorder. Specifically, an effort    depressive symptoms and drinking
                                                                                             Comorbid Alcohol Dependence
should be made to assess and enhance          behavior (particularly heavy drinking)
                                                                                             and Anxiety Disorders
motivation, engage and retain patients        in depressed alcoholics (Cornelius et al.      Benzodiazepines, sometimes used to treat
in treatment, and educate the patient         1997). Consistent with this is a study of      anxiety in alcoholics, are themselves
on the relationship between alcohol use       sertraline (another SSRI), which showed        subject to abuse. Therefore, a number
and psychiatric symptoms. The judi-           that this agent decreases depressive           of studies of buspirone, a nonbenzodi-
cious use of medications for persistent       symptoms in depressed alcoholics (Roy          azepine anti-anxiety medication, have
anxiety or depressive states can augment      1998). That study was deemed by the            been conducted in this patient group. Of
the psychosocial and educational efforts.     author to be of insufficient duration to       four such published studies, three showed
Interventions found to be useful in the       examine effects on drinking behavior.          buspirone to significantly enhance treat-
treatment of alcoholics with comorbid         More recently, a study with the non-SSRI       ment retention (Kranzler 1996). These
mood and anxiety disorders are dis-           antidepressant medication nefazodone           three studies also showed other beneficial
cussed in the following section. A frame-     (Serzone®) showed it to be beneficial in       effects of buspirone over a placebo,
work is also provided for the treatment       decreasing depressive symptoms in              including significantly greater reduction
of alcoholics with comorbid ASPD.             depressed alcoholics (Roy-Byrne et al.         in anxiety. In one study (Kranzler 1996),
                                              in press). However, nefazodone showed          reductions in anxiety among patients with
                                              no effect on drinking behavior. Results        the highest levels of anxiety were associ-
Comorbid Alcohol Dependence                   from other studies of serotonergic antide-     ated with reduced frequency of drinking.
and Mood Disorders                            pressants should soon be published.                The two main advantages of using
To date, studies of the pharmacological           The psychotherapeutic treatment of         buspirone in alcoholics with persistent
treatment of depression in alcoholics         comorbid alcohol and depressive disorders      anxiety are the absence of both addic-
have examined tricyclic antidepressants       has received little research attention. One    tion potential and additive effects (with
(TCAs) and selective serotonin reuptake       randomized trial in alcoholics with high       alcohol) on brain function, including
inhibitors (SSRIs). These studies have        levels of depression conducted in a sub-       eye-hand coordination. However, one
focused on whether antidepressants are        stance abuse partial-hospitalization set-      disadvantage of buspirone is that it
effective in reducing depressive symp-        ting (Brown et al. 1997) compared the          takes at least 2 weeks of treatment at a
toms in alcoholics and whether treating       efficacy of the cognitive-behavioral ther-     therapeutic dosage to exert its anti-anxiety
depression in these patients has a benefi-    apy of depression (CBT–D) to a control         effects. As alcoholic patients often are
cial effect on drinking behavior. Although    relaxation group. This study showed            poorly tolerant of delayed relief of
early studies showed TCAs to be no            that the CBT–D group had significantly         symptoms (in contrast to the rapid
better than placebo for the treatment         greater reductions in depression and           relief that may be provided by alcohol
of depression in alcoholics, this lack of     anxious mood during the study than             or treatment with a benzodiazepine),
efficacy may have been attributable to        did the control group. Furthermore,            they may not accept this medication.
the methodological shortcomings of            at 6-month followup, patients in the           Consequently, it is critical that bus-
these trials (Ciraulo and Jaffe 1981).        CBT–D group had significant reduc-             pirone treatment be combined with
For example, the dosage of TCAs used          tions on drinking measures and attended        patient education to promote realistic
in these studies was probably inadequate      AA meetings more frequently than did           expectations of the time course of effects
to produce a therapeutic effect. Recent       patients in the control group.                 of the medication and concomitant
studies of TCAs in depressed alcoholics           To date, no controlled studies of either   psychosocial treatment to sustain the
have shown both impramine and                 a specific psychotherapeutic approach or       patient’s commitment to treatment.
desipramine to be effective antidepres-       a pharmacological treatment for bipolar        Furthermore, it may be necessary to
sants in alcoholics (Kranzler et al. 1998).   disorder in alcoholics has been published.     prescribe buspirone at the highest rec-
These studies, however, do not provide        Although both lithium and the anticon-         ommended dosage (i.e., 60 milligrams
consistent evidence that the effective        vulsants valproate and carbamazepine           per day [mg/day]) to obtain a good
treatment of depression has beneficial        have demonstrated efficacy in the treat-       treatment response.

Vol. 23, No. 2, 1999                                                                                                                 147
    Despite evidence that a variety of anti-   Comorbid Alcoholism and                       other forms of aggression. They also
depressants, including TCAs, monoamine         Antisocial Personality Disorder               may challenge the program structure or
oxidase inhibitors (MAOIs), and SSRIs,                                                       otherwise attempt to discredit the pro-
                                               Clinicians faced with treating patients
are efficacious in the treatment of panic                                                    gram. To minimize such behaviors, the
                                               with comorbid alcoholism and ASPD             patient should be asked to sign a treat-
disorder, there are no published controlled    may find the task a frustrating one.
trials of the pharmacological treatment                                                      ment contract with explicit rules of
                                               However, the widespread view that             conduct at admission to the program.
of panic disorder in alcoholics. The use       alcoholics with ASPD respond poorly
of both TCAs and MAOIs in alcoholics                                                         This contract should detail the conse-
                                               to treatment may be invalid, particu-         quences of breaking rules, which
requires careful consideration. As men-        larly in light of studies showing that
tioned, TCAs can be lethal in overdose,                                                      should be strictly enforced. Often peer
                                               some substance abusers with ASPD              confrontation can be useful in prevent-
which is related to their capacity to          (e.g., those with a concomitant diagno-
produce cardiac arrthymias. Similarly,                                                       ing patients from rationalizing drinking
                                               sis of depression) do benefit from treat-     and antisocial behavior. In addition,
the use of MAOIs in alcoholic patients         ment (Alterman and Cacciola 1991;
is contraindicated because of the restric-                                                   court-ordered treatment may increase
                                               Cacciola et al. 1995). One study, for         the likelihood of successful outcomes.
tions placed on certain foods, medica-         instance, showed no difference in treat-
tions, and alcoholic beverages to ensure                                                         If, for any reason, the treatment
                                               ment response among alcohol- and              team is unable to enforce the terms of
the safe use of these medications.             cocaine-dependent patients when groups
   Although the efficacy of the SSRIs (e.g.,                                                 the contract, treatment is likely to fail.
                                               based on the presence or absence of           This may occur for various reasons,
fluoxetine, sertraline, paroxetine) has        comorbid ASPD were compared
not been evaluated in alcoholics with                                                        including the absence of an adequately
                                               (Cacciola et al. 1995). Similarly, a study    structured environment or a clinician’s
panic disorder, these agents are the           by Longabaugh and colleagues (1994)
safest. However, abstinent alcoholics                                                        fear of being assaulted. Alcoholic
                                               showed that employed ASPD alcohol             patients with moderate-to-severe ASPD
may be at increased risk for experiencing      abusers responded as well to abstinence-
jitteriness and irritability with SSRI use.                                                  may require such highly structured
                                               focused cognitive-behavioral therapy          programming that treatment may not
Thus, an effort should be made to mini-        as did a heterogeneous group of non-
mize these side effects by starting with                                                     be possible in a regular outpatient set-
                                               ASPD alcohol abusers.                         ting. Under these circumstances, it may
a low dosage and gradually increasing              Because patients with ASPD appear         be necessary to refer the patient to a
it to a therapeutic dosage. Finally, the       to be heterogeneous with respect to           long-term residential treatment facility.
use of benzodiazepines (e.g., diazepam,        treatment response, the question of how           Although the role of medications in
alprazolam) beyond detoxification in           to identify in advance those ASPD alco-       treating ASPD patients has been lim-
alcoholics with panic disorder is proba-       holics who can benefit from treatment         ited, certain medications may improve
bly ill advised, given their addiction         assumes great importance. As mentioned,       symptoms associated with ASPD, such
potential and additive CNS depressant          the ability to experience distress (e.g.,     as aggression or impulsivity. For instance,
effects when taken in combination with         anxiety and depression) may predict a         a 3-month course of lithium was found
alcohol.                                       positive treatment response in ASPD           to be efficacious in managing aggression
    Limited research also exists on psy-       alcoholics (Alterman and Cacciola             in prison inmates but had no effect on
chotherapeutic interventions for alco-         1991). However, a number of clinical          other antisocial behaviors in this popula-
holics with anxiety disorders. One of          features appear to contraindicate psy-        tion (Sheard et al. 1976). In addition,
the few studies to address this issue          chotherapy in patients with ASPD.             some evidence indicates that the SSRI
(Ormrod and Budd 1991) showed                  These features include a history of vio-      fluoxetine has helped personality-disorder
that among 36 anxious alcoholics,              lent behavior resulting in serious injury     patients with prominent histories of
those receiving anxiety management             or death, the absence of remorse or the       impulsive aggressive behavior (Coccaro
and relaxation training experienced            rationalization of antisocial behavior, the   and Kavoussi 1997; Coccaro 1998).
greater decreases in anxiety levels than       inability to develop emotional attach-        However, it must be emphasized that
did a control group that received              ments, and the elicitation of intense fear    the decision to prescribe medications for
“health education.” However, no effect         in the skilled clinician by the patient’s     these patients must be considered care-
was observed on drinking outcomes,             predatory behavior (Gabbard 1990).            fully. This includes identifying target
either during treatment or during a                Because alcoholics with ASPD can          symptoms that may benefit from medi-
3-month followup period. Together              be extremely disruptive to a group treat-     cations, considering the potential risks
with findings described previously for         ment program, the clinician should            and benefits of a specific medication
buspirone, it seems that the combina-          systematically confront the patient’s         and avoiding the use of medications
tion of psychotherapy and pharma-              destructive behavior and ensure that          with abuse liability.
cotherapy may have uniquely beneficial         staff or other patients are not harmed            In the area of personality disorders,
effects in anxious alcoholics. A carefully     or exploited. Common destructive              dialectical behavior therapy (DBT) has
controlled trial of the combined               behaviors displayed by these patients         shown efficacy in the treatment of bor-
approach is necessary.                         include stealing, intimidation, and           derline personality disorder (BPD)

148                                                                                                        Alcohol Research & Health
                                                       Treatment of Patients With Comorbid Psychiatric Disorders

(Linehan 1993). This disorder is char-         References                                                atric disorders in the United States: Results from
acterized by instability of mood, problem-                                                               the National Comorbidity Survey. Archives of
                                               ALTERMAN, A.I., AND CACCIOLA, J.S. The antisocial         General Psychiatry 51:8–19, 1994.
atic interpersonal relations, impulsivity,     personality disorder diagnosis in substance abusers:
and self-destructive behaviors. Accord-        Problems and issues. Journal of Nervous and Mental        KESSLER, R.C.; CRUM, R.M.; WARNER, L.A.;
                                               Disease 179:401–409, 1991.                                NELSON, C.B.; SCHULENBERG, J.; AND ANTHONY,
ingly, DBT focuses on emotion regula-                                                                    J.C. Lifetime co-occurrence of DSM-III-R alcohol
tion, tolerance of emotional distress,         BECK, A.T.; WARD, C.H.; MENDELSON, M.; MOCK,              abuse and dependence with other psychiatric disor-
                                               J.; AND ERBAUGH, J. An inventory for measuring            ders in the National Comorbidity Survey. Archives
interpersonal effectiveness, and self-         depression. Archives of General Psychiatry 4:461–         of General Psychiatry 54:313–321, 1997.
management skills. The overlap of symp-        471, 1961.
toms (e.g., impulsive aggression) among        BROWN, R.A.; EVANS, D.M.; MILLER, I.W.; BURGESS,
                                                                                                         KRANZLER, H.R. Evaluation and treatment of anxi-
                                                                                                         ety symptoms and disorders in alcoholics. Journal of
ASPD, BPD, and alcohol dependence              E.S.; AND MUELLER, T.I. Cognitive-behavioral treatment    Clinical Psychiatry 57:15–21, 1996.
suggests that DBT might profitably be          for depression in alcoholism. Journal of Consulting and
                                               Clinical Psychology 65:715–726, 1997.                     KRANZLER, H.R.; MASON, B.; AND MODESTO-
adapted to address some of the prob-
                                                                                                         LOWE, V. Prevalence, diagnosis, and treatment of
lematic behaviors of heavy drinkers            CACCIOLA, J.S.; ALTERMAN, A.I.; RUTHERFORD,
                                                                                                         comorbid mood disorders and alcoholism. In:
                                               M.J.; AND SNIDER, E.C. Treatment response of
with ASPD.                                     antisocial substance abusers. Journal of Nervous and
                                                                                                         Kranzler, H.R., and Rounsaville, B., eds. Dual
                                               Mental Disease 183:166–171, 1995.                         Diagnosis and Treatment. New York: Marcel
                                                                                                         Dekker, Inc., 1998. pp. 107–136.
                                               CIRAULO, D.A., AND JAFFE, J.H. Tricyclic antide-
Conclusions                                    pressants in the treatment of depression associated       LINEHAN, M.M. Dialectical behavior therapy for
                                               with alcoholism. Journal of Clinical Psychopharma-        treatment of borderline personality disorder:
                                               cology 1:146–150, 1981.                                   Implications for the treatment of substance abuse.
The high rates of comorbid psychiatric                                                                   In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds.
disorders in patients with alcohol-use         COCCARO, E.M. Clinical outcome of psychophar-             Behavioral Treatments for Drug Abuse and
disorders require that alcoholic patients      macologic treatment of borderline and schizotypal         Dependence. NIDA Research Monograph No. 137.
                                               personality disordered subjects. Journal of Clinical      Rockville, MD: U.S. Department of Health and
undergo careful psychiatric evaluation.        Psychiatry 59:30–35, 1998.                                Human Services, 1993. pp. 201–216.
However, the diagnosis of a psychiatric
                                               COCCARO, E.M., AND KAVOUSSI, R.J. Fluoxetine              LONGABAUGH, R.; RUBIN, A.; MALLOY, P.; BEATTIE,
disorder in the context of alcohol depen-      and impulsive aggressive behavior in personality-         M.; CLIFFORD, P.R.; AND NOEL, N. Drinking
dence is complicated by the interactive        disordered subjects. Archives of General Psychiatry       outcomes of alcohol abusers diagnosed as antisocial
effects of heavy drinking and psychiatric      54:1081–1088, 1997.                                       personality disorder. Alcoholism: Clinical and
symptomatology. Similarly, the treatment       CORNELIUS, J.R.; SALLOUM, I.M.; EHLER, J.G.;              Experimental Research 18:778–785, 1994.
of alcohol-dependent patients with             JARRETT, P.J.; CORNELIUS, M.D.; PEREL, J.M.; THASE,
                                                                                                         MEYER, R.E. How to understand the relationship
                                               M.E.; AND BLACK, A. Fluoxetine in depressed alco-
comorbid disorders is complex, because         holics: A double-blind, placebo-controlled trial.
                                                                                                         between psychopathology and addictive disorders:
these patients require help in becoming                                                                  Another example of the chicken and the egg. In:
                                               Archives of General Psychiatry 54(8):700–705, 1997.
                                                                                                         Meyer, R.E., ed. Psychopathology and the Addictive
abstinent from alcohol concomitant             DONOVAN, S.J., AND NUNES, E.V. Treatment of               Disorders. New York: Guildford Press, 1986. pp. 3–16.
with stabilization of their comorbid           comorbid affective and substance use disorders.
                                               American Journal on Addictions 7:210–220, 1998.           ORMROD, J., AND BUDD, R. A comparison of two
psychiatric symptoms. Such efforts are                                                                   treatment interventions aimed at lowering anxiety lev-
important, because untreated psychiatric       GABBARD, G.O. The antisocial patient. In: Gabbard,        els and alcohol consumption amongst alcohol
illness in alcohol-dependent patients is a     G.O., ed. Psychodynamic Psychiatry in Clinical            abusers. Drug Alcohol Dependence 27:233–243, 1991.
                                               Practice. Washington, DC: American Psychiatric
source of added morbidity and mortal-          Press, 1990. pp. 397–422.                                 POWELL, B.J.; PENICK, E.C.; OTHMER, E.;
ity, both directly and by increasing risk                                                                BINGHAM, S.F.; AND RICE, A.S. Prevalence of addi-
                                               HAMILTON, M. The assessment of anxiety states by          tional psychiatric syndromes among male alcoholics.
for continued heavy drinking. Although         rating. British Journal of Medical Psychology 32:50–55,   Journal of Clinical Psychiatry 43:404–407, 1982.
additional studies are needed to evaluate      1959.
the optimal combination of psychother-                                                                   ROY, A. Placebo-controlled study of sertraline in
                                               HESSELBROCK, M.N.; MEYER, R.E.; AND KEENER,               depressed recently abstinent alcoholics. Biological
apy and medication for use in various          J.J. Psychopathology in hospitalized alcoholics.          Psychiatry 44:633–637, 1998.
comorbid subgroups, we have described          Archives of General Psychiatry 42:1050–1055, 1985.
                                                                                                         ROY-BYRNE, P.; PAGES, K.P.; RUSSO, J.E.; BLUME,
a number of promising approaches to            HESSELBROCK, V.M.; MEYER, R.E.; AND HESSEL-
                                                                                                         A.W.; JAFFE, C.; KINGSLEY, E.; COWLEY, D.S.; AND
                                               BROCK, M.N. Psychopathology and addictive disor-
the treatment of the most common               ders: The specific case of antisocial personality
                                                                                                         RIES, R.K. A double-blind placebo-controlled trial
comorbid psychiatric disorders in alco-        disorder. In: O’Brien, C.P., and Jaffe, J.H., eds.        of nefazodone in the treatment of major depression
                                               Addictive States. New York: Raven Press, 1992. pp.        in alcohol dependent patients. Journal of Clinical
holics. Despite the difficulties inherent                                                                Psychopharmacology, in press.
in treating alcoholics with comorbid
                                               KESSLER, R.C.; MCGONALGLE, K.A.; ZHAO, S.;                SHEARD, M.H.; MARIM, J.L.; BRIDGES, C.I.; AND
psychiatric disorders, clinicians can obtain                                                             WAGNER, E. The effect of lithium on impulsive
                                               NELSON, C.B.; HUGHES, M.; ESHLEMAN, S.;
valid diagnoses and deliver efficacious        WITTCHEN, H.U.; AND KENDLER, K.S. Lifetime                aggressive behavior in man. American Journal of
treatment to these patients. s                 and 12-month prevalence of DSM-III-R psychi-              Psychiatry 133:1409–1413, 1976.

Vol. 23, No. 2, 1999                                                                                                                                      149
        ow ble
       N la                    Professional
      Avai                  Education Materials
        A Medical Education Model for
        the Prevention and Treatment
        of Alcohol Use Disorders
         • For teaching general medical
           students and residents in the
           primary care specialties
         • Provides 1-hour modules that can
           be presented independently or
           in clusters
         • Includes modules on topics such as
           doctor-patient communication
           skills, screening and assessment,
           brief intervention, pharmacother-
           apy, and management of pain and
           anxiety in addicted patients
         • Comes complete with
           more than 200 slides on
           computer disk

        Developed by Michael Fleming, MD, MPH, of the University of Wisconsin
        School of Medicine, and Margaret Murray, MSW, of the National Institute on
        Alcohol Abuse and Alcoholism.

                            Copies are $100, including shipping. To order, send payment
                (check, money order, MasterCard, or Visa) to NIAAA Publications Distribution Center,
            P.O. Box 10686, Rockville, MD 20849–0686, or visit the NIAAA Web site (www.niaaa.nih.gov).

150                                                                                        Alcohol Research & Health

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