Patients With Comorbid Psychiatric Disorders

Persons with depressive symptoms or major depression also have high rates of smoking (40%-60% prevalence), and depression appears to be a predictor of 

Rates of smoking among patients with bipolar disorders and anxiety disorders (e.g., posttraumatic stress disorder, panic disorder) are also higher than those in the general population (Lasser et al. 2000), but there has been htde smdy of the factors associated with motivation to quit smoking or of smoking cessation interventions in these patient groups. 

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Pediatric patients with comorbid psychiatric disorders requiring continued treatment for their psychiatric symptomatology (e.g., a schizophrenic patient admitted with an asthma exacerbation)... 

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... 

MDD is quite common lifetime and 12-month prevalence estimates are 16.2% and 6.6%, respectively. Thus, approximately 35 million United States adults will experience MDD in their lifetime.2 Females are approximately twice as likely as males to experience MDD.2 Although MDD may begin at any age, the average age at onset is the mid-20s.3 Interestingly, MDD appears to occur earlier in life in people born in more recent decades.2 Most patients with MDD also suffer from comorbid psychiatric disorders, especially anxiety disorders and substance-use disorders.2... 

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. 

Preliminary evidence that this issue is an important one for clinicians derives from post hoc analyses of the double-blind, placebo-controlled paroxetine withdrawal study (Geller et ah, 2001b), in which no strict exclusionary criteria were applied. In that study, 193/ 335 (58%) patients had at least one psychiatric disorder in addition to OCD and 102/335 (30%) had multiple ( 2) other disorders. The response rates in patients with comorbid ADHD, tic disorder, or oppositional defiant disorder (56%, 53%, and 39%, respectively) were significantly less than in patients with OCD only (75%, [ITT LOCF] p < 0.05). Psychiatric comorbidity was also associated with a greater... 

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. 

Approaches for treating bipolar disorder in special populations (e.g., comorbid medical or psychiatric disorders, pregnancy, or breastfeeding) are found in Table 68-9. Patients with comorbid medical conditions or concomitant substance abuse, those over 65 years of age, and pregnant patients may require different treatment approaches. Approximately 20% to 50% of women with bipolar disorder relapse postpartum therefore prophylaxis with mood stabilizers is recommended immediately postpartum to decrease the risk of relapse. ... 

Anxiety disorders are common in the population and are commonly comorbid with other psychiatric disorders. The proper management of anxiety disorders begins with the correct diagnosis not all patients should receive antianxiety agents. Nonpharmacologic interventions often are effective alone or when combined with drug therapy. 

For MDD with severe anxiety, mirtazapine, TCAs, trazodone, and benzodiazepines should be considered as adjunctive therapy. If the patient is not at least moderately improved after 4-8 weeks, the treatment regimen should be reappraised. Compliance should be checked. It is important to consider pharmacokinetic/pharmacodynamic factors (this may require an evaluation of serum levels of the antidepressant medication), general medical comorbidities, and comorbid psychiatric disorders, including substance abuse and significant psychosocial problems. The initial therapeutic treatment dose should be gradually maximized. For partial responders, the trial should be extended by... 

For patients with PMDD without comorbid psychiatric disorders, intermittent premenstrual dosing is highly effective and very well tolerated, and is likely to be the treatment of choice. Intermittent premenstrual dosing is typically initiated approximately 14 days prior to the anticipated onset of menstrual bleeding and is continued to the menstrual flow. Fluoxetine and sertraline are considered first-line treatment at 20 mg/day and 50-100 mg/day, respectively. 

Future Outlook for Pharmacologic Treatment of Abuse and Dependence. The importance of the psychosocial dimension ia predisposiag iadividuals toward substance use disorders and subsequentiy maintaining the disorder caimot be overestimated. Additionally, genetic influences have been found to exert an important influence on HabiUty for dmg abuse. A high comorbidity of psychiatric illnesses with substance use disorders further compHcates therapeutic iaterventions ia such patients (236). 

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). 

Approximately one-third of patients with MDD do not respond satisfactorily to their first antidepressant medication.37 In such cases, the clinician must evaluate the adequacy of antidepressant therapy, including dosage, duration, and patient compliance.17 Treatment reappraisal also should include verification of the patient s diagnosis and reconsideration of clinical factors that could be impeding successful therapy, such as concurrent medical conditions (e.g., thyroid disorder), comorbid psychiatric conditions (e.g., alcohol abuse), and psychosocial issues (e.g., marital stress).16... 

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. 

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. 

If relapse does occur, it should first be determined whether the patient was compliant with treatment. If the patient was not compliant, antidepressant medication should resume. If the patient was compliant and had been previously responding to the medication (without significant side effects), the existence of ongoing stressors (e.g., conflict, abuse) or comorbid medical or psychiatric disorders should be considered (anxiety disorder, ADHD, substance abuse, dysthymia, bipolar disorder, eating disorder). 

Braun, D., Sunday, S., and Halmi, K.A. (1994) Psychiatric comorbidity in patients with eating disorders. Psychol Med 24 859—967. Brewerton, T.D., Lydiard, R.B., Herzog, D.B., and Brotman A.W. (1995) Comorbidty of axis I psychiatric diagnoses in bulimia nervosa. J Clin Psychiatry 56 77-80. 

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