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 Freud’s 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?

Heroin Where 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 – 2/1 Men more addiction – 2/1 12,500 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 contact Babies cry when they are separated In primitive conditions, crying babies

starve or are eaten Is depression a protest shutoff?

SEPARATION

ANXIETY DEPRESSION

Maternal deprivation a major risk factor for both depression and addiction (Heim…Nemeroff 2008)

Heim/Nemeroff depression model in rats Separation for 15 minutes on days 2 – 14

leads to more licking Separation for 3 hours leads to ignoring,

biting, high CRF Reversed by paroxetine and recurs off

paroxetine

Obvious answer, give antidepressants? (restore brain health)

Keller et al. study NEJM 2000 Response rate nefazodone 50%, CBT

50%, combination 80% Remission rate nefazodone 20%, CBT

20%, combination 40%

Childhood trauma subset: No added benefit of nefazodone

Is 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 home

Wurmser’s “Addictive Search” (1974) Idealization used as a defense against terror Addictive splitting

Wonderfully related/unrelated Omnipotent power/helplessness Independence/dependence Rebellious 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 years

Permanent changes – mood, sleep, pain-tolerance, desire?

Alcohol, cocaine/methamphetamine, opioids – each impair cortical functioning

Drug seeking becomes an automatic, compulsive action mediated by NAC

Cognitively impaired patients most likely to leave psychotherapy

Cognitive 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 (Nunes…Hasin 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 diagnosis

Helps patients see what you are treating Helps with lack of mood-altering effects Helps 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 balance

Bupropion increases libido as side effect, average patient loses 5 pounds

Trazodone is weight and sex neutral

Risk factors for completed suicide History of self harm Prior psychiatric treatment Current psychiatric treatment Benzo (Cooper 2006)Risk factor for subjects over 65 (Voaklander

2008)

Duloxetine 60 220 2640 Imipramine 150 33 396 Trazodone 150 3 40 Propranolol 10 3 40 Paliperidone 900 10800 Haloperidol 2 3 40

Only 1/3 “bipolar” by psychiatrist admitted to Dual Diagnosis Addiction Service met DSM-IV criteria (Goldberg 2008)

Lithium #1 Lamotrigine #2 Avoid antidepressants – work, then

provoke rapid cycling

Which is codeine 60 + acetaminophen 600?

A

BC

D

E

F

Outside A -----Ego-----Inside B Sensation – Felt by all Perception – Felt by some. Can be

pointed out. Requires input from memory

Affect – Specific to each person. Includes relationship

Experience of patient – sensation (outside)

Understanding of physician - complex

WHITE (2004) ADD. BEH. 29:1311-24 RATS IMPLANTED WITH MORPHINE

PELLET INITIAL RESPONSE TO RADIANT HEAT;

ANALGESIA BY 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, METHADONE

METHADONE; 30 HOUR HALF LIFE; PEAK AND TROUGH

COLD PRESSOR TEST: 65 SEC. CONTROLS, 15 SECONDS ON METHADONE

DURATION LESS THAN HALF AT PEAK METHADONE LEVELS

0

5

10

15

20

25

30

35

40

45

<7 mos 7-24 mos >24 mos

Effect of Duration of Methadone Therapy on Percent with Severe Chronic Pain

Age Gender Seconds Pain Medication1 30 female 3 80 hydrocodone 2 26 female 10 80 oxyc 240/day3 40 female 14 10 illicit

painkiller4 42 male 5 8 oxyco 60/day5 17 female 3 minutes 10 oxycodone6 27 male 10 70 hydrocodone,

then methadoneRepeated after detox 3 minutes 20 1 week later

Countertransference: Responsibility is patient’s, not physician’s

Look for a specific cause with a specific intervention

Don’t try to fix emotional or social problems with medications – accept helplessness and model it for the patient (“You have to live with pain”)

Exercise/PT NSAIDS Acetaminophen

Low/usual-dose tricyclics

Antidepressants Anticonvulsants

Anxiety-reducing medications such as propranolol, clonidine

Topical aromatics Topical diclofenac Regional nerve block

Hot yoga Massage Acupuncture

Psychotherapy Family Therapy Group Psychotherapy

Detoxification Naltrexone Reiki

Trazodone 200 – 600/day Triad of ADHD, nicotine, depression

makes bupropion excellent Avoid SSRIs because of sexual side

effects Tricyclics for refractory depressions Include cost as a side effect Addiction included as a side effect

“For every problem there is a pill” mentality

“Racing thoughts” and “Constant worrying” often have to do with living life on life’s terms

Usually anxiety does not require medication, but difficult behavior may require meds to allow treatment

Antidepressants best, but have latency of onset of action

Propranolol, clonidine - cut norepinephrine

Anticonvulsants: valproate, gabapentin Antipsychotics: No reason to pay for

second generation

“The AA Member and Medication” – AA public policy

Go to doctors who understand addiction Tell your doctor that you have an

addiction

Sexuality is a central aspect of relatedness – don’t disrupt it

Medications can be categorized as dulling or promoting relatedness

Dull relatedness: Benzos, opioids, SSRI/SNRIs?

Enhance relatedness: Antidepressants, ADHD meds, antipsychotics – if psychotic

Best understanding of depression and addiction: symptoms of disruption of relatedness

Addiction causes repeated harm (TV, exercise) Treatments focus on promotion of relatedness:

psychotherapy, 12 Step programs Many depressed patients respond to

relatedness alone If prescribing medications, think about using

them to restore relatedness