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Psychiatrists may wonder why both addiction treatment and the 12-step programs recommend abstinence. In his 50-year follow-up of two groups of alcoholics, Vaillant compared those who established secure abstinence with those who continued to drink. Secure abstinence was associated with: Living longer Better mental health Better marriages Being more responsible parents Being successful employees In considering the various routes to secure recovery, Vaillant recommended that clinicians: Offer the patient a nonchemical substitute for alcohol Remind the patient ritually that even one drink can lead to pain and relapse Repair the social and medical damage that the patient has experienced Restore the patient's self-esteem The preponderance of the research data now available indicates that the 12-step programs of AA, NA, Cocaine Anonymous, and Al-Anon are most helpful for alcohol-dependent and other drug-addicted patients as they seek to achieve secure, long-term abstinence. A growing number of clinicians is recommending that physicians become more knowledgeable and skilled in referring and supporting patients in working 12-step programs of recovery. Specific recommendations include: 1. Be familiar with 12-step activities and tools. These include meetings, home groups, sponsors, the Twelve Steps and Twelve Traditions, books, pamphlets, and slogans. To be able to discuss the meanings and applications of these tools for recovery is useful. Physicians can select those that are most suitable for the individual, recognizing that meeting attendance might not be the most important activity. 2. Support referral by facilitating a meeting between the patient and a temporary contact from the 12-step program. This means becoming familiar with local 12-step programs. Phoning the local AA or NA central office or hot line makes connecting patients to someone who will take them to a meeting that same day possible. AA and NA have committees whose members are interested in working with physicians to help get patients to meetings and to get information to physicians. These are the Cooperation with the Professional Community, Treatment Facilities, and Hospitals and Institutions committees. 3. Work with the resistance of patients. Many addicted patients are resistant to the idea of attending 12-step or mutual-help programs. Reminders of their painful personal database associated with the use of alcohol or other drugs can help break through denial. Involvement of family members and friends in the network therapy developed by Galanter can be effective in reducing resistance. Being patient and persistent in developing the therapeutic alliance helps to maintain contact during the first difficult year of recovery. Physicians should be prepared to work with patients as long as necessary to stabilize their sobriety. Zweben has suggested ways psychotherapy can help deepen work with the steps. 4. Help dual diagnosis patients understand AA's and NA's singleness of purpose. These programs work only with addiction; they do not try in any way to deal with other mental disorders. All patients have to say is, "I want to stop drinking or using drugs," and they will be welcomed and accepted at meetings (see Tradition 3). If they talk only about their psychiatric symptoms or medications, someone may suggest that they go elsewhere for help. Occasionally, well-intentioned AA or NA members tell patients to stop taking their medications. The authors always direct patients to the pamphlet The AA Member: Medications and Other Drugs. This pamphlet tells AA members not to play doctor and to take the medications their doctors prescribe. Copies of the pamphlet are widely available at many AA meetings, or they can be ordered by physicians from Alcoholics Anonymous World Services, General Service Office, Box 459, Grand Central Station, New York, NY 10163 (212-870-3400). 5. Get comfortable with the spiritual dimensions of healing. Zweber and Brown offer good suggestions for getting com
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PMID:Twelve-step and mutual-help programs for addictive disorders. 1038 42

Comorbid psychiatric disorders and drug use disorders (DUDs) are common among alcoholics (Regier, Farmer, Rae, Locke, Keith, Judd, & Goodwin, 1990; Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen, & Kendler, 1994). These comorbid disorders often predict a shorter time to relapse of alcoholism (Greenfield, Weiss, Muenz, Vagge, Kelly, Bello, & Michael, 1998). However, despite the prevalence and the adverse effects of this comorbidity, few controlled treatment studies have been conducted involving this dual diagnosis population (Litten & Allen, 1999). To date, most of these few studies of alcoholics with comorbid disorders have been restricted to studies of alcoholics with either comorbid major depression or comorbid anxiety disorders (Litten & Allen, 1995). The results of these trials suggest efficacy for SSRI antidepressants and tricyclic antidepressants for treating alcoholics with comorbid major depression and suggest efficacy for buspirone for treating alcoholics with comorbid anxiety disorders (Mason, Kocsis, Ritvo, & Cutler, 1996; Cornelius, Salloum, Ehler, Jarrett, Cornelius, Perel, Thase, & Black, 1997; Kranzler, Burleson, Del Boca, Babor, Korner, Brown, & Bohn, 1994). However, controlled treatment studies involving alcoholics with other comorbid disorders are almost totally lacking. Consequently, to date, no empirically proven treatment exists for most of these comorbid disorders.
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PMID:Alcohol and psychiatric comorbidity. 1263 46

About half of all bipolar patients have an alcohol abuse problem at some point of their lifetime. However, only one randomized, controlled trial of pharmacotherapy (valproate) in this patient population was published as of 2006. Therefore, we reviewed clinical trials in this indication of the last four years (using mood stabilizers, atypical antipsychotics, and other drugs). Priority was given to randomized trials, comparing drugs with placebo or active comparator. Published studies were found through systematic database search (PubMed, Scirus, EMBASE, Cochrane Library, Science Direct). In these last four years, the only randomized, clinically relevant study in bipolar patients with comorbid alcoholism is that of Brown and colleagues (2008) showing that quetiapine therapy decreased depressive symptoms in the early weeks of use, without modifying alcohol use. Several other open-label trials have been generally positive and support the efficacy and tolerability of agents from different classes in this patient population. Valproate efficacy to reduce excessive alcohol consumption in bipolar patients was confirmed and new controlled studies revealed its therapeutic benefit to prevent relapse in newly abstinent alcoholics and to improve alcohol hallucinosis. Topiramate deserves to be investigated in bipolar patients with comorbid alcoholism since this compound effectively improves physical health and quality of life of alcohol-dependent individuals. In conclusion, randomized, controlled research is still needed to provide guidelines for possible use of valproate and other agents in patients with a dual diagnosis of bipolar disorder and substance abuse or dependence.
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PMID:Possible new ways in the pharmacological treatment of bipolar disorder and comorbid alcoholism. 2036 Oct 60