Addressing addiction. Diagnostic uncertainty because of continued methamphetamine use makes pharmacologic treatment of mood symptoms problematic. Mr. N’s denial of a drug problem complicates the physician’s job; nevertheless explaining to him how methamphetamine use can contribute to his symptoms is essential. Motivational interviewing (Box)2-4 may help you override resistance and motivate behavior change in a patient who is not yet contemplating the need to change.
Keep in mind that methamphetamine use can be linked to other risky behavior such as having multiple sexual partners. Thus, consider screening for sexually transmitted diseases, including HIV.5 Likewise, despite patients’ claim of only intranasal methamphetamine use, consider assessing for hepatitis C if the physical exam reveals evidence of intravenous drug use.
Mr. N’s symptoms escalated from depressed to suicidal before these interventions could be tried, however. Short-term goals for him now include safety and detoxification. Long-term goals include diagnosis and treatment of a possible underlying mood disorder and continued abstinence from methamphetamine use.
How to use motivational interviewing
Motivational interviewing aims to change behavior by helping patients explore and resolve ambivalence. Rather than a set of techniques that are “used on” people, it is an interpersonal style not restricted to formal counseling settings.2
When consulting, recommend the following principles during typical office appointments (5 to 15 minutes) to encourage patients to change destructive behaviors over the long-term:
- Seek to understand the person’s frame of reference, particularly through reflective listening
- Express acceptance and affirmation
- Elicit self-motivational statements and expressions of problem recognition from the patient, and selectively reinforce his or her concerns and desires
- Monitor the patient’s degree of readiness to change, and avoid generating resistance by jumping ahead of the patient
- Affirm the patient’s freedom of choice and self-direction.
Self-training manuals and videotapes of motivational interviewing are available, although 1- or 2-day workshops may be more effective.3 Using the techniques alone or to prepare for more intensive treatment has shown favorable outcomes.4 Visit http://www.motivationalinterview.org for more information.
Deciphering mood disorders. Consider the diagnosis of methamphetamine-induced mood disorder only if symptoms persist or are more severe than would be expected from the pattern of use. Anhedonia and depressed mood usually present in these patients well beyond the typical withdrawal period, but these symptoms persist <1 month. Mr. N’s paranoid symptoms are likely related to methamphetamine intoxication and should resolve within 1 week of detoxification. In some chronic “meth” users, delusions and hallucinations persist for months or even years and are very difficult to distinguish from chronic schizophrenia. These patients require long-term antipsychotic treatment.
Mr. N does not have a substantial period of abstinence from methamphetamine use for us to evaluate symptom resolution. However, we do have a 7-year history of what he calls “depression” and only 5 years of methamphetamine use. This hints that a primary mood disorder existed before substance use, but even here we must be cautious. His description of depression resembles a mixed episode of bipolar disorder, with both manic and depressive elements.
Further exploring early symptoms and family history with Mr. N and his family might suggest major depression or bipolar disorder preceding methamphetamine use.
Comorbid bipolar disorder. If his pre-drug use history suggests bipolar disorder or he continues to show mixed mood symptoms despite sustained abstinence, adding a bipolar diagnosis would be reasonable. For his depressive symptoms, avoid using an antidepressant alone because of the risk of “switching” to mania. All antidepressants can cause switching—paroxetine in Mr. N’s case—but tricyclic antidepressants are most often implicated.
Try a mood stabilizer such as valproate, 20 to 30 mg/kg/d, or olanzapine, 7.5 to 10 mg qhs. After a therapeutic dose is attained, reconsider adding an antidepressant if depressive symptoms still predominate.
Comorbid depression. If, on the other hand, Mr. N’s pre-drug history suggests major depression and he shows essentially depressive symptoms after abstinence, adding a diagnosis of major depression would be reasonable. In that case, retry an antidepressant such as an SSRI.
The sobriety challenge. After Mr. N is discharged from the hospital, continued abstinence from methamphetamines will be a priority, whether his mood disorder was drug-induced or primary.
No specific, well-established treatments exist for methamphetamine dependence. Formal treatment programs use cognitive behavioral therapy, contingency management, and a community reinforcement approach. These techniques have been shown to achieve abstinence and prevent relapse in patients with alcohol, cocaine, and opiate dependence but are not more effective than 12-step community support groups.6,7
Success with 12-step programs requires at least weekly participation. Daily attendance during early recovery may be particularly helpful for Mr. N, who may have excessive unstructured time during his unemployment. The treatment setting depends on where services are available and the patient’s ability to pay.