Depression comorbid psychiatric disorders

The rates of comorbid psychiatric disorders such as depression, ADHD, and antisocial personality disorder are significantly higher in stimulant abusers... 

It is also important to know about comorbid psychiatric disorders. If these are overlooked, treating the substance use disorder becomes significantly more difficult. Recognizing this, most treatment centers have developed dual diagnosis programs to treat those patients who have another major psychiatric illness in addition to a substance use disorder. It may be virtually impossible to discern at first, but the other psychiatric illnesses might either contribute to or be a result of substance use. The social toll of alcoholism alone can trigger a severe clinical depression. However,... 

Appropriate management of AN also requires the early detection and treatment of any comorbid psychiatric disorders. The most common comorbid conditions associated with AN are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and substance use disorders. At the time of presentation, over 50% of AN patients also fulfill criteria for MDD however, accurate diagnosis of depression in these patients is complicated by the fact that prolonged starvation often produces a mood disturbance and neurovegetative symptoms identical to MDD. If MDD appears to be comorbid with AN at the time of presentation, there is debate as to whether it is more prudent to withhold treatment of the depression until weight restoration has been initiated. If the depression persists despite refeeding, then treatment of the depression is likely warranted. 

In early-onset OCD, comorbid psychiatric disorders are present in about 80% of the cases. Major depression is seen in approximately 66% attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or multiple anxiety disorders in 50% and enuresis or speech and language disorders in 33%... 

For patients with severe PMDD with comorbid psychiatric disorders such as depressive or anxiety disorder, continuous dosing (daily dose) is recommended the SSRIs fiuoxetine at a dose of 20 mg/day or sertraiine at a dose of 25-50 mg ay are considered first-line treatment (the doses are somewhat lower than those used in other... 

Behavioral medicine is generally embedded in a comprehensive, multimodal pain treatment program. Patients who suffer from chronic pain may experience higher rates of comorbid psychiatric disorders (e.g. depression, anxiety), as well as sleep disturbances. Effective treatment of these conditions must be part of the management plan. 

Lifetime prevalence rates of psychiatric comorbidity co-existing with bipolar disorder are 42% to 50%.16 Comorbidities, especially substance abuse, make it difficult to establish a definitive diagnosis and complicate treatment. Comorbidities also place the patient at risk for a poorer outcome, high rates of suicidal-ity, and onset of depression.2 Psychiatric comorbidities include ... 

Primary care physicians are critical to the successful identification of GAD. Characterized by often-vague physical complaints, GAD must be distinguished from medical illnesses and other psychiatric disorders, though the high rate of comorbidity requires that a thorough evaluation for GAD be completed even when another disorder has been identified. GAD warrants particular consideration for those patients with nonspecific physical complaints who nevertheless have an urgent need for relief that has resulted in repeated office visits. The differential diagnosis for GAD includes other anxiety disorders, depression, and a variety of medical conditions and substance-induced syndromes. 

Historically, the treatment of alcohol use disorders with medication has focused on the management of withdrawal from the alcohol. In recent years, medication has also been used in an attempt to prevent relapse in alcohol-dependent patients. The treatment of alcohol withdrawal, known as detoxification, by definition uses replacement medications that, like alcohol, act on the GABA receptor. These medications (i.e., barbiturates and benzodiazepines) are cross-tolerant with alcohol and therefore are useful for detoxification. By contrast, a wide variety of theoretical approaches have been used to reduce the likelihood of relapse. This includes aversion therapy and anticraving therapies using reward substitutes and interference approaches. Finally, medications to treat comorbid psychiatric illness, in particular, depression, have also been used in attempts to reduce the likelihood of relapse. 

Kessler RC (2001) Comorbidity of depression and anxiety disorders. In Montgomery SA, den Boer JA (eds) SSRIs in depression and anxiety. Wiley, Chichester, pp 87-106 Kessler RC, Price RH (1993) Primary prevention of secondary disorders a proposal and agenda. Am J Community Psychol 21 607-633 Kessler RC, McGonagle KA, Zhao S (1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 51 (1) 8-19... 

A potential limitation of most of the controlled studies discussed above relates to the numerous exclusion criteria used for patient selection. For example, in order to find homogenous samples, major depression, bipolar disorder, Tourette s disorder, psychosis (clomipramine, fluvoxamine and fluoxetine trials), primary psychiatric disorder other than OCD (clomipramine and sertraline trials), and attention deficit/hyperactivity disorder (ADHD), autism, or other developmental disorders (clomipramine and fluoxetine trials) were excluded. Thus it remains unknown how well these controlled studies will generalize to more naturalistic clinical populations that are highly comorbid and where exclusion criteria are not applied. 

This principle is not applicable in biological psychiatry. One can and should not simply discard the possibility that a biological variable observed in a psychotic condition is linked to a concurrent depression or that one found in depression is in fact related to a comorbid anxiety disorder. The hierarchical principle is a deus ex machina that resolves the problem of comorbidity only in appearance. Comorbidity in itself is merely a descriptive, not an explanatory, term. The multiplicity of psychiatric disorders, as they are presently defined, in so many patients permits a variety of explanations (Van Praag 1996], and thus the term comorbidity conceals more than it discloses. 

Posttraumatic stress disorder (PTSD) is another anxiety disorder that can be characterized by attacks of anxiety or panic, but it is notably different from panic disorder or social phobia in that the initial anxiety or panic attack is in response to a real threat (being raped, for example) and subsequent attacks are usually linked to memories, thoughts, or flashbacks of the original trauma. The lifetime incidence of PTSD is about 1%. Patients have disturbed sleep and frequent sleep complaints. Comorbidities with other psychiatric disorders, especially depression and drug and alcohol abuse, are the rule rather than the exception. The DSM-IV diagnostic criteria are given in Table 9—11. 

And the comorbidity of medical and psychiatric disorders requires at least some degree of multiple drug prescribing. For example, many patients suffering from serious physical disorders as well as depression will require medication treatment for both conditions. Examples include diabetes mellitus, cancer, and cardiovascular disease. Familiarity with drug interactions can be an important addition to diagnostic skills. 

Generalized anxiety disorder (GAD) (6) is defined as excessive anxiety and worry occurring more days than not for a period of at least 6 months. The anxiety is accompanied by at least three of the following symptoms restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbance. The anxiety is uncontrollable and causes clinically significant distress. GAD has a lifetime prevalence of 6-10% (7), and the NCS study (3) indicates a high comorbidity with other psychiatric disorders, especially depression and panic disorder. 

Identify comorbid psychiatric conditions (e.g., depression, anxiety disorder, substance abuse, or bipolar disorder). 

Anxiety and dissociative symptoms (e.g., sense of numbing or absence of emotional responsiveness, derealization, depersonalization, inability to recall important features of the event) emerging within 1 month after exposure to a traumatic stressor are classified as ASD. Symptoms of ASD are experienced during or immediately after the trauma, last for at least 2 days, and resolve within 4 weeks. The age of onset and course of PTSD are variable. PTSD can occur at any age. The presentation is not predictable because symptoms are related to the duration and intensity of the trauma, the presence of other psychiatric disorders, and how the patient deals with the trauma. The average duration of symptoms in patients in treatment is about 36 months. In those not receiving treatment, symptoms can last for a mean of 5 years. About one-third of patients with PTSD have a poor prognosis for recovery. About 80% of patients with PTSD have a concurrent depression or anxiety disorder. Over half of men with PTSD suffer from comorbid alcohol abuse or dependence. About 20% of patients with PTSD attempt suicide. ... 

In summary, research on the use of antidepressants to treat cannabis dependence, particularly among individuals with comorbid major depressive disorder, although limited, offers a promising avenue for the development of pharmacological aids to assist in the treatment of cannabis withdrawal. There are clear parallels between this literature and the existing research on the use of antidepressants in the treatment of alcohol dependence comorbid with major depressive disorder (see Chapter 1, Medications to Treat Co-occurring Psychiatric Symptoms or Disorders in Alcoholic Patients). 

Children of opiate addicts have been shown to have poorer social, educational and health status and to be at higher risk of abuse than their peers (Keen et al., 2000). However, given the high rates of psychiatric comorbidity (in particular, depression) in opiate-dependent patients (Brooner et al., 1997 Khantzian and Treece, 1985), it may be that some of the increased risk in children stems from this greater parental depression. Nunes et al. (1998) reported higher incidence of conduct disorder and global and social impairment for children of addicts with major depression compared to addicts without depression and controls, but not compared with children of depressed patients without substance use disorders. 

Merikangas KR (1990) Comorbidity for anxiety and depression review of family and genetic studies. In Cloninger CR (ed) Cormorbidity of mood and anxiety disorders. American Psychiatric Press, Washington, pp 331-348... 

Birmaher, B., McCafferty, J.P., Bellow, K.M., and Beebe, K.L. (2000b) Comorbid ADHD and disruptive behavior disorders as predictors of response in adolescents treated for major depression. Presented at the American Psychiatric Association Annual Meeting, Chicago, IL. 

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