Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

286 IV. SPECIAL POPULATIONSPHARMACOTHERAPY FOR DUALLY DIAGNOSED PATIENTSDuring the past decade, the literature regarding when to prescribe pharmacotherapyfor dually diagnosed patients has changed considerably. Previous consensusin the field reflected reluctance to prescribe psychotropic medicationsin these populations. However, this consensus was based on earlier, methodologicallyflawed studies. For example, older studies examining the use ofantidepressants in alcoholics often did not use standardized methods to assessthe depressed population, had inadequate dosing or duration of antidepressants,and sometimes measured mood or drinking outcomes, but not both(Ciraulo & Jaffe, 1981). More recent studies have demonstrated that pharmacotherapycan improve outcomes for the psychiatric disorder and sometimesfor the SUD as well (Greenfield et al., 1998; Schubiner et al., 2002).Still, it is important also to incorporate psychosocial treatments directed atimproving substance use outcomes when treating dually diagnosed patients.The literature on treatments for specific psychiatric disorders is reviewedbelow.Major DepressionNunes and Levin (2004) performed a meta-analysis of antidepressant medicationefficacy for the treatment of co-occurring depression and SUD. The resultsindicated that in this patient population, the efficacy of antidepressants is comparableto that seen in patients with depression alone. Studies that required atleast 1 week of abstinence before treating the depression yielded larger effectsizes and lower placebo response, suggesting that requiring even at least 1 weekof abstinence before initiating medication treatment can successfully screen outtransient depressive symptoms. Also, studies that exhibited better depressionoutcomes as a result of antidepressants also showed decreased quantity of substanceuse. However, rates of sustained abstinence or SUD remission were lowacross studies, highlighting the importance of treatment directed at the SUD aswell when treating these patients.Bipolar DisorderAlthough face validity would suggest that stabilizing mania or hypomania inpatients with bipolar disorder would improve impulse control and judgment,and therefore lead to decreases in substance use, the literature is thin regardingthe efficacy of mood stabilizing medications on bipolar and SUD outcomes. Anopen pilot trial by Gawin and Kleber (1984) suggested that lithium may beeffective in reducing cocaine use in patients with cyclothymia and cocaineabuse. However, an open trial of lithium in patients with bipolar spectrum disordersand cocaine abuse (Nunes, McGrath, Wager, & Quitkin, 1990) demon-