Grenoble 14th European Congress. Heroin Addiction & Related Clinical Problems. Abstract Poster.

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Depression resistant to antidepressant medications or depression complicated by hypophoria? A case report.

Walter Paganin 1, Sabrina Signorini 2, and Icro Maremmani 3,4,5

1 Department of Mental Health ASL RM/5, Tivoli, Italy, EU

2 Centro Nautilus, Tivoli, Italy, EU

3 Vincent P. Dole Dual Disorder Unit, 2nd Psychiatric Unit, Santa Chiara University Hospital, University of Pisa, Italy, EU

  1. Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, Lucca, Italy, EU
  2. De Lisio Institute of Behavioural Sciences, Pisa, Italy, EU

Background. The clinical condition of depression resistant to antidepressant drug treatment (TRD) has been described since the early Seventies. In the case of Dual Disorder (Heroin Use Disorder/Depressive) patients, the tendency of psychiatrists to treat subjects with depression by using predominantly psychiatric drugs instead of agonist opioid therapy still persists. The aim of this case study presentation is to support this assessment. Case Presentation. A 45-year-old male with a history of opiate addiction, use and resistance to treatment was monitored for many years, while continuing to be treated with an antidepressant, while a correct methadone or buprenorphine treatment was avoided; the outcome was that no significant clinical improvement occurred until a very complex treatment system was applied. Comment. This patient was misdiagnosed as resistant to treatment. None of the doctors responsible for his health considered the possibility that the severity of his symptoms and the low level of his response to therapy might be due to a hypophoric/dysphoric syndrome induced by previous long-term opiate abuse and not responding to standard agonist opioid treatment. In such cases, good clinical practice suggests that agonist opioid therapy with over-standard dosages may be indicated in depressed patients with opioid addiction.

Key Words: Depression; resistance to treatment; hypophoria; Agonist Opioid Treatment; Dual Disorder; misdiagnosis.

This clinical case exemplifies the tendency of psychiatrists to treat subjects with dual diagnoses by using predominantly psychiatric drugs instead of a correct agonist opioid therapy [9]. When the patient was first examined by us, it was clear that agonist opioid therapy had been incorrectly applied [15, 16]. The se- verity of the clinical condition would, in fact, have required treatment with a total opioid agonist, not with a partial agonist. In addition, the dosage of the partial agonist had always been insufficient, because the dos- ages prescribed to block the action of heroin were not enough to stop craving for the substance, due to the poor opiate power of the drug. Thirdly, an increase in therapeutic pressure (pharmacological and psycho- therapeutic) was accompanied by a decrease in the use of heroin and a parallel decrease in the need for the opiate drug. Thus the previous treatment had been interrupted several times – a change that destabilized the patient’s opiate system. The diagnosis, quite probably incorrect, was resistant depression (TRD). More likely, it should have been a diagnosis of depression complicated by the hypophoric syndrome, which is present in all heroin addicts, especially so in poly- users. This ‘double depression’ cannot be relieved just by antidepressants, because the hypophoric component, in the case of patients addicted to heroin, is sensitive only to opioids. Since addiction is not under control, depressive symptoms cannot be controlled either. In a proper treatment of the dual disorder   of a heroin-addicted patient, the increase in therapeutic pressure (psychopharmacological and psychotherapeutic) must always be accompanied by optimal opiate agonist treatment [13, 19].

References

  1. Chang L., Ernst T., Strickland T., Mehringer C. M. (1999): Gender effects on persistent cerebral metabolite changes in the frontal lobes of abstinent cocaine users. Am J Psychiatry. 156(5): 716-722.
  2. Coid J.,Yang M., Tyrer P., Roberts A., Ullrich S. (2006): Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry. 188: 423-431.
  3. De Sousa R. T., Zanetti M. V., Brunoni A. R., Machado- Vieira R. (2015): Challenging Treatment-Resistant Major Depressive Disorder: A Roadmap for Improved Therapeutics. Curr Neuropharmacol. 13(5): 616-635.
  4. Fava M., Davidson K. G. (1996): Definition and epidemiology of treatment-resistant depression. Psychiatr Clin North Am. 19(2): 179-200.
  5. Graves S. M., Persons A. L., Riddle J. L., Napier T.C. (2012): The atypical antidepressant mirtazapine attenuates expression of morphine-induced place preference and motor sensitization. Brain Res. 1472: 45-53.
  6. Herbeck D. M., Fitek D. J., Svikis D. S., Montoya I. D., Marcus S. C., West J. C. (2005): Treatment compliance in patients with comorbid psychiatric and substance use disorders. Am J Addict. 14(3): 195-207.
  7. Ijaz S., Davies P., Williams C. J., Kessler D., Lewis G., Wiles N. (2018): Psychological therapies for treatment- resistant depression in adults. Cochrane Database Syst Rev. 5: CD010558.
  8. Jaafari N. (2013): Avancèes therapeutiques dans la depression rèsistente. L’Encèphale. 39: 15-17.
  9. Lovrecic M., Lovrecic B., Dernovsek M. Z., Tavcar R., Maremmani I. (2004): Unreported double frequency of heroin addicts visiting psychiatric services and addiction treatment services. Heroin Addict Relat Clin Probl. 6(3): 27-32.
  10. Lucas N., Hubain P., Loas G., Jurysta F. (2017): Treatment resistant depression: actuality and perspectives in 2017. Rev Med Brux. 38(1): 16-25.
  11. Luchini F., Cosentino L., Pensabene L., Mauri M., Lattanzi L. (2014): [Treatment-resistant depression: state of the art Part II. Treatment]. Riv Psichiatr. 49(6): 228-240.
  12. Luchini F., Cosentino L., Pensabene L., Mauri M., Lattanzi L. (2014): [Treatment-resistant depression: state of the art. Part I. Nosography and clinic]. Riv Psichiatr. 49(5): 207-216.
  13. Maremmani A. G. I., Pacini M., Maremmani I. (2019): What we have learned from the Methadone Treatment of Dual Disorder Heroin Addicts. Int J Environ Res Public Health. 16(447): doi: 10.3390/ijerph16030447.
  14. Maremmani I., Canoniero S., Pacini M. (2002): Psico(pato)logia dell’”addiction”. Un’ipotesi interpretativa. Ann Ist Super Sanita. 38(3): 241-257.
  15. Maremmani I., Pacini M., Lubrano S., Lovrecic M., Perugi G. (2003): Dual diagnosis heroin addicts. The clinical and therapeutic aspects. Heroin Addict Relat Clin Probl. 5(2): 7-98.
  16. Maremmani I., Pacini M., Pani P. P. (2006): Effectiveness of buprenorphine in double diagnosed patients. Buprenorphine as psychothropic drug. Heroin Addict Relat Clin Probl. 8(1): 31-48.
  17. Nelson J. C. (2003): Managing treatment-resistant major depression. J Clin Psychiatry. 64 Suppl 1: 5-12.
  18. Nunes E.V., Sullivan M.A., Levin F. R. (2004): Treatment of depression in patients with opiate dependence. Biol Psychiatry. 56(10): 793-802.
  19. Pacini M., Maremmani I. (2017): What have we learned from the Agonist Opioid Treatment of dual disorder heroin addicts? Addict Disord Their Treatment. 16(4): 164-174.
  20. Rovai L., Maremmani A. G. I., Pacini M., Pani P. P., Rugani F., Lamanna F., Schiavi E., Mautone S., Dell’osso L., Maremmani I. (2013): Negative dimensions in Psychiatry. Amotivation syndrome as a paradigme of negative symptoms in substance abuse. Riv Psichiatr. 48(1): 1-9.
  21. Ruhe H. G., Van Rooijen G., Spijker J., Peeters F. P., Schene A. H. (2012): Staging methods for treatment resistant depression.A systematic review. J Affect Disord. 137(1-3): 35-45.
  22. Speranza M., Corcos M., Stephan P., Loas G., Perez- Diaz F., Lang F., Venisse J. L., Bizouard P., Flament M., Halfon O., Jeammet P. (2004): Alexithymia, depressive experiences, and dependency in addictive Subst Use Misuse. 39(4): 551-579.

Grenoble 14th European Congress. Heroin Addiction & Related Clinical Problems. Abstract Poster.