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SUDs and Depressive Disorders
Goal 4(iii). Patients with SUDs and Depressive Disorders
SUD and depressive disorders commonly co-occur. The Epidemiological Catchment Area Study found 13.4 % of persons with a lifetime alcohol disorder and 26.4% of those with a lifetime drug use disorder also had a lifetime affective disorder. The National Comorbidity Study found a greater prevalence of such comorbidity- for example, 24.3% of men and 48.5% of women with a lifetime alcohol disorder also reported a lifetime major depressive disorder. More recently, the National Epidemiologic Survey on Alcoholism and Related Conditions found that 40.3% of persons surveyed meeting DSM-IV criteria for lifetime MDD also met criteria for either alcohol abuse or dependence. Substance use treatment samples report even higher levels of comorbidity – with some studies finding 50-70% of individuals in treatment for substance disorders have comorbid depression.
Current SUD treatment guidelines recommend pharmacotherapy for comorbid depression if symptoms persist after a 4-week "wash-out" period for detoxification, and sooner in cases where the depressive disorder is considered primary. Practice guidelines also recommend rapid introduction of evidence-based therapies, such as cognitive behavioral therapy (CBT). Guideline-concordant management of depression for persons with comorbid substance use and depressive disorders, however, is not routine in many VA SUD treatment settings. Practice guidelines for primary care recommend screening for both depression and alcohol use, along with brief interventions for alcohol use and "collaborative care" interventions for depression. While screening has been the standard of care in VA, brief interventions for alcohol use and collaborative care interventions for depression are not. However, VA is currently beginning a widespread implementation and evaluation effort involving several models of integrated mental health/alcohol use in primary care.
The SUD and Depression Task Group was convened just over a year ago to prioritize and lead the efforts of SUDQ and MHQ members in developing research and implementation projects to improve care for persons with co-occurring SUDs and depression. The Task group is co-lead by SUDQ and MHQ Executive Committee member Geoffrey M. Curran, PhD (Central Arkansas Veterans Healthcare System) and Steven Dobsha, M.D. (Portland VAMC). The group meets monthly by conference call. Aims are to: (i) Implement/evaluate integrated collaborative care models in primary care for depressive and substance use disorders (especially alcohol); (ii) Implement/evaluate evidence-based practices for depressive disorders in SUD treatment settings; (iii) Document care delivery patterns in mental health clinics for persons with SUDs; (iv) Evaluate the prevalence of co-occurring alcohol misuse among veterans with active depression symptoms and identify associations between co-occurring alcohol and depression symptoms and measures of health status; and (v) Document disparities in comorbidity of SUDs/depression and in receipt of best practices.
Toward fulfillment of above goals, group members recently worked with Ira Katz, M.D., Deputy Chief Patient Care Services Officer for Mental Health, in modeling integrated collaborative care options for programs participating in the MH-PC Initiative. Additionally, group members are in contact with the Initiative's evaluators to collaborate on future projects/extensions concerning veterans with co-occurring alcohol use and depressive disorders. Other projects of Task Group members include a new SDP (to be funded in early 2008) on "Training SUD Counselors CBT for Depression" (PI, Curran; Co-PI, Weingardt). This project will adapt, through iterative cycles of development, stakeholder feedback, and revise an existing CBT for Depression manual into a web-based training module for use by VA addiction therapists. The SDP will also develop and test a supervision plan to accompany the therapist training, and a workbook for use by veterans using MyHealtheVet. Further, Task Group members have recently initiated a project (MHQ LIP) to document the formal and informal policies for treatment of persons with SUDs in mental health settings. Another project has begun a series of analyses to evaluate the prevalence of co-occurring alcohol misuse among veterans with active depressive symptoms and identify associations between co-occurring alcohol and depression symptoms and measures of health status. Investigators will use the VA Survey of the Health Experiences of Patients (SHEP) from FY2005 (255,530 veterans treated in VA ambulatory care clinics). Additionally, task group members are exploring their existing databases regarding comorbidity of SUD/depression and disparities in the receipt of best practices
- Secured funding for an FY08-10 SDP to develop and test CBT for Depression web-training for addiction therapists. Drs. Curran and Weingardt were funded for an HSR&D SDP in FY08 to develop and test this web-training and to develop and test an accompanying MyHeatheVet workbook for veterans and a supervision plan for therapists. The project is a collaborative effort among the SUD and MH QUERIs, as well as the Office of MH Services and EES.
Progress and Accomplishments
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