Brian Johnson M.D.Assoc Prof Psychiatry and AnesthesiaSUNY Upstate Medical UniversityMember Boston Psychoanalytic Society

I have never taken a pen or drank a soda at a drug-sponsored event. I have not benefitted personally from sponsorship by a drug company; except-Research on shifts in the hypothalamic-pituitary-adrenal system and depression during and after alcohol withdrawal sponsored by the Distilled Spirits Council of the United States (Johnson 1986)

Takes advantage of advances in both neuroscience and psychoanalysis to formulate testable hypotheses.Like Freuds original models of mental functioning, neurology is the material base.Contrast with cognitive-behavioral psychology where the brain is a black box, outcomes are counted.Example Reward versus SEEKING

If depression is so disabling, why is it so prevalent? It must have some functional use.What is an addiction?HeroinWhere is the line on drinking?What could the brain mechanism be in gambling?Internet? Exercise? TV watching?Repeated harm from X

Lifetime incidence of MDD 13%12 month prevalence 5%Lifetime MDD Alcoholism 40% (8.5%)Nicotine addiction 30%(20%)Drug addiction 17% (2%)Why?

Women more MDD than men 2/1Men more addiction 2/112,500 Amish, no addiction 1/1 (Egeland & Hostetter 1983)Women tolerate emotional distress better without resorting to drugs (Khantzian)Could we be observing symptom constellations with similar underpinning?

PANIC (GRIEF) system-Insures contactBabies cry when they are separatedIn primitive conditions, crying babies starve or are eatenIs depression a protest shutoff?

SEPARATIONANXIETYDEPRESSION

Maternal deprivation a major risk factor for both depression and addiction (HeimNemeroff 2008)Heim/Nemeroff depression model in ratsSeparation for 15 minutes on days 2 14 leads to more lickingSeparation for 3 hours leads to ignoring, biting, high CRFReversed by paroxetine and recurs off paroxetine

Obvious answer, give antidepressants? (restore brain health)Keller et al. study NEJM 2000Response rate nefazodone 50%, CBT 50%, combination 80%Remission rate nefazodone 20%, CBT 20%, combination 40%

Childhood trauma subset: No added benefit of nefazodoneIs there a subset of depressive illness (anaclitic) that responds to psychotherapy and not antidepressants?(Lack of efficacy of antidepressants except for severe depression)

Addictive behavior has a transitional object quality for teenagers leaving homeWurmsers Addictive Search (1974)Idealization used as a defense against terrorAddictive splittingWonderfully related/unrelatedOmnipotent power/helplessnessIndependence/dependenceRebellious separateness/not autonomous

Changes in sleep induced by cocaine only became worse over 17 days (Morgan 2006)Hyperalgesia induced by opioid exposure persisted for months in abstinent subjects (Prosser 2008)Drug dreams persisted for 5 years of abstinence (Johnson 2001)Anecdotal drug dreams for alcohol 32 years, nicotine 50 yearsPermanent changes mood, sleep, pain-tolerance, desire?

Alcohol, cocaine/methamphetamine, opioids each impair cortical functioningDrug seeking becomes an automatic, compulsive action mediated by NACCognitively impaired patients most likely to leave psychotherapyCognitive evaluation of patients central to any evaluation (word-finding)

Patients in alcohol WD: HRSD bifurcated after one week (Johnson, Perry 1986)110 patients followed for 1 year: dep equally likely independent or subst. induced depression (NunesHasin 2007)Depressed patients started at McLean (Greenfield 1998): 20% sober if on antidepressants, none stayed sober 4 months off antidepressants

Repeat during early abstinence for diagnosisHelps patients see what you are treatingHelps with lack of mood-altering effectsHelps patients see constellation of anxiety, somatic and vegetative sxs

ADHD 62%Amphetamines 71%Methylphenidate 37%Methylphenidate ER 39%Opioids 35%Bupropion - 0

Triangle placebo,

SSRIs and SNRIs inhibit at least one phase of sexual functioning in 96% of women and 98% of men; interest, erection/lubrication, orgasm (Clayton 2006, 3114 subjects)Mechanism of decreased libido decreased testosterone: dopamine/serotonin balanceBupropion increases libido as side effect, average patient loses 5 poundsTrazodone is weight and sex neutral

Risk factors for completed suicideHistory of self harmPrior psychiatric treatmentCurrent psychiatric treatmentBenzo (Cooper 2006)Risk factor for subjects over 65 (Voaklander 2008)

Duloxetine 602202640Imipramine 150 33 396Trazodone 150 3 40Propranolol 10 3 40Paliperidone90010800Haloperidol 2 3 40

Only 1/3 bipolar by psychiatrist admitted to Dual Diagnosis Addiction Service met DSM-IV criteria (Goldberg 2008)Lithium #1Lamotrigine #2Avoid antidepressants work, then provoke rapid cycling

Which is codeine 60 + acetaminophen 600?ABCDEF

Outside A -----Ego-----Inside BSensation Felt by allPerception Felt by some. Can be pointed out. Requires input from memoryAffect Specific to each person. Includes relationshipExperience of patient sensation (outside)Understanding of physician - complex

WHITE (2004) ADD. BEH. 29:1311-24RATS IMPLANTED WITH MORPHINE PELLETINITIAL RESPONSE TO RADIANT HEAT; ANALGESIABY DAY 4, CLEAR HYPERALGESIA (ON MORPHINE!)BIPHASIC RESPONSE TO OPIATES; RELIEF FOLLOWED BY MORE PAIN; REPEATEDLY

HAY-WHITE 2009 CPT 31 CONTROL, 18-20 ON MORPHINE, METHADONEMETHADONE; 30 HOUR HALF LIFE; PEAK AND TROUGHCOLD PRESSOR TEST: 65 SEC. CONTROLS, 15 SECONDS ON METHADONEDURATION LESS THAN HALF AT PEAK METHADONE LEVELS

AgeGenderSecondsPainMedication130female 380 hydrocodone 226female1080 oxyc 240/day340female1410 illicit painkiller442male58 oxyco 60/day517female3 minutes10oxycodone627male10 70hydrocodone, then methadoneRepeated after detox3 minutes201 week later

Countertransference: Responsibility is patients, not physiciansLook for a specific cause with a specific interventionDont try to fix emotional or social problems with medications accept helplessness and model it for the patient (You have to live with pain)

Exercise/PTNSAIDSAcetaminophenLow/usual-dose tricyclicsAntidepressantsAnticonvulsantsAnxiety-reducing medications such as propranolol, clonidineTopical aromaticsTopical diclofenacRegional nerve blockHot yogaMassageAcupuncturePsychotherapyFamily TherapyGroup PsychotherapyDetoxificationNaltrexoneReiki

Trazodone 200 600/dayTriad of ADHD, nicotine, depression makes bupropion excellentAvoid SSRIs because of sexual side effectsTricyclics for refractory depressionsInclude cost as a side effectAddiction included as a side effect

For every problem there is a pill mentalityRacing thoughts and Constant worrying often have to do with living life on lifes termsUsually anxiety does not require medication, but difficult behavior may require meds to allow treatment

Antidepressants best, but have latency of onset of actionPropranolol, clonidine - cut norepinephrineAnticonvulsants: valproate, gabapentinAntipsychotics: No reason to pay for second generation

The AA Member and Medication AA public policyGo to doctors who understand addictionTell your doctor that you have an addiction

Sexuality is a central aspect of relatedness dont disrupt itMedications can be categorized as dulling or promoting relatednessDull relatedness: Benzos, opioids, SSRI/SNRIs?Enhance relatedness: Antidepressants, ADHD meds, antipsychotics if psychotic

Best understanding of depression and addiction: symptoms of disruption of relatednessAddiction causes repeated harm (TV, exercise)Treatments focus on promotion of relatedness: psychotherapy, 12 Step programsMany depressed patients respond to relatedness aloneIf prescribing medications, think about using them to restore relatedness