Psychiatric Comorbidity And Sequelae

More than one-half of all cocaine abusers meet criteria for a current psychiatric diagnosis and nearly three-fourths for a lifetime psychiatric diagnosis (Ziedonis, Rayford, Bryant, Kendall, & Rounsaville, 1994). The most common comor-bid psychiatric diagnoses among cocaine abusers include alcohol dependence, affective disorders, anxiety disorders, and antisocial personality disorder (Kleinman et al., 1990; Marlowe, Husband, Lamb, & Kirby, 1995; Mirin, Weiss, Griffin, & Michael, 1991; Rounsaville et al., 1991; Weiss, Mirin, Griffin, Gunderson, & Hufford, 1993). For most cocaine users, co-occurring psychiatric disorders (including agoraphobia, alcohol abuse, alcohol dependence, depression, posttraumatic stress disorder (PTSD), simple phobia, and social phobia) precede cocaine use (Abraham & Fava, 1999; Shaffer &Eber, 2002).

The most frequent co-occurring substance use disorder is alcoholism; 29% of cocaine abusers have a current alcoholism diagnosis, and 62% a lifetime alcoholism diagnosis (Rounsaville et al., 1991). These findings are alarming considering that individuals with comorbid cocaine and alcohol use disorders manifest a more severe form of cocaine dependence, and comorbid alcohol abuse is associated with poorer retention in treatment and poorer treatment outcomes for both disorders (Brady, Sonne, Randall, Adinoff, & Malcolm, 1995). Cocaine use disorders also are common among opioid abusers. In addition, 66% of methadone-maintained patients abuse cocaine (Kosten, Rounsaville, & Kleber, 1987), and 75% of the heroin addicts admitted to methadone programs identify cocaine as their secondary drug of abuse (New York State Division of Substance Abuse Services, 1990). A national survey of 15 clinics (General Accounting Office, 1990) revealed continued cocaine use in as many as 40% of patients after 6 months of treatment. Marijuana is also commonly misused among cocaine-dependent patients. Studies have found that 25-70% of cocaine-dependent patients also abuse marijuana (Higgins, Budney, Bickel, & Badger, 1994). Similarly, 80.5% of cocaine-dependent patients smoke tobacco cigarettes (Patkar et al., 2002), and the heavier the tobacco smoking, the heavier the use of cocaine (Henningfield, Clayton, & Pollin, 1990). In addition, cocaine-dependent individuals who smoke tobacco report an earlier age of onset and more frequent use of cocaine than cocaine-dependent individuals who do not smoke (Budney, Higgins, Hughes, & Bickel, 1993).

Non-substance-related Axis I disorders are also common among cocaine addicts. The rates for current depressive disorders vary between 11 and 55% (Carroll et al., 1994; Griffin, Weiss, Mirin, & Lange, 1989; Haller, Knisely, Dawson, & Schnoll, 1993), whereas those for lifetime depression range from 40 to 60% (Kleinman et al., 1990). Bipolar depression appears to be over-represented among cocaine users. In a large, community-based sample, 42.1% of cocaine abusers were found to have bipolar disorder (Karam, Yabroudi, & Melhem, 2002). Because of the specific actions and effects of cocaine, it is sometimes difficult to determine whether depression is independent of cocaine use or the result of chronic self-administration. However, depression that predates drug use or persists beyond the 1-2 weeks characteristic of cocaine withdrawal may indicate a coexisting disorder. Also, if a cocaine abuser becomes acutely depressed or suicidal after ingesting only very small amounts of the drug, a primary depressive disorder may be indicated (Kosten et al., 1987). In most cases of comorbid depression and cocaine use, depression precedes cocaine use by an average of 7 years (Abraham & Fava, 1999). Panic disorder is prevalent among cocaine abusers, and the literature contains a number of case reports of individuals who developed panic disorder following cocaine use (Aronson & Craig, 1986; Bystritsky, Ackerman, & Pasnau, 1991). Among 122 cocaine-dependent outpatients, 30.2% of women and 15.2% of men met DSM criteria for PTSD (Najavits et al., 1998). Furthermore, in a large epidemiological study, rates of PTSD among cocaine-dependent individuals were 10 times higher than among non-cocaine-dependent individuals. Findings suggest that cocaine dependence is a risk factor for PTSD, because it usually precedes the trauma and places individuals in situations where traumatic events are more likely to occur (Cottler, Compton, Mager, Spitznagel, & Janca, 1992).

Attention-deficit/hyperactivity disorder (ADHD) is an important comor-bid condition. In a large longitudinal study, approximately 21% of adults with ADHD were cocaine dependent, compared to 10% of agemate controls (Lambert & Hartsough, 1998). Studies indicate that between 12 and 35% of cocaine addicts meet childhood criteria for ADHD (Carroll & Rounsaville, 1993; Levin, Evans, & Kleber, 1998; Rounsaville et al., 1991). Compared to cocaine abusers without comorbid ADHD, those with ADHD are more likely to be male and to also meet criteria for conduct disorder and antisocial personality disorder. Cocaine abusers with ADHD evidence earlier age of onset of use, more frequent and severe use, more alcoholism, and more prior treatment episodes. Men who score high on an ADHD measure also report more use of cocaine for the purpose of self-medication (Horner, Scheibe, & Stine, 1996). Although somewhat controversial, several case reports suggest that stimulants (e.g., magnesium pemoline, and methylphenidate) can be successfully used to treat patients with comorbid cocaine abuse and ADHD (Khantzian, Gawin,

Kleber, & Riordan, 1984; Weiss, Pope, & Mirin, 1985). This treatment effect appears to be selective, because non-ADHD cocaine abusers derive no apparent benefit from stimulants but do manifest cross-tolerance (Gawin, Riordan, & Kleber, 1985).

Studies conducted with both inpatients and outpatients with schizophrenia show prevalence of cocaine use falling between 20 and 93% (Regier et al., 1990; Rosenthal, Hellerstein, Miner, & Christian, 1994; Schwartz, Swanson, & Hannon 2003; Ziedonis & Fischer, 1996). Cocaine-abusing persons with schizophrenia have fewer negative signs (Lysaker, Bell, Beam-Goulet, & Milstein, 1994), but more depression and anxiety at the time of hospital admission (Serper, Alpert, Richardson, & Dickson, 1995); at posttreatment, no differences in negative signs or mood are observed, suggesting that differences result from the effects of cocaine. Persons with schizophrenia who abuse cocaine have increased morbidity, evidenced by higher rates of hospitalization, greater suicidality, and the need for higher doses of neuroleptics than both users of other drugs and nonusers (Seibyl, Satel, Anthoy, & Southwick, 1993). Cocaine use may itself induce noxious psychiatric effects, some of them psychotic in nature. Bruxism, picking at the face and body, and other stereotypical or repetitious behaviors may occur. Cocaine hallucinosis may include visual, tactile, auditory, and olfactory hallucinations, along with delusions. Cocaine users may also perceive "cocaine bugs" on their skin, as well as visual "snow lights." In less severe cases, the user is aware that the hallucinations and delusions are not real. However, in more severe cases, individuals may show a full-blown toxic psychosis with extreme paranoia, hypervigilance, and ideas of persecution. This toxic psychosis can potentially lead to unusual aggressiveness, damaged property, and homicidal or suicidal behavior. Fortunately, these effects are generally limited to the time of cocaine intoxication.

Comorbid Axis II disorders are even more prevalent than Axis I disorders, with rates of personality disorders in cocaine abusers ranging from 30 to 75% in inpatient samples (Kleinman et al., 1990; Kranzler, Satel, & Apter, 1994; Weiss et al., 1993). Cocaine addicts with personality disorders tend to have greater psychiatric severity than those without personality disorders and are also at greater risk for both anxiety and mood disorders (Bunt, Galanter, Lifshutz, & Castaneda, 1990; Stone, 1992). Among cocaine-abusing outpatients, 48% have at least one personality disorder, whereas 18% have two or more (Barber, Frank, Weiss, & Blane, 1996). Even more compelling, 65% of those with a comorbid Axis II diagnosis have a Cluster B disorder, antisocial and borderline personality disorder (BPD) being the most frequent. Patients with BPD have higher levels of polysubstance and cocaine dependence, and also have more personality disorders such as avoidant, antisocial, and dependent personality disorder (Kranzler et al., 1994; Nurnberg, Rifkin, & Doddi, 1993). For cocaine abusers in intensive outpatient treatment, the rates of co-occurring personality disorders are quite high; three-fourths meet criteria for at least one Axis II diagnosis and more than one-third have two or more (Haller et al., 1993; Marlowe et al., 1995). Males are more likely to have comorbid alcohol dependence, stimulant dependence, antisocial personality disorder, and narcissistic personality disorder, whereas females are more likely to be diagnosed with mood disorders and BPD. It is important to evaluate patients routinely for Axis II disorders at point of treatment entry and to design drug treatment programs that provide adequate attention to these comorbid conditions.

Unfortunately, psychiatric comorbidity has negative implications for symptom expression, prognosis, medical compliance, and services utilization (Bartels et al., 1993; Moos, Mertens, & Brennan, 1994; Moos & Moos, 1995; Pristach & Smith, 1990). It is important for substance abuse and mental health clinicians to become aware of patterns of comorbidity among their patients and to develop treatment plans that address dual disorders simultaneously. Awareness of subtypes of cocaine abusers may help to guide treatment in both pharmacological and psychological intervention.

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