Timothy W. Lineberry, MD

Clinicians could become discouraged when confronting methamphetamine-dependent patients’ wide-ranging psychiatric symptoms.

These patients often present with:

• overlapping primary psychiatric syndromes and secondary substance abuse
  
• complex histories fraught with psychological trauma, limited social supports, and court involvement.
  

Treatment can be successful, however, and patients can change their addictive behaviors with a chronic disease management approach that targets the drug’s cognitive sequelae and psychiatric effects. Medications show limited benefit (Box 1),^1-8 but behavioral treatments—including cognitive behavioral therapy (CBT) and motivational incentives—have proven efficacy in treating methamphetamine addiction.

This article discusses how to counteract methamphetamine’s negative cognitive effects and enable patients to engage in psychosocial treatment. Our discussion is informed by an extensive literature search and clinical experience from treating patients in the Midwest—at the geographic heart of the “meth” epidemic.

CASE REPORT: Overwhelmed and suicidal

Ms. D, age 27, presents to the emergency department with anxiety, dysphoria, and a plan to commit suicide by overdose. She feels overwhelmed by her 4-hour-a-day customer service job—a prerequisite for staying at the halfway house where she has lived for 2 months. She has a 13-year history of polysubstance dependence and is under court order to complete chemical dependence treatment or go to jail.

Box 1

Methamphetamine has been Ms. D’s primary drug of abuse for 5 years, with some intervals of treatment and sobriety. She has not used methamphetamine in 3 months, after a severe relapse when she used methamphetamine daily for 6 months.

Ms. D began using drugs at age 14 and has 3 convictions for driving under the influence of alcohol. An average student, she dropped out of high school but obtained a GED certificate. She first had psychiatric contact at age 16 and has been diagnosed at various times with attention deficit/hyperactivity disorder, bipolar disorder, and anxiety disorder. She also has been violently sexually assaulted while engaging in prostitution to support her drug habit.

Ms. D has been hospitalized multiple times—voluntarily and involuntarily—in dual diagnosis treatment centers. Her 5-year-old son no longer lives with her, and she has limited social supports beyond her parents, who live in a neighboring state.

Table 1

Antidepressant trials for treating methamphetamine dependence

Drug	Investigation	Comments
Bupropion2-4	Laboratory	Safety of bupropion with MAP
	Laboratory	Reduced subjective effects and cue-induced craving
	Clinical trial	Trend toward reduced MAP use compared with placebo
Sertraline7	Clinical trial	Sertraline-treated subjects showed higher use of MAP compared with those receiving placebo and were less likely to complete treatment
MAP: methamphetamine

3-step approach

For patients such as Ms. D, clinical evidence supports a 3-step approach to treating methamphetamine dependence:

• step 1: institute acute management and stabilization
  
• step 2: eliminate or decrease methamphetamine use to “move the frontal lobe back to the front”
  
• step 3: identify and target psychiatric and psychosocial comorbidities.
  

We discussed step 1 and the methamphetamine epidemic in the November 2006 Current Psychiatry.⁹ For Ms. D, step 1 means inpatient psychiatric care to protect her from suicidal intent and manage dysphoria and anxiety. In step 2, we aim to:

• help her eliminate or decrease methamphetamine use to allow neuronal systems to recover
  
• target maladaptive behaviors that hinder sobriety while providing motivational incentives to help her maintain a methamphetamine-free life.
  

Improved executive functioning, a frontal lobe task, becomes possible as the brain recovers from methamphetamine’s effects. Patients then are able to use healthier coping strategies to live drug-free. We call this step “moving the frontal lobe back to the front” because its goal is to restore the normal relationship between the frontal lobe and limbic system.

How ‘meth’ affects cognition

Methamphetamine use has been associated with cognitive dysfunction at initial abstinence and even years later in some patients.¹⁰ Ms. D’s cognitive limitations in a fast-paced customer service job—even though hours are limited—lead to anxiety, dysphoria, and loss of self-esteem when she can’t manage patrons’ requests.

 

Methamphetamine has profound acute and chronic effects on the sympathetic nervous system, and dopaminergic, serotonergic, and noradrenergic neuronal networks. Most evidence of chronic neuronal effects comes from animal research and reflects toxic damage to dopaminergic and serotonergic neuronal systems. Postmortem human studies of direct neurotoxicity from chronic methamphetamine exposure show:

• decreased dopamine and tyrosine hydroxylase levels
  
• reduced concentrations of dopamine transporters.¹¹
  

Methamphetamine selectively affects dopamine in the nigrostriatal system, causing substantial dopamine depletion in the ventral tegmental reward system but relatively sparing motor regions. This may explain the lack of parkinsonism with methamphetamine dependence.¹² In a study comparing serotonergic system damage caused by methamphetamine or 3,4-methylenedioxymethamphetamine (MDMA [“Ecstasy”]),¹³ methamphetamine had greater toxicity in the forebrain, including the septum, anterior cingulate, caudate nucleus, and nucleus accumbens.

In chronic methamphetamine abusers, functional magnetic resonance imaging, proton magnetic resonance spectroscopy, and positron emission tomography show:

• changes in neurotransmitter, protein, brain metabolism, and transporter levels
  
• damage in multiple brain areas including the frontal region, basal ganglia, grey matter, corpus callosum, and striatum; smaller hippocampi; and cerebral vasculature changes.^14-16
  

Imaging studies typically have enrolled abstinent users, which emphasizes methamphetamine’s long-lasting effects. For practical purposes, the extent of brain damage is fairly dependably associated with the length and intensity of methamphetamine abuse. Because these changes may last for years and can be permanent,¹⁷ how does this play out clinically?

CASE CONTINUED: Does she understand?

After Ms. D is stabilized, her case manager expresses concern about her ability to follow through with treatment planning. He says, “I just don’t think she understands some of the things we discuss.” She then is referred for neuropsychological testing, which shows clear cognitive impairment. Specifically, she has a slowed rate of thinking, general cognitive ineficiency, deficits in learning and memory retention, and mild impulsivity.

Patients with a history of extensive methamphetamine abuse are ruled by the limbic system and may have higher cortical damage that complicates initiating, maintaining, and fully participating in treatment. Patients’ deficits in memory, executive functioning, attention, and cognitive speed may require you to simplify, repeat, and otherwise modify your treatment plan. You will need to provide clear instructions and consistent support—individually and psychosocially—and to recognize and reinforce patients’ treatment gains.

Even before using methamphetamine, patients may have had academic problems or learning disabilities that will compromise their ability to participate in treatment. Infection with HIV, syphilis, or hepatitis C can further hamper cognitive function.¹⁸

Screen methamphetamine abusers—particularly those such as Ms. D with a history of high-risk behavior—for sexually transmitted diseases. Also provide care address to common medical complications of methamphetamine abuse, including cardiac damage, dental disease, and skin lesions. Centers for Disease Control and Prevention guidelines recommend vaccinating methamphetamine-abusing patients against hepatitis A and B viruses (see Related Resources).

What treatments are effective?

Medications. Evidence is extremely limited, and no medications are approved to treat methamphetamine-addicted patients. Bupropion has shown some efficacy (Table 1),^2-4,7 but other drugs such as sertraline and topiramate may aggravate rather than diminish methamphetamine dependence (Table 2).^5,6,8,19

Behavioral treatments supply the evidence basis for methamphetamine dependence treatment. Cognitive behavioral therapy (CBT),²⁰ contingency management (CM),^21,22 and a manualized structured treatment—the Matrix Model²³—all have proven efficacy.

CBT involves functional analysis and skills training. Patients are guided through analyzing their drug use and associated cognitions, emotions, and expectations and in identifying situations that trigger methamphetamine use or relapse. Skills training involves identifying, reinforcing, and practicing coping skills to help the patient avoid drug use and reinforce the ability to refuse use.

CM is based on operant conditioning—the use of consequences to modify behavior. It involves establishing a “contingent” relationship between a desired behavior/outcome (such as methamphetamine-free urinalysis) and delivering a positive reinforcing event to promote abstinence:

• Vouchers, privileges, or small amounts of money linked to healthy behaviors serve as incentives for negative urine testing.
  
• Rewards increase as periods of confirmed abstinence lengthen and are reset to smaller rewards if relapse occurs.
  

The precise reward structure that provides optimal treatment value is under study.²⁴

CM does not require extensive staff training and has been described as relatively simple to implement. CM also has been used successfully in urban gay and bisexual men with methamphetamine dependence (Box 2).^18,25-29

Although CM’s efficacy is well-supported by clinical trials, we have encountered some resistance to the idea of “paying individuals to not use drugs” when training medical students, allied health staff, and residents. The National Institute on Drug Abuse (NIDA) supports the use of motivational incentives in treating substance abuse and offers support materials, resources, and training on this approach (see Related Resources).

 

Multiple studies show that CBT and CM are equally effective for treating chronic methamphetamine abuse at a 1-year follow-up, although CM may be more effective than CBT for acute treatment.

The Matrix model is a 4-month intensive, manualized treatment program that uses CBT, education on drug effects, positive reinforcement for intended behavioral change, and a 12-step approach.

Methamphetamine dependence outcomes based on the Matrix treatment model were compared with community treatment as usual in a project sponsored by The Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.³⁰ End-point outcomes were similar, but the Matrix treatment was more effective in early treatment, including decreased urinalyses positive for methamphetamine and increased abstinence.

Box 2

Recommendations. Select a psychosocial treatment approach with your patient’s strengths, social setting, and community resources in mind. Twelve-step approaches may play an important role.

In patients such as Ms. D, the structure of court-ordered treatment can provide accountability, enforced abstinence, and mandated treatment resources. This, in turn, may give your patient a better chance to engage a recovering and better functioning frontal lobe to inhibit urges for methamphetamine use and manage stress.

Table 2

Other agents studied in methamphetamine dependence trials

Drug	Investigation	Comment
Baclofen6 (GABAergic)	Clinical trial	No statistically significant effect compared with placebo; post hoc analysis showed ‘small’ treatment effects vs placebo
Gabapentin6 (GABAergic)	Clinical trial	No statistically signicant effect compared with placebo; post hoc analysis showed no treatment effects vs placebo
Topiramate8 (anticonvulsant)	Laboratory	Accentuated (rather than diminished) subjective effects of MAP
Aripiprazole19 (SGA)	Laboratory	Decreased subjective effects of amphetamine
Modafinil5 (wakefulness agent)	Clinical trial	Successful trial in cocaine dependence; potential option for MAP
MAP: methamphetamine; SGA: second-generation antipsychotic

CASE CONTINUED: Racing thoughts and psychosis

Before hospital admission, Ms. D was being treated with gabapentin, 300 mg bid, and sustained-release bupropion, 150 mg/d, for anxiety and dysphoria. Previously, she has received multiple antidepressants and mood stabilizers with reportedly little effect.

She describes racing thoughts and profound anxiety, but her presentation is remarkable for latency in response, apathy, and amotivation. She intermittently refuses to take medication, and collateral history shows adherence problems with medication and psychosocial treatment in her group home. She refuses to take bupropion, saying it makes her symptoms worse, but agrees to take quetiapine to address her complaints of anxiety and “being manic.”

Initially guarded, she at first denies psychotic symptoms but acknowledges their extent several days later. She describes periods of 6 months or more when she feels “lost.” The treatment team titrates quetiapine up to 200 mg/d and restarts duloxetine, 30 mg/d, for depressive symptoms, based on her past positive response to this antidepressant.

Box 3

 

Targeting psychiatric symptoms

Step 3 in the chronic disease management approach to methamphetamine dependence is to identify and target psychiatric and psychosocial comorbidities. When approaching psychiatric symptoms, high priorities are to aim for abstinence and manage the patient’s stress (Box 3).^31-33

Psychotic symptoms may present acutely, continue as residual symptoms, or reappear at stressful times long after an individual no longer abuses methamphetamine. Acute psychotic symptom intensity appears to be methamphetamine dose-related.³⁴

In clinical practice, we find it difficult to diagnostically categorize and treat methamphetamine-abusing patients who show residual post-acute psychotic symptoms. Some appear to have no risk factors for primary psychotic illness, and their symptoms show an association with the severity of their past methamphetamine abuse.

Other patient presentations can be difficult to separate from family histories of psychotic illness. Research suggests that genetic risk factors may be associated with methamphetamine psychosis in some vulnerable patients.³⁵

Unfortunately, no data exist to guide the use of antipsychotics to maintain symptom control. Some patients may need low-dose antipsychotics for maintenance treatment, and second-generation antipsychotics may have a theoretical advantage over first-generation antipsychotics. Use your clinical judgment in determining dosing and treatment duration, and in weighing risks and benefits of continued treatment.

Residual violent behavior. Violence, aggression, and poor impulse control are synonymous with methamphetamine abuse and have devastating individual, societal, and public health effects. Even abstinent methamphetamine abusers show long-standing elevated baseline aggression, compared with controls.

Using imaging, researchers found aggression severity to be directly correlated with past total methamphetamine use and globally decreased serotonin transporter density.³⁶ Serotonin transporter densities were 30% lower in methamphetamine users vs controls after >1 year of abstinence.

CASE CONTINUED: Discharge plans

Because of the severity of her psychiatric symptoms, Ms. D is unable to return to the halfway house after discharge. As her treatment team works to coordinate discharge placement, Ms. D continues to improve. Her psychotic and dysphoria symptoms resolve, and she shows increased spontaneity. These changes—attributed to supports during hospitalization, decreased stressors, and quetiapine treatment—continue until her discharge to a combined mental illness and chemical dependence program.

Ms. D’s report of “racing thoughts” is clarified; rather than mania, they represent recurrent thoughts and ruminations about past sexual abuse. Her psychotic symptoms resolve quickly with quetiapine, but she struggles with morning sedation. The team reduces the dosage, and she tolerates quetiapine, 25 mg hs, with trazodone, 100 mg hs, for sleep, anxiety, and psychotic symptoms. She is discharged on this regimen plus duloxetine, 60 mg/d, with plans to continue psychosocial treatment for methamphetamine dependence and posttraumatic stress.

Related resources

• Methamphetamine use and sexually transmitted diseases. Centers for Disease Control and Prevention. www.cdc.gov/std/DearColleagueRiskBehaviorMetUse8-18-2006.pdf.
  
• National Institute on Drug Abuse Blending Initiative. Promoting Awareness of Motivational Incentives (PAMI). www.drugabuse.gov/blending/PAMI.html.
  

Drug brand names

• Aripiprazole • Abilify
  
• Baclofen • various
  
• Bupropion • Wellbutrin
  
• Duloxetine • Cymbalta
  
• Gabapentin • Neurontin
  
• Modafinil • Provigil
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  
• Topiramate • Topamax
  
• Trazodone • Desyrel
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Clinicians could become discouraged when confronting methamphetamine-dependent patients’ wide-ranging psychiatric symptoms.

These patients often present with:

• overlapping primary psychiatric syndromes and secondary substance abuse
  
• complex histories fraught with psychological trauma, limited social supports, and court involvement.
  

Treatment can be successful, however, and patients can change their addictive behaviors with a chronic disease management approach that targets the drug’s cognitive sequelae and psychiatric effects. Medications show limited benefit (Box 1),^1-8 but behavioral treatments—including cognitive behavioral therapy (CBT) and motivational incentives—have proven efficacy in treating methamphetamine addiction.

This article discusses how to counteract methamphetamine’s negative cognitive effects and enable patients to engage in psychosocial treatment. Our discussion is informed by an extensive literature search and clinical experience from treating patients in the Midwest—at the geographic heart of the “meth” epidemic.

CASE REPORT: Overwhelmed and suicidal

Ms. D, age 27, presents to the emergency department with anxiety, dysphoria, and a plan to commit suicide by overdose. She feels overwhelmed by her 4-hour-a-day customer service job—a prerequisite for staying at the halfway house where she has lived for 2 months. She has a 13-year history of polysubstance dependence and is under court order to complete chemical dependence treatment or go to jail.

Box 1

Methamphetamine has been Ms. D’s primary drug of abuse for 5 years, with some intervals of treatment and sobriety. She has not used methamphetamine in 3 months, after a severe relapse when she used methamphetamine daily for 6 months.

Ms. D began using drugs at age 14 and has 3 convictions for driving under the influence of alcohol. An average student, she dropped out of high school but obtained a GED certificate. She first had psychiatric contact at age 16 and has been diagnosed at various times with attention deficit/hyperactivity disorder, bipolar disorder, and anxiety disorder. She also has been violently sexually assaulted while engaging in prostitution to support her drug habit.

Ms. D has been hospitalized multiple times—voluntarily and involuntarily—in dual diagnosis treatment centers. Her 5-year-old son no longer lives with her, and she has limited social supports beyond her parents, who live in a neighboring state.

Table 1

Antidepressant trials for treating methamphetamine dependence

Drug	Investigation	Comments
Bupropion2-4	Laboratory	Safety of bupropion with MAP
	Laboratory	Reduced subjective effects and cue-induced craving
	Clinical trial	Trend toward reduced MAP use compared with placebo
Sertraline7	Clinical trial	Sertraline-treated subjects showed higher use of MAP compared with those receiving placebo and were less likely to complete treatment
MAP: methamphetamine

3-step approach

For patients such as Ms. D, clinical evidence supports a 3-step approach to treating methamphetamine dependence:

• step 1: institute acute management and stabilization
  
• step 2: eliminate or decrease methamphetamine use to “move the frontal lobe back to the front”
  
• step 3: identify and target psychiatric and psychosocial comorbidities.
  

We discussed step 1 and the methamphetamine epidemic in the November 2006 Current Psychiatry.⁹ For Ms. D, step 1 means inpatient psychiatric care to protect her from suicidal intent and manage dysphoria and anxiety. In step 2, we aim to:

• help her eliminate or decrease methamphetamine use to allow neuronal systems to recover
  
• target maladaptive behaviors that hinder sobriety while providing motivational incentives to help her maintain a methamphetamine-free life.
  

Improved executive functioning, a frontal lobe task, becomes possible as the brain recovers from methamphetamine’s effects. Patients then are able to use healthier coping strategies to live drug-free. We call this step “moving the frontal lobe back to the front” because its goal is to restore the normal relationship between the frontal lobe and limbic system.

How ‘meth’ affects cognition

Methamphetamine use has been associated with cognitive dysfunction at initial abstinence and even years later in some patients.¹⁰ Ms. D’s cognitive limitations in a fast-paced customer service job—even though hours are limited—lead to anxiety, dysphoria, and loss of self-esteem when she can’t manage patrons’ requests.

 

Methamphetamine has profound acute and chronic effects on the sympathetic nervous system, and dopaminergic, serotonergic, and noradrenergic neuronal networks. Most evidence of chronic neuronal effects comes from animal research and reflects toxic damage to dopaminergic and serotonergic neuronal systems. Postmortem human studies of direct neurotoxicity from chronic methamphetamine exposure show:

• decreased dopamine and tyrosine hydroxylase levels
  
• reduced concentrations of dopamine transporters.¹¹
  

Methamphetamine selectively affects dopamine in the nigrostriatal system, causing substantial dopamine depletion in the ventral tegmental reward system but relatively sparing motor regions. This may explain the lack of parkinsonism with methamphetamine dependence.¹² In a study comparing serotonergic system damage caused by methamphetamine or 3,4-methylenedioxymethamphetamine (MDMA [“Ecstasy”]),¹³ methamphetamine had greater toxicity in the forebrain, including the septum, anterior cingulate, caudate nucleus, and nucleus accumbens.

In chronic methamphetamine abusers, functional magnetic resonance imaging, proton magnetic resonance spectroscopy, and positron emission tomography show:

• changes in neurotransmitter, protein, brain metabolism, and transporter levels
  
• damage in multiple brain areas including the frontal region, basal ganglia, grey matter, corpus callosum, and striatum; smaller hippocampi; and cerebral vasculature changes.^14-16
  

Imaging studies typically have enrolled abstinent users, which emphasizes methamphetamine’s long-lasting effects. For practical purposes, the extent of brain damage is fairly dependably associated with the length and intensity of methamphetamine abuse. Because these changes may last for years and can be permanent,¹⁷ how does this play out clinically?

CASE CONTINUED: Does she understand?

After Ms. D is stabilized, her case manager expresses concern about her ability to follow through with treatment planning. He says, “I just don’t think she understands some of the things we discuss.” She then is referred for neuropsychological testing, which shows clear cognitive impairment. Specifically, she has a slowed rate of thinking, general cognitive ineficiency, deficits in learning and memory retention, and mild impulsivity.

Patients with a history of extensive methamphetamine abuse are ruled by the limbic system and may have higher cortical damage that complicates initiating, maintaining, and fully participating in treatment. Patients’ deficits in memory, executive functioning, attention, and cognitive speed may require you to simplify, repeat, and otherwise modify your treatment plan. You will need to provide clear instructions and consistent support—individually and psychosocially—and to recognize and reinforce patients’ treatment gains.

Even before using methamphetamine, patients may have had academic problems or learning disabilities that will compromise their ability to participate in treatment. Infection with HIV, syphilis, or hepatitis C can further hamper cognitive function.¹⁸

Screen methamphetamine abusers—particularly those such as Ms. D with a history of high-risk behavior—for sexually transmitted diseases. Also provide care address to common medical complications of methamphetamine abuse, including cardiac damage, dental disease, and skin lesions. Centers for Disease Control and Prevention guidelines recommend vaccinating methamphetamine-abusing patients against hepatitis A and B viruses (see Related Resources).

What treatments are effective?

Medications. Evidence is extremely limited, and no medications are approved to treat methamphetamine-addicted patients. Bupropion has shown some efficacy (Table 1),^2-4,7 but other drugs such as sertraline and topiramate may aggravate rather than diminish methamphetamine dependence (Table 2).^5,6,8,19

Behavioral treatments supply the evidence basis for methamphetamine dependence treatment. Cognitive behavioral therapy (CBT),²⁰ contingency management (CM),^21,22 and a manualized structured treatment—the Matrix Model²³—all have proven efficacy.

CBT involves functional analysis and skills training. Patients are guided through analyzing their drug use and associated cognitions, emotions, and expectations and in identifying situations that trigger methamphetamine use or relapse. Skills training involves identifying, reinforcing, and practicing coping skills to help the patient avoid drug use and reinforce the ability to refuse use.

CM is based on operant conditioning—the use of consequences to modify behavior. It involves establishing a “contingent” relationship between a desired behavior/outcome (such as methamphetamine-free urinalysis) and delivering a positive reinforcing event to promote abstinence:

• Vouchers, privileges, or small amounts of money linked to healthy behaviors serve as incentives for negative urine testing.
  
• Rewards increase as periods of confirmed abstinence lengthen and are reset to smaller rewards if relapse occurs.
  

The precise reward structure that provides optimal treatment value is under study.²⁴

CM does not require extensive staff training and has been described as relatively simple to implement. CM also has been used successfully in urban gay and bisexual men with methamphetamine dependence (Box 2).^18,25-29

Although CM’s efficacy is well-supported by clinical trials, we have encountered some resistance to the idea of “paying individuals to not use drugs” when training medical students, allied health staff, and residents. The National Institute on Drug Abuse (NIDA) supports the use of motivational incentives in treating substance abuse and offers support materials, resources, and training on this approach (see Related Resources).

 

Multiple studies show that CBT and CM are equally effective for treating chronic methamphetamine abuse at a 1-year follow-up, although CM may be more effective than CBT for acute treatment.

The Matrix model is a 4-month intensive, manualized treatment program that uses CBT, education on drug effects, positive reinforcement for intended behavioral change, and a 12-step approach.

Methamphetamine dependence outcomes based on the Matrix treatment model were compared with community treatment as usual in a project sponsored by The Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.³⁰ End-point outcomes were similar, but the Matrix treatment was more effective in early treatment, including decreased urinalyses positive for methamphetamine and increased abstinence.

Box 2

Recommendations. Select a psychosocial treatment approach with your patient’s strengths, social setting, and community resources in mind. Twelve-step approaches may play an important role.

In patients such as Ms. D, the structure of court-ordered treatment can provide accountability, enforced abstinence, and mandated treatment resources. This, in turn, may give your patient a better chance to engage a recovering and better functioning frontal lobe to inhibit urges for methamphetamine use and manage stress.

Table 2

Other agents studied in methamphetamine dependence trials

Drug	Investigation	Comment
Baclofen6 (GABAergic)	Clinical trial	No statistically significant effect compared with placebo; post hoc analysis showed ‘small’ treatment effects vs placebo
Gabapentin6 (GABAergic)	Clinical trial	No statistically signicant effect compared with placebo; post hoc analysis showed no treatment effects vs placebo
Topiramate8 (anticonvulsant)	Laboratory	Accentuated (rather than diminished) subjective effects of MAP
Aripiprazole19 (SGA)	Laboratory	Decreased subjective effects of amphetamine
Modafinil5 (wakefulness agent)	Clinical trial	Successful trial in cocaine dependence; potential option for MAP
MAP: methamphetamine; SGA: second-generation antipsychotic

CASE CONTINUED: Racing thoughts and psychosis

Before hospital admission, Ms. D was being treated with gabapentin, 300 mg bid, and sustained-release bupropion, 150 mg/d, for anxiety and dysphoria. Previously, she has received multiple antidepressants and mood stabilizers with reportedly little effect.

She describes racing thoughts and profound anxiety, but her presentation is remarkable for latency in response, apathy, and amotivation. She intermittently refuses to take medication, and collateral history shows adherence problems with medication and psychosocial treatment in her group home. She refuses to take bupropion, saying it makes her symptoms worse, but agrees to take quetiapine to address her complaints of anxiety and “being manic.”

Initially guarded, she at first denies psychotic symptoms but acknowledges their extent several days later. She describes periods of 6 months or more when she feels “lost.” The treatment team titrates quetiapine up to 200 mg/d and restarts duloxetine, 30 mg/d, for depressive symptoms, based on her past positive response to this antidepressant.

Box 3

 

Targeting psychiatric symptoms

Step 3 in the chronic disease management approach to methamphetamine dependence is to identify and target psychiatric and psychosocial comorbidities. When approaching psychiatric symptoms, high priorities are to aim for abstinence and manage the patient’s stress (Box 3).^31-33

Psychotic symptoms may present acutely, continue as residual symptoms, or reappear at stressful times long after an individual no longer abuses methamphetamine. Acute psychotic symptom intensity appears to be methamphetamine dose-related.³⁴

In clinical practice, we find it difficult to diagnostically categorize and treat methamphetamine-abusing patients who show residual post-acute psychotic symptoms. Some appear to have no risk factors for primary psychotic illness, and their symptoms show an association with the severity of their past methamphetamine abuse.

Other patient presentations can be difficult to separate from family histories of psychotic illness. Research suggests that genetic risk factors may be associated with methamphetamine psychosis in some vulnerable patients.³⁵

Unfortunately, no data exist to guide the use of antipsychotics to maintain symptom control. Some patients may need low-dose antipsychotics for maintenance treatment, and second-generation antipsychotics may have a theoretical advantage over first-generation antipsychotics. Use your clinical judgment in determining dosing and treatment duration, and in weighing risks and benefits of continued treatment.

Residual violent behavior. Violence, aggression, and poor impulse control are synonymous with methamphetamine abuse and have devastating individual, societal, and public health effects. Even abstinent methamphetamine abusers show long-standing elevated baseline aggression, compared with controls.

Using imaging, researchers found aggression severity to be directly correlated with past total methamphetamine use and globally decreased serotonin transporter density.³⁶ Serotonin transporter densities were 30% lower in methamphetamine users vs controls after >1 year of abstinence.

CASE CONTINUED: Discharge plans

Because of the severity of her psychiatric symptoms, Ms. D is unable to return to the halfway house after discharge. As her treatment team works to coordinate discharge placement, Ms. D continues to improve. Her psychotic and dysphoria symptoms resolve, and she shows increased spontaneity. These changes—attributed to supports during hospitalization, decreased stressors, and quetiapine treatment—continue until her discharge to a combined mental illness and chemical dependence program.

Ms. D’s report of “racing thoughts” is clarified; rather than mania, they represent recurrent thoughts and ruminations about past sexual abuse. Her psychotic symptoms resolve quickly with quetiapine, but she struggles with morning sedation. The team reduces the dosage, and she tolerates quetiapine, 25 mg hs, with trazodone, 100 mg hs, for sleep, anxiety, and psychotic symptoms. She is discharged on this regimen plus duloxetine, 60 mg/d, with plans to continue psychosocial treatment for methamphetamine dependence and posttraumatic stress.

Related resources

• Methamphetamine use and sexually transmitted diseases. Centers for Disease Control and Prevention. www.cdc.gov/std/DearColleagueRiskBehaviorMetUse8-18-2006.pdf.
  
• National Institute on Drug Abuse Blending Initiative. Promoting Awareness of Motivational Incentives (PAMI). www.drugabuse.gov/blending/PAMI.html.
  

Drug brand names

• Aripiprazole • Abilify
  
• Baclofen • various
  
• Bupropion • Wellbutrin
  
• Duloxetine • Cymbalta
  
• Gabapentin • Neurontin
  
• Modafinil • Provigil
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  
• Topiramate • Topamax
  
• Trazodone • Desyrel
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Clinicians could become discouraged when confronting methamphetamine-dependent patients’ wide-ranging psychiatric symptoms.

These patients often present with:

• overlapping primary psychiatric syndromes and secondary substance abuse
  
• complex histories fraught with psychological trauma, limited social supports, and court involvement.
  

Treatment can be successful, however, and patients can change their addictive behaviors with a chronic disease management approach that targets the drug’s cognitive sequelae and psychiatric effects. Medications show limited benefit (Box 1),^1-8 but behavioral treatments—including cognitive behavioral therapy (CBT) and motivational incentives—have proven efficacy in treating methamphetamine addiction.

This article discusses how to counteract methamphetamine’s negative cognitive effects and enable patients to engage in psychosocial treatment. Our discussion is informed by an extensive literature search and clinical experience from treating patients in the Midwest—at the geographic heart of the “meth” epidemic.

CASE REPORT: Overwhelmed and suicidal

Ms. D, age 27, presents to the emergency department with anxiety, dysphoria, and a plan to commit suicide by overdose. She feels overwhelmed by her 4-hour-a-day customer service job—a prerequisite for staying at the halfway house where she has lived for 2 months. She has a 13-year history of polysubstance dependence and is under court order to complete chemical dependence treatment or go to jail.

Box 1

Methamphetamine has been Ms. D’s primary drug of abuse for 5 years, with some intervals of treatment and sobriety. She has not used methamphetamine in 3 months, after a severe relapse when she used methamphetamine daily for 6 months.

Ms. D began using drugs at age 14 and has 3 convictions for driving under the influence of alcohol. An average student, she dropped out of high school but obtained a GED certificate. She first had psychiatric contact at age 16 and has been diagnosed at various times with attention deficit/hyperactivity disorder, bipolar disorder, and anxiety disorder. She also has been violently sexually assaulted while engaging in prostitution to support her drug habit.

Ms. D has been hospitalized multiple times—voluntarily and involuntarily—in dual diagnosis treatment centers. Her 5-year-old son no longer lives with her, and she has limited social supports beyond her parents, who live in a neighboring state.

Table 1

Antidepressant trials for treating methamphetamine dependence

Drug	Investigation	Comments
Bupropion2-4	Laboratory	Safety of bupropion with MAP
	Laboratory	Reduced subjective effects and cue-induced craving
	Clinical trial	Trend toward reduced MAP use compared with placebo
Sertraline7	Clinical trial	Sertraline-treated subjects showed higher use of MAP compared with those receiving placebo and were less likely to complete treatment
MAP: methamphetamine

3-step approach

For patients such as Ms. D, clinical evidence supports a 3-step approach to treating methamphetamine dependence:

• step 1: institute acute management and stabilization
  
• step 2: eliminate or decrease methamphetamine use to “move the frontal lobe back to the front”
  
• step 3: identify and target psychiatric and psychosocial comorbidities.
  

We discussed step 1 and the methamphetamine epidemic in the November 2006 Current Psychiatry.⁹ For Ms. D, step 1 means inpatient psychiatric care to protect her from suicidal intent and manage dysphoria and anxiety. In step 2, we aim to:

• help her eliminate or decrease methamphetamine use to allow neuronal systems to recover
  
• target maladaptive behaviors that hinder sobriety while providing motivational incentives to help her maintain a methamphetamine-free life.
  

Improved executive functioning, a frontal lobe task, becomes possible as the brain recovers from methamphetamine’s effects. Patients then are able to use healthier coping strategies to live drug-free. We call this step “moving the frontal lobe back to the front” because its goal is to restore the normal relationship between the frontal lobe and limbic system.

How ‘meth’ affects cognition

Methamphetamine use has been associated with cognitive dysfunction at initial abstinence and even years later in some patients.¹⁰ Ms. D’s cognitive limitations in a fast-paced customer service job—even though hours are limited—lead to anxiety, dysphoria, and loss of self-esteem when she can’t manage patrons’ requests.

 

Methamphetamine has profound acute and chronic effects on the sympathetic nervous system, and dopaminergic, serotonergic, and noradrenergic neuronal networks. Most evidence of chronic neuronal effects comes from animal research and reflects toxic damage to dopaminergic and serotonergic neuronal systems. Postmortem human studies of direct neurotoxicity from chronic methamphetamine exposure show:

• decreased dopamine and tyrosine hydroxylase levels
  
• reduced concentrations of dopamine transporters.¹¹
  

Methamphetamine selectively affects dopamine in the nigrostriatal system, causing substantial dopamine depletion in the ventral tegmental reward system but relatively sparing motor regions. This may explain the lack of parkinsonism with methamphetamine dependence.¹² In a study comparing serotonergic system damage caused by methamphetamine or 3,4-methylenedioxymethamphetamine (MDMA [“Ecstasy”]),¹³ methamphetamine had greater toxicity in the forebrain, including the septum, anterior cingulate, caudate nucleus, and nucleus accumbens.

In chronic methamphetamine abusers, functional magnetic resonance imaging, proton magnetic resonance spectroscopy, and positron emission tomography show:

• changes in neurotransmitter, protein, brain metabolism, and transporter levels
  
• damage in multiple brain areas including the frontal region, basal ganglia, grey matter, corpus callosum, and striatum; smaller hippocampi; and cerebral vasculature changes.^14-16
  

Imaging studies typically have enrolled abstinent users, which emphasizes methamphetamine’s long-lasting effects. For practical purposes, the extent of brain damage is fairly dependably associated with the length and intensity of methamphetamine abuse. Because these changes may last for years and can be permanent,¹⁷ how does this play out clinically?

CASE CONTINUED: Does she understand?

After Ms. D is stabilized, her case manager expresses concern about her ability to follow through with treatment planning. He says, “I just don’t think she understands some of the things we discuss.” She then is referred for neuropsychological testing, which shows clear cognitive impairment. Specifically, she has a slowed rate of thinking, general cognitive ineficiency, deficits in learning and memory retention, and mild impulsivity.

Patients with a history of extensive methamphetamine abuse are ruled by the limbic system and may have higher cortical damage that complicates initiating, maintaining, and fully participating in treatment. Patients’ deficits in memory, executive functioning, attention, and cognitive speed may require you to simplify, repeat, and otherwise modify your treatment plan. You will need to provide clear instructions and consistent support—individually and psychosocially—and to recognize and reinforce patients’ treatment gains.

Even before using methamphetamine, patients may have had academic problems or learning disabilities that will compromise their ability to participate in treatment. Infection with HIV, syphilis, or hepatitis C can further hamper cognitive function.¹⁸

Screen methamphetamine abusers—particularly those such as Ms. D with a history of high-risk behavior—for sexually transmitted diseases. Also provide care address to common medical complications of methamphetamine abuse, including cardiac damage, dental disease, and skin lesions. Centers for Disease Control and Prevention guidelines recommend vaccinating methamphetamine-abusing patients against hepatitis A and B viruses (see Related Resources).

What treatments are effective?

Medications. Evidence is extremely limited, and no medications are approved to treat methamphetamine-addicted patients. Bupropion has shown some efficacy (Table 1),^2-4,7 but other drugs such as sertraline and topiramate may aggravate rather than diminish methamphetamine dependence (Table 2).^5,6,8,19

Behavioral treatments supply the evidence basis for methamphetamine dependence treatment. Cognitive behavioral therapy (CBT),²⁰ contingency management (CM),^21,22 and a manualized structured treatment—the Matrix Model²³—all have proven efficacy.

CBT involves functional analysis and skills training. Patients are guided through analyzing their drug use and associated cognitions, emotions, and expectations and in identifying situations that trigger methamphetamine use or relapse. Skills training involves identifying, reinforcing, and practicing coping skills to help the patient avoid drug use and reinforce the ability to refuse use.

CM is based on operant conditioning—the use of consequences to modify behavior. It involves establishing a “contingent” relationship between a desired behavior/outcome (such as methamphetamine-free urinalysis) and delivering a positive reinforcing event to promote abstinence:

• Vouchers, privileges, or small amounts of money linked to healthy behaviors serve as incentives for negative urine testing.
  
• Rewards increase as periods of confirmed abstinence lengthen and are reset to smaller rewards if relapse occurs.
  

The precise reward structure that provides optimal treatment value is under study.²⁴

CM does not require extensive staff training and has been described as relatively simple to implement. CM also has been used successfully in urban gay and bisexual men with methamphetamine dependence (Box 2).^18,25-29

Although CM’s efficacy is well-supported by clinical trials, we have encountered some resistance to the idea of “paying individuals to not use drugs” when training medical students, allied health staff, and residents. The National Institute on Drug Abuse (NIDA) supports the use of motivational incentives in treating substance abuse and offers support materials, resources, and training on this approach (see Related Resources).

 

Multiple studies show that CBT and CM are equally effective for treating chronic methamphetamine abuse at a 1-year follow-up, although CM may be more effective than CBT for acute treatment.

The Matrix model is a 4-month intensive, manualized treatment program that uses CBT, education on drug effects, positive reinforcement for intended behavioral change, and a 12-step approach.

Methamphetamine dependence outcomes based on the Matrix treatment model were compared with community treatment as usual in a project sponsored by The Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.³⁰ End-point outcomes were similar, but the Matrix treatment was more effective in early treatment, including decreased urinalyses positive for methamphetamine and increased abstinence.

Box 2

Recommendations. Select a psychosocial treatment approach with your patient’s strengths, social setting, and community resources in mind. Twelve-step approaches may play an important role.

In patients such as Ms. D, the structure of court-ordered treatment can provide accountability, enforced abstinence, and mandated treatment resources. This, in turn, may give your patient a better chance to engage a recovering and better functioning frontal lobe to inhibit urges for methamphetamine use and manage stress.

Table 2

Other agents studied in methamphetamine dependence trials

Drug	Investigation	Comment
Baclofen6 (GABAergic)	Clinical trial	No statistically significant effect compared with placebo; post hoc analysis showed ‘small’ treatment effects vs placebo
Gabapentin6 (GABAergic)	Clinical trial	No statistically signicant effect compared with placebo; post hoc analysis showed no treatment effects vs placebo
Topiramate8 (anticonvulsant)	Laboratory	Accentuated (rather than diminished) subjective effects of MAP
Aripiprazole19 (SGA)	Laboratory	Decreased subjective effects of amphetamine
Modafinil5 (wakefulness agent)	Clinical trial	Successful trial in cocaine dependence; potential option for MAP
MAP: methamphetamine; SGA: second-generation antipsychotic

CASE CONTINUED: Racing thoughts and psychosis

Before hospital admission, Ms. D was being treated with gabapentin, 300 mg bid, and sustained-release bupropion, 150 mg/d, for anxiety and dysphoria. Previously, she has received multiple antidepressants and mood stabilizers with reportedly little effect.

She describes racing thoughts and profound anxiety, but her presentation is remarkable for latency in response, apathy, and amotivation. She intermittently refuses to take medication, and collateral history shows adherence problems with medication and psychosocial treatment in her group home. She refuses to take bupropion, saying it makes her symptoms worse, but agrees to take quetiapine to address her complaints of anxiety and “being manic.”

Initially guarded, she at first denies psychotic symptoms but acknowledges their extent several days later. She describes periods of 6 months or more when she feels “lost.” The treatment team titrates quetiapine up to 200 mg/d and restarts duloxetine, 30 mg/d, for depressive symptoms, based on her past positive response to this antidepressant.

Box 3

 

Targeting psychiatric symptoms

Step 3 in the chronic disease management approach to methamphetamine dependence is to identify and target psychiatric and psychosocial comorbidities. When approaching psychiatric symptoms, high priorities are to aim for abstinence and manage the patient’s stress (Box 3).^31-33

Psychotic symptoms may present acutely, continue as residual symptoms, or reappear at stressful times long after an individual no longer abuses methamphetamine. Acute psychotic symptom intensity appears to be methamphetamine dose-related.³⁴

In clinical practice, we find it difficult to diagnostically categorize and treat methamphetamine-abusing patients who show residual post-acute psychotic symptoms. Some appear to have no risk factors for primary psychotic illness, and their symptoms show an association with the severity of their past methamphetamine abuse.

Other patient presentations can be difficult to separate from family histories of psychotic illness. Research suggests that genetic risk factors may be associated with methamphetamine psychosis in some vulnerable patients.³⁵

Unfortunately, no data exist to guide the use of antipsychotics to maintain symptom control. Some patients may need low-dose antipsychotics for maintenance treatment, and second-generation antipsychotics may have a theoretical advantage over first-generation antipsychotics. Use your clinical judgment in determining dosing and treatment duration, and in weighing risks and benefits of continued treatment.

Residual violent behavior. Violence, aggression, and poor impulse control are synonymous with methamphetamine abuse and have devastating individual, societal, and public health effects. Even abstinent methamphetamine abusers show long-standing elevated baseline aggression, compared with controls.

Using imaging, researchers found aggression severity to be directly correlated with past total methamphetamine use and globally decreased serotonin transporter density.³⁶ Serotonin transporter densities were 30% lower in methamphetamine users vs controls after >1 year of abstinence.

CASE CONTINUED: Discharge plans

Because of the severity of her psychiatric symptoms, Ms. D is unable to return to the halfway house after discharge. As her treatment team works to coordinate discharge placement, Ms. D continues to improve. Her psychotic and dysphoria symptoms resolve, and she shows increased spontaneity. These changes—attributed to supports during hospitalization, decreased stressors, and quetiapine treatment—continue until her discharge to a combined mental illness and chemical dependence program.

Ms. D’s report of “racing thoughts” is clarified; rather than mania, they represent recurrent thoughts and ruminations about past sexual abuse. Her psychotic symptoms resolve quickly with quetiapine, but she struggles with morning sedation. The team reduces the dosage, and she tolerates quetiapine, 25 mg hs, with trazodone, 100 mg hs, for sleep, anxiety, and psychotic symptoms. She is discharged on this regimen plus duloxetine, 60 mg/d, with plans to continue psychosocial treatment for methamphetamine dependence and posttraumatic stress.

Related resources

• Methamphetamine use and sexually transmitted diseases. Centers for Disease Control and Prevention. www.cdc.gov/std/DearColleagueRiskBehaviorMetUse8-18-2006.pdf.
  
• National Institute on Drug Abuse Blending Initiative. Promoting Awareness of Motivational Incentives (PAMI). www.drugabuse.gov/blending/PAMI.html.
  

Drug brand names

• Aripiprazole • Abilify
  
• Baclofen • various
  
• Bupropion • Wellbutrin
  
• Duloxetine • Cymbalta
  
• Gabapentin • Neurontin
  
• Modafinil • Provigil
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  
• Topiramate • Topamax
  
• Trazodone • Desyrel
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Methamphetamine abuse has spread to every region of the United States in the past 10 years (Table 1).¹ Its long-lasting, difficult-to-treat medical effects destroy lives and create psychiatric and physical comorbidities that confound clinicians in emergency rooms and community practice settings.

This first in a series of two articles describes methamphetamine’s growing use and offers guidance to identify abusers and manage acute “meth” intoxication. Methamphetamine-abusing patients can appear in any area of acute psychiatric practice—during emergency department (ED) evaluations, medical-surgical consultations, and inpatient psychiatric admissions. Using case examples, we describe key clinical principles to help you assess patients in each of these settings.

Table 1

10-year growth in hospitalization rates
for methamphetamine/amphetamine use*

	Year
State	1993	2003
U.S. national rate	13	56
Northeast
Connecticut	1	4
Maine	2	5
Massachusetts	<1	2
New Hampshire	<1	2
New Jersey	3	2
New York	2	4
Pennsylvania	3	2
Rhode Island	2	2
Vermont	5	4
South
Alabama	1	45
Arkansas	13	130
Delaware	2	2
District of Columbia	—	2
Florida	2	7
Georgia	3	39
Kentucky	—	20
Louisiana	4	21
Maryland	1	3
Mississippi	—	23
North Carolina	<1	4
Oklahoma	19	117
South Carolina	1	9
Tennessee	†	6
Texas	7	17
Virginia	1	4
West Virginia	<1	—
Midwest
Illinois	1	19
Indiana	3	28
Iowa	13	213
Kansas	15	65
Michigan	2	7
Minnesota	8	100
Missouri	7	84
Nebraska	8	117
North Dakota	3	44
Ohio	3	3
South Dakota	5	90
Wisconsin	<1	5
West
Alaska	4	13
Arizona	—	36
California	66	212
Colorado	18	86
Hawaii	52	241
Idaho	20	72
Montana	30	133
Nevada	59	176
New Mexico	7	10
Oregon	98	251
Utah	16	186
Washington	18	143
Wyoming	15	209
* Per 100,000 population aged 12 or older, with methamphetamine/amphetamine use as the primary diagnosis. Percentages in boldface exceed the national rate for that year.
† <0.05%
–No data available
Source: Reference 1

Scourge of the Heartland

A stimulant first synthesized in Japan,² methamphetamine is the primary drug of abuse in Asia³ and the leading drug threat in the United States, according to U.S. law enforcement officials.⁴ Although most methamphetamine used in the United States is manufactured in “super-labs” along the U.S.-Mexican border,⁴ the drug is also easily made from common ingredients in small-scale home laboratories.

These smaller domestic “meth labs” have devastated rural communities and altered demographic patterns of methamphetamine abuse (Figure 1).⁵ Two aspects of rural life—relative isolation and availability of ingredients for production—proved critical in the initial spread of methamphetamine production and use in the United States. As a result, production by smaller labs is being targeted by state and federal law enforcement officers, who have had some success in eradicating this scourge (Box 1, Figure 2).^6-9

Figure 1 Substance abuse treatment admission rates
for methamphetamine-related diagnoses

Substance abuse treatment centers in rural areas had the highest admission rates for methamphetamine/amphetamine-related diagnoses in 2004. Admission rates in nonmetropolitan regions containing cities with populations >10,000 were triple those of suburbs, nearly twice those of big cities, and twice the U.S. average.

Source: Reference 5

Figure 2 Methamphetamine clandestine laboratory incidents,* 2005

* Incidents include chemicals, contaminated glass, and equipment used in methamphetamine production found by law enforcement agencies at laboratories or dump sites.

Source: Drug Enforcement Administration database, reference 9Box 1

Symptoms of ‘Meth’ Use

Physiologic effects. Methamphetamine is taken because it induces euphoria, anorexia, and increased energy, sexual stimulation, and alertness. Initial use evolves into abuse because of the drug’s highly addictive properties. Available in multiple forms and carrying a variety of labels (see Related resources), methamphetamine causes CNS release of monoamines—particularly dopamine—and damages dopaminergic neurons in the striatum and serotonergic neurons in the frontal lobes, striatum, and hippocampus.^10,11

Through sympathetic nervous system activation, methamphetamine can cause reversible or irreversible damage to organ systems (Table 2).^12-17

Table 2

Physiologic signs of methamphetamine abuse

Vital signs	Tachycardia
	Hypertension
	Pyrexia
Laboratory abnormalities	Metabolic acidosis
	Evidence of rhabdomyolysis
Organ damage	Cardiomyopathy
	Acute coronary syndrome
	Pulmonary edema
Stigmata of chronic use	Premature aging
	Cachexia
	Discolored and fractured teeth
	Skin lesions from stereotypical scratching related to formication (“meth bugs”) and/or compulsive picking
Source: References 12-17

Psychiatric effects. Methamphetamine abusers frequently report depressive symptoms, including irritability, anxiety, social isolation, and suicidal ideation.^10,18 These patients may show:

 

• signs of psychosis, including paranoia, hallucinations, and homicidal thoughts
• neurocognitive changes, including poor attention, impaired verbal memory, and decreased executive functioning.¹⁹

Agitation is frequent, and its severity appears to correlate directly with methamphetamine blood levels.²⁰ Violent behavior is common. In 1,016 previous users, 40% of men and 46% of women described difficulty controlling their behavior when under methamphetamine’s influence.¹⁸

In acute clinical practice, differentiating a primary thought disorder from methamphetamine-induced psychosis is challenging—especially when a patient shows signs of both.²¹ Methamphetamine also can contribute profoundly to depressive and anxiety disorders. Users may experience residual psychotic symptoms years after the original abuse ends, particularly when stressed. Their positive and negative symptoms are strikingly similar to those seen in schizophrenia.²¹

Longitudinal illness course, recent history, collateral information, and laboratory and physical data may all inform clinical presentations and comorbidity.

Emergent Evaluation

Gathering data. Police bring Mr. J, age 22, to the ED after his parents said he talked about killing himself and the mother of his 4-year-old child. Police report that Mr. J’s parents said he and his friends abuse methamphetamine, but no first-hand information is available.

Disheveled and uncooperative, Mr. J threatens to harm ED staff. His speech is pressured, and he appears to be responding to internal stimuli. Vital signs include temperature 37.8° C, pulse rate 105 bpm, blood pressure 140/85 mm Hg, and respiration rate 18 breaths per minute.

Mr. J refuses to provide blood or urine for drug screening or to provide a history to the ED physician. He attempts to walk out and is placed in restraints after he tries to punch the ED security officer.

Options for containing uncooperative and agitated patients such as Mr. J are extremely limited, and the overriding concern with violently intoxicated patients is to minimize damage to self, others, and property. Methamphetamine abusers have a propensity for impulsivity and violence;¹⁸ many are brought to the hospital by police and have criminal histories.¹ In emergent evaluation, begin by searching patients and their belongings for weapons.

Because laboratory results and patient history are not immediately available, methamphetamine abuse often is not included in the initial differential diagnosis—particularly for patients with pre-existing primary affective or psychotic disorders. It is critical to remember that methamphetamine abuse might be complicating a patient’s psychiatric presentation.

Managing agitation. When agitation is prominent, secure the patient in a quiet room to reduce stimulation. Have on hand adequate staffing and benzodiazepines, antipsychotics, or both.

In theory, using an antipsychotic to control methamphetamine-induced agitation is problematic because synergy between the two agents might adversely affect cardiac function.¹⁵ On the other hand, acute treatment of agitation often leads to salutary declines in pulse rate, blood pressure, respiration rate, and body temperature.

Box 2

Evidence on treating methamphetamine-induced agitation is limited (Box 2).^22-26 Before you prescribe any medication, keep in mind its side effect profile, the patient’s age and physical condition, and the possibility that other substances might be contributing to emergent presentations.

We have repeatedly and effectively treated acutely agitated patients in the ED with haloperidol and lorazepam without observing adverse effects. Psychiatrists generally favor haloperidol and lorazepam over droperidol and midazolam. When a patient can cooperate with treatment, we recommend an ECG to rule out prolonged QTc interval, an uncommon complication. Telemetry and a cardiology consultation are indicated with a QTc interval >450 msec or >25% over previous ECGs, particularly if you plan to continue haloperidol treatment.²⁷

Physical examination. Because methamphetamine use can cause substantial physical morbidity, we recommend a thorough physical exam aimed at identifying its stigmata (Table 2). Look especially for injuries resulting from violence, and test for sexually-transmitted diseases. Drug testing in the ED is essential to diagnosis and for planning treatment (Box 3).^28,29

 

Medical-Surgical Consultation

Ensuring safety. Ms. A, age 41, is admitted to the trauma surgery service after a motor vehicle accident in which she was the driver. She has long-standing methamphetamine dependence and is severely agitated. Urine drug testing is positive for methamphetamine, marijuana, and alcohol. Her alcohol serum level of 165 mg/dL exceeds the legal threshold for intoxication.

Tibial and fibular fractures sustained in the car accident require open reduction and internal fixation. On the postsurgical floor 2 days later, Ms. A remains “extremely irritable, dysphoric, and suicidal,” according to the trauma surgery consultation. Staff is concerned about her boyfriend’s behavior: “We think he’s using drugs and might be bringing her drugs.”

Understanding Ms. A’s behavior requires us to consider a broad range of diagnostic contributors, including:

• untreated withdrawal from alcohol or other drugs
• delirium from ongoing effects of the trauma or corrective operation
• inadequate pain control, particularly given her history of substance dependence
• psychiatric comorbidity.

Management includes:

• monitoring for withdrawal and treating it if symptoms emerge
• identifying and minimizing medical factors contributing to confusion, and medicating agitation with psychotropics
• providing adequate analgesia, mindful that dosing may need to be aggressive—particularly if the abused substances include narcotics
• assessing for pre-existing and methamphetamine-induced psychiatric disorders.

If the patient is cognitively able to cooperate, perform a thorough suicide assessment and provide initial supportive and cognitive-behavioral therapy to target suicidal behavior. Consider one-to-one monitoring, depending on the potential for deliberate self-injury, and guard against impulsive actions occurring in a drug- or treatment-induced delirium that could endanger the patient or staff.

A one-to-one monitor also can watch for smuggled contraband. When hospitalized, patients who are chronic substance abusers are prone to continue using illicit substances smuggled in by associates, such as the boyfriend in this case. Consider further testing for illicit drugs if you suspect smuggling.

Acute Psychiatric Inpatient

Initial diagnosis and treatment planning. Miss G, age 23 and homeless, is admitted directly to the inpatient psychiatric unit from an urgent care clinic. She reports being “depressed and suicidal.” An intermittent methamphetamine abuser, she says she last used the drug the previous day.

Miss G reveals that she is on probation for forged checks and drug use. She believes she failed a random urinalysis given earlier in the day as a condition of her probation, and she fears being sent back to jail. Her history includes childhood sexual abuse and emotional abuse in a relationship that ended the previous year.

Box 3

Physical examination shows multiple erythematous excoriations on her arms from repetitive picking at her skin, poor dentition, and cachexia. She reports multiple recent sexual partners without using condoms. She cannot remember when she last menstruated, and she doesn’t recall ever being tested for sexually transmitted disease.

As in any medical setting involving methamphetamine abusers, acute management of psychiatric inpatients includes careful attention to methamphetamine-related physical conditions—in Miss G’s case possible sexually transmitted diseases, pregnancy, cellulitis, and dental disease.

Mood and anxiety disorders. Methamphetamine users may present with depressive symptoms and suicidality.^18,30 In a study of Taiwanese methamphetamine abusers who had recently quit the drug, depressive symptoms were common on cessation but often resolved without antidepressants within 2 to 3 weeks.³⁰ Evidence on antidepressant use in the methamphetamine-dependent patient is limited, and the existing studies have yielded conflicting results (as we will detail in part 2 of this article).

For patients previously diagnosed with mood or anxiety disorders, do not restart psychotropics until you have considered how methamphetamine use is contributing to the immediate presentation. We recommend initial observation for several weeks before starting an antidepressant if there is no pre-methamphetamine history of mood or anxiety symptoms.

 

Psychosocial treatments. Involve social services in assessing the patient’s need for community resources. Miss G’s ability to benefit from these programs will depend on her cognitive capacity, education level, trauma history, and comorbid psychiatric illness.

For patients who relapse to methamphetamine use, previous successful treatment and abstinence may be a hopeful prognostic sign and warrant referral to a program for recidivists. The patient’s legal status may limit some options in the community but open others in the criminal justice system.

Methamphetamine users often have multiple problems that require attention. For example, compared with other mothers under investigation by child welfare services in California, methamphetamine-abusing mothers were younger and less educated on average, less likely to have had substance-abuse treatment, and more likely to have criminal records.³¹ These findings underscore the challenge of coordinating a response that integrates separate and complex systems—psychiatric/substance abuse treatment, child welfare, and criminal justice.

Related resources

• Methresources. Web site pooling information from multiple agencies for communities, law enforcement, and policy makers. www.methresources.gov.
• Methamphetamine. National drug threat assessment, with information on methamphetamine production, trafficking, and patterns of use. U.S. Department of Justice. Drug Enforcement Administration. www.dea.gov/concern/18862/meth.htm.
• Substance Abuse and Mental Health Services Administration. Drug and Alcohol Services Information System. Trends in methamphetamine/amphetamine admissions to treatment: 1993-2003. The DASIS Report 2006; Issue 9. www.oas.samhsa.gov/2k6/methTX/methTX.pdf.

Drug brand names

• Droperidol • Inapsine
• Haloperidol • Haldol
• Lorazepam • Ativan
• Midazolam • Versed

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Methamphetamine abuse has spread to every region of the United States in the past 10 years (Table 1).¹ Its long-lasting, difficult-to-treat medical effects destroy lives and create psychiatric and physical comorbidities that confound clinicians in emergency rooms and community practice settings.

This first in a series of two articles describes methamphetamine’s growing use and offers guidance to identify abusers and manage acute “meth” intoxication. Methamphetamine-abusing patients can appear in any area of acute psychiatric practice—during emergency department (ED) evaluations, medical-surgical consultations, and inpatient psychiatric admissions. Using case examples, we describe key clinical principles to help you assess patients in each of these settings.

Table 1

10-year growth in hospitalization rates
for methamphetamine/amphetamine use*

	Year
State	1993	2003
U.S. national rate	13	56
Northeast
Connecticut	1	4
Maine	2	5
Massachusetts	<1	2
New Hampshire	<1	2
New Jersey	3	2
New York	2	4
Pennsylvania	3	2
Rhode Island	2	2
Vermont	5	4
South
Alabama	1	45
Arkansas	13	130
Delaware	2	2
District of Columbia	—	2
Florida	2	7
Georgia	3	39
Kentucky	—	20
Louisiana	4	21
Maryland	1	3
Mississippi	—	23
North Carolina	<1	4
Oklahoma	19	117
South Carolina	1	9
Tennessee	†	6
Texas	7	17
Virginia	1	4
West Virginia	<1	—
Midwest
Illinois	1	19
Indiana	3	28
Iowa	13	213
Kansas	15	65
Michigan	2	7
Minnesota	8	100
Missouri	7	84
Nebraska	8	117
North Dakota	3	44
Ohio	3	3
South Dakota	5	90
Wisconsin	<1	5
West
Alaska	4	13
Arizona	—	36
California	66	212
Colorado	18	86
Hawaii	52	241
Idaho	20	72
Montana	30	133
Nevada	59	176
New Mexico	7	10
Oregon	98	251
Utah	16	186
Washington	18	143
Wyoming	15	209
* Per 100,000 population aged 12 or older, with methamphetamine/amphetamine use as the primary diagnosis. Percentages in boldface exceed the national rate for that year.
† <0.05%
–No data available
Source: Reference 1

Scourge of the Heartland

A stimulant first synthesized in Japan,² methamphetamine is the primary drug of abuse in Asia³ and the leading drug threat in the United States, according to U.S. law enforcement officials.⁴ Although most methamphetamine used in the United States is manufactured in “super-labs” along the U.S.-Mexican border,⁴ the drug is also easily made from common ingredients in small-scale home laboratories.

These smaller domestic “meth labs” have devastated rural communities and altered demographic patterns of methamphetamine abuse (Figure 1).⁵ Two aspects of rural life—relative isolation and availability of ingredients for production—proved critical in the initial spread of methamphetamine production and use in the United States. As a result, production by smaller labs is being targeted by state and federal law enforcement officers, who have had some success in eradicating this scourge (Box 1, Figure 2).^6-9

Figure 1 Substance abuse treatment admission rates
for methamphetamine-related diagnoses

Substance abuse treatment centers in rural areas had the highest admission rates for methamphetamine/amphetamine-related diagnoses in 2004. Admission rates in nonmetropolitan regions containing cities with populations >10,000 were triple those of suburbs, nearly twice those of big cities, and twice the U.S. average.

Source: Reference 5

Figure 2 Methamphetamine clandestine laboratory incidents,* 2005

* Incidents include chemicals, contaminated glass, and equipment used in methamphetamine production found by law enforcement agencies at laboratories or dump sites.

Source: Drug Enforcement Administration database, reference 9Box 1

Symptoms of ‘Meth’ Use

Physiologic effects. Methamphetamine is taken because it induces euphoria, anorexia, and increased energy, sexual stimulation, and alertness. Initial use evolves into abuse because of the drug’s highly addictive properties. Available in multiple forms and carrying a variety of labels (see Related resources), methamphetamine causes CNS release of monoamines—particularly dopamine—and damages dopaminergic neurons in the striatum and serotonergic neurons in the frontal lobes, striatum, and hippocampus.^10,11

Through sympathetic nervous system activation, methamphetamine can cause reversible or irreversible damage to organ systems (Table 2).^12-17

Table 2

Physiologic signs of methamphetamine abuse

Vital signs	Tachycardia
	Hypertension
	Pyrexia
Laboratory abnormalities	Metabolic acidosis
	Evidence of rhabdomyolysis
Organ damage	Cardiomyopathy
	Acute coronary syndrome
	Pulmonary edema
Stigmata of chronic use	Premature aging
	Cachexia
	Discolored and fractured teeth
	Skin lesions from stereotypical scratching related to formication (“meth bugs”) and/or compulsive picking
Source: References 12-17

Psychiatric effects. Methamphetamine abusers frequently report depressive symptoms, including irritability, anxiety, social isolation, and suicidal ideation.^10,18 These patients may show:

 

• signs of psychosis, including paranoia, hallucinations, and homicidal thoughts
• neurocognitive changes, including poor attention, impaired verbal memory, and decreased executive functioning.¹⁹

Agitation is frequent, and its severity appears to correlate directly with methamphetamine blood levels.²⁰ Violent behavior is common. In 1,016 previous users, 40% of men and 46% of women described difficulty controlling their behavior when under methamphetamine’s influence.¹⁸

In acute clinical practice, differentiating a primary thought disorder from methamphetamine-induced psychosis is challenging—especially when a patient shows signs of both.²¹ Methamphetamine also can contribute profoundly to depressive and anxiety disorders. Users may experience residual psychotic symptoms years after the original abuse ends, particularly when stressed. Their positive and negative symptoms are strikingly similar to those seen in schizophrenia.²¹

Longitudinal illness course, recent history, collateral information, and laboratory and physical data may all inform clinical presentations and comorbidity.

Emergent Evaluation

Gathering data. Police bring Mr. J, age 22, to the ED after his parents said he talked about killing himself and the mother of his 4-year-old child. Police report that Mr. J’s parents said he and his friends abuse methamphetamine, but no first-hand information is available.

Disheveled and uncooperative, Mr. J threatens to harm ED staff. His speech is pressured, and he appears to be responding to internal stimuli. Vital signs include temperature 37.8° C, pulse rate 105 bpm, blood pressure 140/85 mm Hg, and respiration rate 18 breaths per minute.

Mr. J refuses to provide blood or urine for drug screening or to provide a history to the ED physician. He attempts to walk out and is placed in restraints after he tries to punch the ED security officer.

Options for containing uncooperative and agitated patients such as Mr. J are extremely limited, and the overriding concern with violently intoxicated patients is to minimize damage to self, others, and property. Methamphetamine abusers have a propensity for impulsivity and violence;¹⁸ many are brought to the hospital by police and have criminal histories.¹ In emergent evaluation, begin by searching patients and their belongings for weapons.

Because laboratory results and patient history are not immediately available, methamphetamine abuse often is not included in the initial differential diagnosis—particularly for patients with pre-existing primary affective or psychotic disorders. It is critical to remember that methamphetamine abuse might be complicating a patient’s psychiatric presentation.

Managing agitation. When agitation is prominent, secure the patient in a quiet room to reduce stimulation. Have on hand adequate staffing and benzodiazepines, antipsychotics, or both.

In theory, using an antipsychotic to control methamphetamine-induced agitation is problematic because synergy between the two agents might adversely affect cardiac function.¹⁵ On the other hand, acute treatment of agitation often leads to salutary declines in pulse rate, blood pressure, respiration rate, and body temperature.

Box 2

Evidence on treating methamphetamine-induced agitation is limited (Box 2).^22-26 Before you prescribe any medication, keep in mind its side effect profile, the patient’s age and physical condition, and the possibility that other substances might be contributing to emergent presentations.

We have repeatedly and effectively treated acutely agitated patients in the ED with haloperidol and lorazepam without observing adverse effects. Psychiatrists generally favor haloperidol and lorazepam over droperidol and midazolam. When a patient can cooperate with treatment, we recommend an ECG to rule out prolonged QTc interval, an uncommon complication. Telemetry and a cardiology consultation are indicated with a QTc interval >450 msec or >25% over previous ECGs, particularly if you plan to continue haloperidol treatment.²⁷

Physical examination. Because methamphetamine use can cause substantial physical morbidity, we recommend a thorough physical exam aimed at identifying its stigmata (Table 2). Look especially for injuries resulting from violence, and test for sexually-transmitted diseases. Drug testing in the ED is essential to diagnosis and for planning treatment (Box 3).^28,29

 

Medical-Surgical Consultation

Ensuring safety. Ms. A, age 41, is admitted to the trauma surgery service after a motor vehicle accident in which she was the driver. She has long-standing methamphetamine dependence and is severely agitated. Urine drug testing is positive for methamphetamine, marijuana, and alcohol. Her alcohol serum level of 165 mg/dL exceeds the legal threshold for intoxication.

Tibial and fibular fractures sustained in the car accident require open reduction and internal fixation. On the postsurgical floor 2 days later, Ms. A remains “extremely irritable, dysphoric, and suicidal,” according to the trauma surgery consultation. Staff is concerned about her boyfriend’s behavior: “We think he’s using drugs and might be bringing her drugs.”

Understanding Ms. A’s behavior requires us to consider a broad range of diagnostic contributors, including:

• untreated withdrawal from alcohol or other drugs
• delirium from ongoing effects of the trauma or corrective operation
• inadequate pain control, particularly given her history of substance dependence
• psychiatric comorbidity.

Management includes:

• monitoring for withdrawal and treating it if symptoms emerge
• identifying and minimizing medical factors contributing to confusion, and medicating agitation with psychotropics
• providing adequate analgesia, mindful that dosing may need to be aggressive—particularly if the abused substances include narcotics
• assessing for pre-existing and methamphetamine-induced psychiatric disorders.

If the patient is cognitively able to cooperate, perform a thorough suicide assessment and provide initial supportive and cognitive-behavioral therapy to target suicidal behavior. Consider one-to-one monitoring, depending on the potential for deliberate self-injury, and guard against impulsive actions occurring in a drug- or treatment-induced delirium that could endanger the patient or staff.

A one-to-one monitor also can watch for smuggled contraband. When hospitalized, patients who are chronic substance abusers are prone to continue using illicit substances smuggled in by associates, such as the boyfriend in this case. Consider further testing for illicit drugs if you suspect smuggling.

Acute Psychiatric Inpatient

Initial diagnosis and treatment planning. Miss G, age 23 and homeless, is admitted directly to the inpatient psychiatric unit from an urgent care clinic. She reports being “depressed and suicidal.” An intermittent methamphetamine abuser, she says she last used the drug the previous day.

Miss G reveals that she is on probation for forged checks and drug use. She believes she failed a random urinalysis given earlier in the day as a condition of her probation, and she fears being sent back to jail. Her history includes childhood sexual abuse and emotional abuse in a relationship that ended the previous year.

Box 3

Physical examination shows multiple erythematous excoriations on her arms from repetitive picking at her skin, poor dentition, and cachexia. She reports multiple recent sexual partners without using condoms. She cannot remember when she last menstruated, and she doesn’t recall ever being tested for sexually transmitted disease.

As in any medical setting involving methamphetamine abusers, acute management of psychiatric inpatients includes careful attention to methamphetamine-related physical conditions—in Miss G’s case possible sexually transmitted diseases, pregnancy, cellulitis, and dental disease.

Mood and anxiety disorders. Methamphetamine users may present with depressive symptoms and suicidality.^18,30 In a study of Taiwanese methamphetamine abusers who had recently quit the drug, depressive symptoms were common on cessation but often resolved without antidepressants within 2 to 3 weeks.³⁰ Evidence on antidepressant use in the methamphetamine-dependent patient is limited, and the existing studies have yielded conflicting results (as we will detail in part 2 of this article).

For patients previously diagnosed with mood or anxiety disorders, do not restart psychotropics until you have considered how methamphetamine use is contributing to the immediate presentation. We recommend initial observation for several weeks before starting an antidepressant if there is no pre-methamphetamine history of mood or anxiety symptoms.

 

Psychosocial treatments. Involve social services in assessing the patient’s need for community resources. Miss G’s ability to benefit from these programs will depend on her cognitive capacity, education level, trauma history, and comorbid psychiatric illness.

For patients who relapse to methamphetamine use, previous successful treatment and abstinence may be a hopeful prognostic sign and warrant referral to a program for recidivists. The patient’s legal status may limit some options in the community but open others in the criminal justice system.

Methamphetamine users often have multiple problems that require attention. For example, compared with other mothers under investigation by child welfare services in California, methamphetamine-abusing mothers were younger and less educated on average, less likely to have had substance-abuse treatment, and more likely to have criminal records.³¹ These findings underscore the challenge of coordinating a response that integrates separate and complex systems—psychiatric/substance abuse treatment, child welfare, and criminal justice.

Related resources

• Methresources. Web site pooling information from multiple agencies for communities, law enforcement, and policy makers. www.methresources.gov.
• Methamphetamine. National drug threat assessment, with information on methamphetamine production, trafficking, and patterns of use. U.S. Department of Justice. Drug Enforcement Administration. www.dea.gov/concern/18862/meth.htm.
• Substance Abuse and Mental Health Services Administration. Drug and Alcohol Services Information System. Trends in methamphetamine/amphetamine admissions to treatment: 1993-2003. The DASIS Report 2006; Issue 9. www.oas.samhsa.gov/2k6/methTX/methTX.pdf.

Drug brand names

• Droperidol • Inapsine
• Haloperidol • Haldol
• Lorazepam • Ativan
• Midazolam • Versed

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Methamphetamine abuse has spread to every region of the United States in the past 10 years (Table 1).¹ Its long-lasting, difficult-to-treat medical effects destroy lives and create psychiatric and physical comorbidities that confound clinicians in emergency rooms and community practice settings.

This first in a series of two articles describes methamphetamine’s growing use and offers guidance to identify abusers and manage acute “meth” intoxication. Methamphetamine-abusing patients can appear in any area of acute psychiatric practice—during emergency department (ED) evaluations, medical-surgical consultations, and inpatient psychiatric admissions. Using case examples, we describe key clinical principles to help you assess patients in each of these settings.

Table 1

10-year growth in hospitalization rates
for methamphetamine/amphetamine use*

	Year
State	1993	2003
U.S. national rate	13	56
Northeast
Connecticut	1	4
Maine	2	5
Massachusetts	<1	2
New Hampshire	<1	2
New Jersey	3	2
New York	2	4
Pennsylvania	3	2
Rhode Island	2	2
Vermont	5	4
South
Alabama	1	45
Arkansas	13	130
Delaware	2	2
District of Columbia	—	2
Florida	2	7
Georgia	3	39
Kentucky	—	20
Louisiana	4	21
Maryland	1	3
Mississippi	—	23
North Carolina	<1	4
Oklahoma	19	117
South Carolina	1	9
Tennessee	†	6
Texas	7	17
Virginia	1	4
West Virginia	<1	—
Midwest
Illinois	1	19
Indiana	3	28
Iowa	13	213
Kansas	15	65
Michigan	2	7
Minnesota	8	100
Missouri	7	84
Nebraska	8	117
North Dakota	3	44
Ohio	3	3
South Dakota	5	90
Wisconsin	<1	5
West
Alaska	4	13
Arizona	—	36
California	66	212
Colorado	18	86
Hawaii	52	241
Idaho	20	72
Montana	30	133
Nevada	59	176
New Mexico	7	10
Oregon	98	251
Utah	16	186
Washington	18	143
Wyoming	15	209
* Per 100,000 population aged 12 or older, with methamphetamine/amphetamine use as the primary diagnosis. Percentages in boldface exceed the national rate for that year.
† <0.05%
–No data available
Source: Reference 1

Scourge of the Heartland

A stimulant first synthesized in Japan,² methamphetamine is the primary drug of abuse in Asia³ and the leading drug threat in the United States, according to U.S. law enforcement officials.⁴ Although most methamphetamine used in the United States is manufactured in “super-labs” along the U.S.-Mexican border,⁴ the drug is also easily made from common ingredients in small-scale home laboratories.

These smaller domestic “meth labs” have devastated rural communities and altered demographic patterns of methamphetamine abuse (Figure 1).⁵ Two aspects of rural life—relative isolation and availability of ingredients for production—proved critical in the initial spread of methamphetamine production and use in the United States. As a result, production by smaller labs is being targeted by state and federal law enforcement officers, who have had some success in eradicating this scourge (Box 1, Figure 2).^6-9

Figure 1 Substance abuse treatment admission rates
for methamphetamine-related diagnoses

Substance abuse treatment centers in rural areas had the highest admission rates for methamphetamine/amphetamine-related diagnoses in 2004. Admission rates in nonmetropolitan regions containing cities with populations >10,000 were triple those of suburbs, nearly twice those of big cities, and twice the U.S. average.

Source: Reference 5

Figure 2 Methamphetamine clandestine laboratory incidents,* 2005

* Incidents include chemicals, contaminated glass, and equipment used in methamphetamine production found by law enforcement agencies at laboratories or dump sites.

Source: Drug Enforcement Administration database, reference 9Box 1

Symptoms of ‘Meth’ Use

Physiologic effects. Methamphetamine is taken because it induces euphoria, anorexia, and increased energy, sexual stimulation, and alertness. Initial use evolves into abuse because of the drug’s highly addictive properties. Available in multiple forms and carrying a variety of labels (see Related resources), methamphetamine causes CNS release of monoamines—particularly dopamine—and damages dopaminergic neurons in the striatum and serotonergic neurons in the frontal lobes, striatum, and hippocampus.^10,11

Through sympathetic nervous system activation, methamphetamine can cause reversible or irreversible damage to organ systems (Table 2).^12-17

Table 2

Physiologic signs of methamphetamine abuse

Vital signs	Tachycardia
	Hypertension
	Pyrexia
Laboratory abnormalities	Metabolic acidosis
	Evidence of rhabdomyolysis
Organ damage	Cardiomyopathy
	Acute coronary syndrome
	Pulmonary edema
Stigmata of chronic use	Premature aging
	Cachexia
	Discolored and fractured teeth
	Skin lesions from stereotypical scratching related to formication (“meth bugs”) and/or compulsive picking
Source: References 12-17

Psychiatric effects. Methamphetamine abusers frequently report depressive symptoms, including irritability, anxiety, social isolation, and suicidal ideation.^10,18 These patients may show:

 

• signs of psychosis, including paranoia, hallucinations, and homicidal thoughts
• neurocognitive changes, including poor attention, impaired verbal memory, and decreased executive functioning.¹⁹

Agitation is frequent, and its severity appears to correlate directly with methamphetamine blood levels.²⁰ Violent behavior is common. In 1,016 previous users, 40% of men and 46% of women described difficulty controlling their behavior when under methamphetamine’s influence.¹⁸

In acute clinical practice, differentiating a primary thought disorder from methamphetamine-induced psychosis is challenging—especially when a patient shows signs of both.²¹ Methamphetamine also can contribute profoundly to depressive and anxiety disorders. Users may experience residual psychotic symptoms years after the original abuse ends, particularly when stressed. Their positive and negative symptoms are strikingly similar to those seen in schizophrenia.²¹

Longitudinal illness course, recent history, collateral information, and laboratory and physical data may all inform clinical presentations and comorbidity.

Emergent Evaluation

Gathering data. Police bring Mr. J, age 22, to the ED after his parents said he talked about killing himself and the mother of his 4-year-old child. Police report that Mr. J’s parents said he and his friends abuse methamphetamine, but no first-hand information is available.

Disheveled and uncooperative, Mr. J threatens to harm ED staff. His speech is pressured, and he appears to be responding to internal stimuli. Vital signs include temperature 37.8° C, pulse rate 105 bpm, blood pressure 140/85 mm Hg, and respiration rate 18 breaths per minute.

Mr. J refuses to provide blood or urine for drug screening or to provide a history to the ED physician. He attempts to walk out and is placed in restraints after he tries to punch the ED security officer.

Options for containing uncooperative and agitated patients such as Mr. J are extremely limited, and the overriding concern with violently intoxicated patients is to minimize damage to self, others, and property. Methamphetamine abusers have a propensity for impulsivity and violence;¹⁸ many are brought to the hospital by police and have criminal histories.¹ In emergent evaluation, begin by searching patients and their belongings for weapons.

Because laboratory results and patient history are not immediately available, methamphetamine abuse often is not included in the initial differential diagnosis—particularly for patients with pre-existing primary affective or psychotic disorders. It is critical to remember that methamphetamine abuse might be complicating a patient’s psychiatric presentation.

Managing agitation. When agitation is prominent, secure the patient in a quiet room to reduce stimulation. Have on hand adequate staffing and benzodiazepines, antipsychotics, or both.

In theory, using an antipsychotic to control methamphetamine-induced agitation is problematic because synergy between the two agents might adversely affect cardiac function.¹⁵ On the other hand, acute treatment of agitation often leads to salutary declines in pulse rate, blood pressure, respiration rate, and body temperature.

Box 2

Evidence on treating methamphetamine-induced agitation is limited (Box 2).^22-26 Before you prescribe any medication, keep in mind its side effect profile, the patient’s age and physical condition, and the possibility that other substances might be contributing to emergent presentations.

We have repeatedly and effectively treated acutely agitated patients in the ED with haloperidol and lorazepam without observing adverse effects. Psychiatrists generally favor haloperidol and lorazepam over droperidol and midazolam. When a patient can cooperate with treatment, we recommend an ECG to rule out prolonged QTc interval, an uncommon complication. Telemetry and a cardiology consultation are indicated with a QTc interval >450 msec or >25% over previous ECGs, particularly if you plan to continue haloperidol treatment.²⁷

Physical examination. Because methamphetamine use can cause substantial physical morbidity, we recommend a thorough physical exam aimed at identifying its stigmata (Table 2). Look especially for injuries resulting from violence, and test for sexually-transmitted diseases. Drug testing in the ED is essential to diagnosis and for planning treatment (Box 3).^28,29

 

Medical-Surgical Consultation

Ensuring safety. Ms. A, age 41, is admitted to the trauma surgery service after a motor vehicle accident in which she was the driver. She has long-standing methamphetamine dependence and is severely agitated. Urine drug testing is positive for methamphetamine, marijuana, and alcohol. Her alcohol serum level of 165 mg/dL exceeds the legal threshold for intoxication.

Tibial and fibular fractures sustained in the car accident require open reduction and internal fixation. On the postsurgical floor 2 days later, Ms. A remains “extremely irritable, dysphoric, and suicidal,” according to the trauma surgery consultation. Staff is concerned about her boyfriend’s behavior: “We think he’s using drugs and might be bringing her drugs.”

Understanding Ms. A’s behavior requires us to consider a broad range of diagnostic contributors, including:

• untreated withdrawal from alcohol or other drugs
• delirium from ongoing effects of the trauma or corrective operation
• inadequate pain control, particularly given her history of substance dependence
• psychiatric comorbidity.

Management includes:

• monitoring for withdrawal and treating it if symptoms emerge
• identifying and minimizing medical factors contributing to confusion, and medicating agitation with psychotropics
• providing adequate analgesia, mindful that dosing may need to be aggressive—particularly if the abused substances include narcotics
• assessing for pre-existing and methamphetamine-induced psychiatric disorders.

If the patient is cognitively able to cooperate, perform a thorough suicide assessment and provide initial supportive and cognitive-behavioral therapy to target suicidal behavior. Consider one-to-one monitoring, depending on the potential for deliberate self-injury, and guard against impulsive actions occurring in a drug- or treatment-induced delirium that could endanger the patient or staff.

A one-to-one monitor also can watch for smuggled contraband. When hospitalized, patients who are chronic substance abusers are prone to continue using illicit substances smuggled in by associates, such as the boyfriend in this case. Consider further testing for illicit drugs if you suspect smuggling.

Acute Psychiatric Inpatient

Initial diagnosis and treatment planning. Miss G, age 23 and homeless, is admitted directly to the inpatient psychiatric unit from an urgent care clinic. She reports being “depressed and suicidal.” An intermittent methamphetamine abuser, she says she last used the drug the previous day.

Miss G reveals that she is on probation for forged checks and drug use. She believes she failed a random urinalysis given earlier in the day as a condition of her probation, and she fears being sent back to jail. Her history includes childhood sexual abuse and emotional abuse in a relationship that ended the previous year.

Box 3

Physical examination shows multiple erythematous excoriations on her arms from repetitive picking at her skin, poor dentition, and cachexia. She reports multiple recent sexual partners without using condoms. She cannot remember when she last menstruated, and she doesn’t recall ever being tested for sexually transmitted disease.

As in any medical setting involving methamphetamine abusers, acute management of psychiatric inpatients includes careful attention to methamphetamine-related physical conditions—in Miss G’s case possible sexually transmitted diseases, pregnancy, cellulitis, and dental disease.

Mood and anxiety disorders. Methamphetamine users may present with depressive symptoms and suicidality.^18,30 In a study of Taiwanese methamphetamine abusers who had recently quit the drug, depressive symptoms were common on cessation but often resolved without antidepressants within 2 to 3 weeks.³⁰ Evidence on antidepressant use in the methamphetamine-dependent patient is limited, and the existing studies have yielded conflicting results (as we will detail in part 2 of this article).

For patients previously diagnosed with mood or anxiety disorders, do not restart psychotropics until you have considered how methamphetamine use is contributing to the immediate presentation. We recommend initial observation for several weeks before starting an antidepressant if there is no pre-methamphetamine history of mood or anxiety symptoms.

 

Psychosocial treatments. Involve social services in assessing the patient’s need for community resources. Miss G’s ability to benefit from these programs will depend on her cognitive capacity, education level, trauma history, and comorbid psychiatric illness.

For patients who relapse to methamphetamine use, previous successful treatment and abstinence may be a hopeful prognostic sign and warrant referral to a program for recidivists. The patient’s legal status may limit some options in the community but open others in the criminal justice system.

Methamphetamine users often have multiple problems that require attention. For example, compared with other mothers under investigation by child welfare services in California, methamphetamine-abusing mothers were younger and less educated on average, less likely to have had substance-abuse treatment, and more likely to have criminal records.³¹ These findings underscore the challenge of coordinating a response that integrates separate and complex systems—psychiatric/substance abuse treatment, child welfare, and criminal justice.

Related resources

• Methresources. Web site pooling information from multiple agencies for communities, law enforcement, and policy makers. www.methresources.gov.
• Methamphetamine. National drug threat assessment, with information on methamphetamine production, trafficking, and patterns of use. U.S. Department of Justice. Drug Enforcement Administration. www.dea.gov/concern/18862/meth.htm.
• Substance Abuse and Mental Health Services Administration. Drug and Alcohol Services Information System. Trends in methamphetamine/amphetamine admissions to treatment: 1993-2003. The DASIS Report 2006; Issue 9. www.oas.samhsa.gov/2k6/methTX/methTX.pdf.

Drug brand names

• Droperidol • Inapsine
• Haloperidol • Haldol
• Lorazepam • Ativan
• Midazolam • Versed

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Sexual trauma may cause or exacerbate posttraumatic stress disorder (PTSD).^{See "Traumatized Troops: How to treat combat-related PTSD"). Two recommended questions (Box) for men and women can help you start discussing MST.}

Use compassion and sensitivity, recognizing the stigma of sexual assault while fastidiously preserving confidentiality. Establish a comfortable environment for disclosure, be nonjudgmental, and maintain good eye contact as you gradually introduce the questions.

Box

Recommended treatment

Comprehensive MST management includes assessing for PTSD, major depression, and substance abuse. When a veteran screens positive for MST, validation and empathy are first-line treatment. Provide MST education, assess health status, and ask them about their support systems.

Sexual trauma survivors often suffer low selfesteem, self-blame, anger, difficulties with interpersonal relationships, and sexual dysfunction. “PTSD flare-ups” can occur during medical encounters and clinical procedures. Evaluate MST survivors regularly for re-victimization, as they may be at risk to be sexually abused again outside the military.⁵

Referral. Consider referring veterans to a local VA facility, which all have a “military sexual trauma coordinator” to help veterans obtain treatment. Other VA resources include referrals to the women veterans program manager or mental health clinic.

Veterans living in the community can be referred to readjustment counseling service offices, which have sexual trauma counselors on staff. This may be an option for the veteran who does not want to obtain mental health services from the VA.

Related resources

• Street A, Stafford J. Military sexual trauma: Issues in caring for veterans. National Center for Posttraumatic Stress Disorder. http://www.ncptsd.org//war/military_sexual_trauma.html.
  

Sexual trauma may cause or exacerbate posttraumatic stress disorder (PTSD).^{See "Traumatized Troops: How to treat combat-related PTSD"). Two recommended questions (Box) for men and women can help you start discussing MST.}

Use compassion and sensitivity, recognizing the stigma of sexual assault while fastidiously preserving confidentiality. Establish a comfortable environment for disclosure, be nonjudgmental, and maintain good eye contact as you gradually introduce the questions.

Box

Recommended treatment

Comprehensive MST management includes assessing for PTSD, major depression, and substance abuse. When a veteran screens positive for MST, validation and empathy are first-line treatment. Provide MST education, assess health status, and ask them about their support systems.

Sexual trauma survivors often suffer low selfesteem, self-blame, anger, difficulties with interpersonal relationships, and sexual dysfunction. “PTSD flare-ups” can occur during medical encounters and clinical procedures. Evaluate MST survivors regularly for re-victimization, as they may be at risk to be sexually abused again outside the military.⁵

Referral. Consider referring veterans to a local VA facility, which all have a “military sexual trauma coordinator” to help veterans obtain treatment. Other VA resources include referrals to the women veterans program manager or mental health clinic.

Veterans living in the community can be referred to readjustment counseling service offices, which have sexual trauma counselors on staff. This may be an option for the veteran who does not want to obtain mental health services from the VA.

Related resources

• Street A, Stafford J. Military sexual trauma: Issues in caring for veterans. National Center for Posttraumatic Stress Disorder. http://www.ncptsd.org//war/military_sexual_trauma.html.
  

Sexual trauma may cause or exacerbate posttraumatic stress disorder (PTSD).^{See "Traumatized Troops: How to treat combat-related PTSD"). Two recommended questions (Box) for men and women can help you start discussing MST.}

Use compassion and sensitivity, recognizing the stigma of sexual assault while fastidiously preserving confidentiality. Establish a comfortable environment for disclosure, be nonjudgmental, and maintain good eye contact as you gradually introduce the questions.

Box

Recommended treatment

Comprehensive MST management includes assessing for PTSD, major depression, and substance abuse. When a veteran screens positive for MST, validation and empathy are first-line treatment. Provide MST education, assess health status, and ask them about their support systems.

Sexual trauma survivors often suffer low selfesteem, self-blame, anger, difficulties with interpersonal relationships, and sexual dysfunction. “PTSD flare-ups” can occur during medical encounters and clinical procedures. Evaluate MST survivors regularly for re-victimization, as they may be at risk to be sexually abused again outside the military.⁵

Referral. Consider referring veterans to a local VA facility, which all have a “military sexual trauma coordinator” to help veterans obtain treatment. Other VA resources include referrals to the women veterans program manager or mental health clinic.

Veterans living in the community can be referred to readjustment counseling service offices, which have sexual trauma counselors on staff. This may be an option for the veteran who does not want to obtain mental health services from the VA.

Related resources

• Street A, Stafford J. Military sexual trauma: Issues in caring for veterans. National Center for Posttraumatic Stress Disorder. http://www.ncptsd.org//war/military_sexual_trauma.html.
  

National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.^1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.⁴ An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).⁵

Table 1

Mental health problems reported by troops returning from combat in Iraq*

Problem	Number among 193,000 U.S. soldiers
Nightmares or unwanted war recollections	20,000
Might “hurt or lose control” with someone else	3,700
Suicidal thoughts/feeling better off dead	1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.

Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.⁶ This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al⁷ found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrier	Met screening criteria for a mental disorder?
	Yes (N=731)	No (N=5,422)
I would be seen as weak	65%	31%
My unit leadership might treat me differently	63%	33%
Members of my unit might have less confidence in me	59%	31%
I would have difficulty getting time off work for treatment	55%	22%
My leaders would blame me for the problem	51%	20%
It would harm my career	50%	24%
It is difficult to schedule an appointment	45%	17%
It would be too embarrassing	41%	18%
I don’t trust mental health professionals	38%	17%
Mental health care costs too much money	25%	10%
Mental health care doesn’t work	25%	9%
I don’t know where to get help	22%	6%
I don’t have adequate transportation	18%	6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).⁸ Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.

 

PTSD in combat veterans

Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).^9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.⁹

Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.⁷ These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.¹⁰

If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).

Box

Resiliency and PTSD. Resiliency among service members in combat is the norm, and most will not develop PTSD. Military efforts at increasing resilience and performance include intense training with realistic combat simulation and education. A selected sample of experienced elite soldiers has been shown to have lower cortisol levels in response to simulated combat stress than younger soldiers with less training.¹¹

To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.¹¹

Mr. L’s story: Detached and irritable

As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.

Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.

Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.⁷ Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.

Table 3

Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan

Experience	Army groups		Marine group
	Afghanistan	Iraq
Being attacked or ambushed	58%	89%	95%
Receiving incoming artillery, rocket or mortar fire	84%	86%	92%
Being shot at or receiving small-arms fire	66%	93%	97%
Shooting or directing fire at the enemy	27%	77%	87%
Being responsible for death of an enemy combatant	12%	48%	65%
Being responsible for death of a noncombatant	1%	14%	28%
Seeing dead bodies or human remains	39%	95%	94%
Seeing dead or seriously injured Americans	30%	65%	75%
Knowing someone seriously injured or killed	43%	86%	87%
Participating in demining operations	16%	38%	34%
Seeing ill or injured women or children whom you were unable to help	46%	69%	83%
Being wounded or injured	5%	14%	9%
Being shot or hit, but protective gear saved you	*	8%	10%
Having a buddy who was near you shot or hit	*	22%	26%
Clearing or searching homes or buildings	57%	80%	86%
Engaging in hand-to-hand combat	3%	22%	9%
Saved the life of a soldier or civilian	6%	21%	19%
* Question not included in this survey
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

 

Workup of combat veterans

Military psychiatrists provide support and treatment during and immediately after combat, but they do not associate acute reactions with specific psychiatric diagnoses to avoid “pathologizing” brief reactions to combat. To provide appropriate treatment for returning troops, however, you will need to characterize clinically significant psychopathology by using DSM IV-TR criteria for acute stress disorder and PTSD.¹²

We recommend that you manage a returning service member according to usual clinical practice. This includes a thorough history and appropriate medical and laboratory workup. Because soldiers commonly minimize their symptoms and concerns—particularly if they fear full disclosure could jeopardize their military careers—consider including collateral history from the patient’s family and friends in your assessment.

Differential diagnosis of mental disorders in combat troops is broad. You will need to obtain a thorough substance abuse history, with particular attention to use of alcohol to self-medicate symptoms. It will be important to assess safety issues, including potential for suicide, homicide, and domestic violence.

Many soldiers report difficulties with re-entering family life. Marital and sexual problems may develop because of role changes that occurred during a long separation. Pre-existing marital problems may be exacerbated, and both military members and spouses may express concerns about infidelity. Separation and divorce rates may be high.

Mr. L’s story: Alcohol ‘helps me sleep’

When you ask Mr. L about his use of alcohol, he notes that he was cited for driving while intoxicated at age 28. “I used to have a problem with drinking, but after my ticket I didn’t drink ‘til I came back from Iraq,” he says. “Now it’s the only thing that calms me down and helps me sleep.”

Comorbid diagnoses associated with PTSD are the rule. Mr. L’s drinking to self-medicate his PTSD symptoms puts him at risk of redeveloping alcohol problems. Use current best practices for managing depression, anxiety disorders, and substance abuse (if present) to guide treatment.

Suicidal behavior has also been strongly associated with PTSD.¹³ Thus, address Mr. L’s access to firearms, and include suicide assessment and regular followup in any treatment plan.

Head injuries in iraq

The use of effective body armor has dramatically changed the types of wounds and injuries sustained in combat. Kevlar body armor has decreased the frequency of mortal chest and abdominal wounds, leading to an unprecedented proportion of head and neck wounds, including eye injuries. In the war in Iraq and Afghanistan, 22% of evacuated casualties have injuries to the head, neck, and face.¹⁴

At the same time, rapid treatment of open and closed head injuries—often fatal in past wars—has improved survival. As a result, the prevalence of traumatic brain injury in veteran populations is believed to be substantially higher now than in previous conflicts.¹⁵

Mr. L’s story: ‘I forget everything’

Mr. L reports that after he served 8 months in Iraq, his vehicle was destroyed by a roadside bomb. He lost consciousness and was hospitalized briefly before returning to duty and completing his tour.

“I’m having trouble concentrating at work, and it seems like I forget everything,” he says. “My boss has complained about mistakes I make when planning our construction jobs. Could that explosion be causing my problems?”

Mr. L’s loss of consciousness associated with a blast injury and his cognitive complaints suggest possible mild traumatic brain injury. Consider neuropsychological testing and brain imaging studies, along with possible referral to appropriate rehabilitation programs if needed.

Treatment resources

The Iraq War Clinician Guide¹⁶ delineates military approaches to prevention, as well as acute intervention and initial treatment after evacuation from a war zone. This guide also:

• outlines rationales for removing affected service members from combat and eventually returning them to duty or medically retiring them if severe symptoms continue to interfere with ability to function.
  
• describes the biopsychosocial approach used by the Walter Reed Army Medical Center Psychiatric Consultation Service to address the multifactorial needs of the traumatized amputee.
  

Other resources. Detailed analyses of treatment options and their efficacy, along with algorithms for treatment, are available online (Related resources). Because practice guidelines might not apply to all situations, it will be important to develop patient-specific treatment plans.

Related resources

• National Center for PTSD: The War in Iraq. www.ncptsd.va.gov/topics/war.html
  Comprehensive Web site designated by Congress to provide information for military veterans with PTSD. Clinician’s guide available, plus fact sheets for family and patients.
  
• National Center for PTSD. Iraq War Clinician Guide (2nd ed). www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf
  Detailed guide for treating the soldier in combat. Includes treatment options for PTSD and the veteran with amputation.
  
• U.S. Army Center for Health Promotion and Preventive Medicine. Supporting Guidelines. www.pdhealth.mil/clinicians/support.asp
  Collection of guidelines for PTSD, major depression, and medically unexplained symptoms following combat.
  
• Military One Source. www.militaryonesource.com
  Resource for active duty and reserve soldiers and family members. Portal for support services, policies, and education. Brief confidential counseling support for soldiers and family members.
  
• Veterans Administration (VA)/Department of Defense (DOD) Clinical Practice Guideline for Management of PTSD, January 2004. www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm
  Includes list of clinical trials, medication dosing, and evidence basis for treatment with pharmacotherapy and psychotherapy.
  
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
  Background and guidelines for managing PTSD, including treatment recommendations, evidence basis, background, and areas for future research.
  

 

Disclosure

Drs. Lineberry, Bostwick, and Rundell previously served on active duty in the U.S. Air Force for 12, 5, and 23 years, respectively.

National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.^1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.⁴ An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).⁵

Table 1

Mental health problems reported by troops returning from combat in Iraq*

Problem	Number among 193,000 U.S. soldiers
Nightmares or unwanted war recollections	20,000
Might “hurt or lose control” with someone else	3,700
Suicidal thoughts/feeling better off dead	1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.

Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.⁶ This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al⁷ found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrier	Met screening criteria for a mental disorder?
	Yes (N=731)	No (N=5,422)
I would be seen as weak	65%	31%
My unit leadership might treat me differently	63%	33%
Members of my unit might have less confidence in me	59%	31%
I would have difficulty getting time off work for treatment	55%	22%
My leaders would blame me for the problem	51%	20%
It would harm my career	50%	24%
It is difficult to schedule an appointment	45%	17%
It would be too embarrassing	41%	18%
I don’t trust mental health professionals	38%	17%
Mental health care costs too much money	25%	10%
Mental health care doesn’t work	25%	9%
I don’t know where to get help	22%	6%
I don’t have adequate transportation	18%	6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).⁸ Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.

 

PTSD in combat veterans

Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).^9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.⁹

Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.⁷ These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.¹⁰

If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).

Box

Resiliency and PTSD. Resiliency among service members in combat is the norm, and most will not develop PTSD. Military efforts at increasing resilience and performance include intense training with realistic combat simulation and education. A selected sample of experienced elite soldiers has been shown to have lower cortisol levels in response to simulated combat stress than younger soldiers with less training.¹¹

To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.¹¹

Mr. L’s story: Detached and irritable

As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.

Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.

Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.⁷ Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.

Table 3

Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan

Experience	Army groups		Marine group
	Afghanistan	Iraq
Being attacked or ambushed	58%	89%	95%
Receiving incoming artillery, rocket or mortar fire	84%	86%	92%
Being shot at or receiving small-arms fire	66%	93%	97%
Shooting or directing fire at the enemy	27%	77%	87%
Being responsible for death of an enemy combatant	12%	48%	65%
Being responsible for death of a noncombatant	1%	14%	28%
Seeing dead bodies or human remains	39%	95%	94%
Seeing dead or seriously injured Americans	30%	65%	75%
Knowing someone seriously injured or killed	43%	86%	87%
Participating in demining operations	16%	38%	34%
Seeing ill or injured women or children whom you were unable to help	46%	69%	83%
Being wounded or injured	5%	14%	9%
Being shot or hit, but protective gear saved you	*	8%	10%
Having a buddy who was near you shot or hit	*	22%	26%
Clearing or searching homes or buildings	57%	80%	86%
Engaging in hand-to-hand combat	3%	22%	9%
Saved the life of a soldier or civilian	6%	21%	19%
* Question not included in this survey
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

 

Workup of combat veterans

Military psychiatrists provide support and treatment during and immediately after combat, but they do not associate acute reactions with specific psychiatric diagnoses to avoid “pathologizing” brief reactions to combat. To provide appropriate treatment for returning troops, however, you will need to characterize clinically significant psychopathology by using DSM IV-TR criteria for acute stress disorder and PTSD.¹²

We recommend that you manage a returning service member according to usual clinical practice. This includes a thorough history and appropriate medical and laboratory workup. Because soldiers commonly minimize their symptoms and concerns—particularly if they fear full disclosure could jeopardize their military careers—consider including collateral history from the patient’s family and friends in your assessment.

Differential diagnosis of mental disorders in combat troops is broad. You will need to obtain a thorough substance abuse history, with particular attention to use of alcohol to self-medicate symptoms. It will be important to assess safety issues, including potential for suicide, homicide, and domestic violence.

Many soldiers report difficulties with re-entering family life. Marital and sexual problems may develop because of role changes that occurred during a long separation. Pre-existing marital problems may be exacerbated, and both military members and spouses may express concerns about infidelity. Separation and divorce rates may be high.

Mr. L’s story: Alcohol ‘helps me sleep’

When you ask Mr. L about his use of alcohol, he notes that he was cited for driving while intoxicated at age 28. “I used to have a problem with drinking, but after my ticket I didn’t drink ‘til I came back from Iraq,” he says. “Now it’s the only thing that calms me down and helps me sleep.”

Comorbid diagnoses associated with PTSD are the rule. Mr. L’s drinking to self-medicate his PTSD symptoms puts him at risk of redeveloping alcohol problems. Use current best practices for managing depression, anxiety disorders, and substance abuse (if present) to guide treatment.

Suicidal behavior has also been strongly associated with PTSD.¹³ Thus, address Mr. L’s access to firearms, and include suicide assessment and regular followup in any treatment plan.

Head injuries in iraq

The use of effective body armor has dramatically changed the types of wounds and injuries sustained in combat. Kevlar body armor has decreased the frequency of mortal chest and abdominal wounds, leading to an unprecedented proportion of head and neck wounds, including eye injuries. In the war in Iraq and Afghanistan, 22% of evacuated casualties have injuries to the head, neck, and face.¹⁴

At the same time, rapid treatment of open and closed head injuries—often fatal in past wars—has improved survival. As a result, the prevalence of traumatic brain injury in veteran populations is believed to be substantially higher now than in previous conflicts.¹⁵

Mr. L’s story: ‘I forget everything’

Mr. L reports that after he served 8 months in Iraq, his vehicle was destroyed by a roadside bomb. He lost consciousness and was hospitalized briefly before returning to duty and completing his tour.

“I’m having trouble concentrating at work, and it seems like I forget everything,” he says. “My boss has complained about mistakes I make when planning our construction jobs. Could that explosion be causing my problems?”

Mr. L’s loss of consciousness associated with a blast injury and his cognitive complaints suggest possible mild traumatic brain injury. Consider neuropsychological testing and brain imaging studies, along with possible referral to appropriate rehabilitation programs if needed.

Treatment resources

The Iraq War Clinician Guide¹⁶ delineates military approaches to prevention, as well as acute intervention and initial treatment after evacuation from a war zone. This guide also:

• outlines rationales for removing affected service members from combat and eventually returning them to duty or medically retiring them if severe symptoms continue to interfere with ability to function.
  
• describes the biopsychosocial approach used by the Walter Reed Army Medical Center Psychiatric Consultation Service to address the multifactorial needs of the traumatized amputee.
  

Other resources. Detailed analyses of treatment options and their efficacy, along with algorithms for treatment, are available online (Related resources). Because practice guidelines might not apply to all situations, it will be important to develop patient-specific treatment plans.

Related resources

• National Center for PTSD: The War in Iraq. www.ncptsd.va.gov/topics/war.html
  Comprehensive Web site designated by Congress to provide information for military veterans with PTSD. Clinician’s guide available, plus fact sheets for family and patients.
  
• National Center for PTSD. Iraq War Clinician Guide (2nd ed). www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf
  Detailed guide for treating the soldier in combat. Includes treatment options for PTSD and the veteran with amputation.
  
• U.S. Army Center for Health Promotion and Preventive Medicine. Supporting Guidelines. www.pdhealth.mil/clinicians/support.asp
  Collection of guidelines for PTSD, major depression, and medically unexplained symptoms following combat.
  
• Military One Source. www.militaryonesource.com
  Resource for active duty and reserve soldiers and family members. Portal for support services, policies, and education. Brief confidential counseling support for soldiers and family members.
  
• Veterans Administration (VA)/Department of Defense (DOD) Clinical Practice Guideline for Management of PTSD, January 2004. www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm
  Includes list of clinical trials, medication dosing, and evidence basis for treatment with pharmacotherapy and psychotherapy.
  
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
  Background and guidelines for managing PTSD, including treatment recommendations, evidence basis, background, and areas for future research.
  

 

Disclosure

Drs. Lineberry, Bostwick, and Rundell previously served on active duty in the U.S. Air Force for 12, 5, and 23 years, respectively.

National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.^1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.⁴ An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).⁵

Table 1

Mental health problems reported by troops returning from combat in Iraq*

Problem	Number among 193,000 U.S. soldiers
Nightmares or unwanted war recollections	20,000
Might “hurt or lose control” with someone else	3,700
Suicidal thoughts/feeling better off dead	1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.

Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.⁶ This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al⁷ found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrier	Met screening criteria for a mental disorder?
	Yes (N=731)	No (N=5,422)
I would be seen as weak	65%	31%
My unit leadership might treat me differently	63%	33%
Members of my unit might have less confidence in me	59%	31%
I would have difficulty getting time off work for treatment	55%	22%
My leaders would blame me for the problem	51%	20%
It would harm my career	50%	24%
It is difficult to schedule an appointment	45%	17%
It would be too embarrassing	41%	18%
I don’t trust mental health professionals	38%	17%
Mental health care costs too much money	25%	10%
Mental health care doesn’t work	25%	9%
I don’t know where to get help	22%	6%
I don’t have adequate transportation	18%	6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).⁸ Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.

 

PTSD in combat veterans

Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).^9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.⁹

Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.⁷ These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.¹⁰

If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).

Box

Resiliency and PTSD. Resiliency among service members in combat is the norm, and most will not develop PTSD. Military efforts at increasing resilience and performance include intense training with realistic combat simulation and education. A selected sample of experienced elite soldiers has been shown to have lower cortisol levels in response to simulated combat stress than younger soldiers with less training.¹¹

To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.¹¹

Mr. L’s story: Detached and irritable

As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.

Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.

Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.⁷ Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.

Table 3

Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan

Experience	Army groups		Marine group
	Afghanistan	Iraq
Being attacked or ambushed	58%	89%	95%
Receiving incoming artillery, rocket or mortar fire	84%	86%	92%
Being shot at or receiving small-arms fire	66%	93%	97%
Shooting or directing fire at the enemy	27%	77%	87%
Being responsible for death of an enemy combatant	12%	48%	65%
Being responsible for death of a noncombatant	1%	14%	28%
Seeing dead bodies or human remains	39%	95%	94%
Seeing dead or seriously injured Americans	30%	65%	75%
Knowing someone seriously injured or killed	43%	86%	87%
Participating in demining operations	16%	38%	34%
Seeing ill or injured women or children whom you were unable to help	46%	69%	83%
Being wounded or injured	5%	14%	9%
Being shot or hit, but protective gear saved you	*	8%	10%
Having a buddy who was near you shot or hit	*	22%	26%
Clearing or searching homes or buildings	57%	80%	86%
Engaging in hand-to-hand combat	3%	22%	9%
Saved the life of a soldier or civilian	6%	21%	19%
* Question not included in this survey
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

 

Workup of combat veterans

Military psychiatrists provide support and treatment during and immediately after combat, but they do not associate acute reactions with specific psychiatric diagnoses to avoid “pathologizing” brief reactions to combat. To provide appropriate treatment for returning troops, however, you will need to characterize clinically significant psychopathology by using DSM IV-TR criteria for acute stress disorder and PTSD.¹²

We recommend that you manage a returning service member according to usual clinical practice. This includes a thorough history and appropriate medical and laboratory workup. Because soldiers commonly minimize their symptoms and concerns—particularly if they fear full disclosure could jeopardize their military careers—consider including collateral history from the patient’s family and friends in your assessment.

Differential diagnosis of mental disorders in combat troops is broad. You will need to obtain a thorough substance abuse history, with particular attention to use of alcohol to self-medicate symptoms. It will be important to assess safety issues, including potential for suicide, homicide, and domestic violence.

Many soldiers report difficulties with re-entering family life. Marital and sexual problems may develop because of role changes that occurred during a long separation. Pre-existing marital problems may be exacerbated, and both military members and spouses may express concerns about infidelity. Separation and divorce rates may be high.

Mr. L’s story: Alcohol ‘helps me sleep’

When you ask Mr. L about his use of alcohol, he notes that he was cited for driving while intoxicated at age 28. “I used to have a problem with drinking, but after my ticket I didn’t drink ‘til I came back from Iraq,” he says. “Now it’s the only thing that calms me down and helps me sleep.”

Comorbid diagnoses associated with PTSD are the rule. Mr. L’s drinking to self-medicate his PTSD symptoms puts him at risk of redeveloping alcohol problems. Use current best practices for managing depression, anxiety disorders, and substance abuse (if present) to guide treatment.

Suicidal behavior has also been strongly associated with PTSD.¹³ Thus, address Mr. L’s access to firearms, and include suicide assessment and regular followup in any treatment plan.

Head injuries in iraq

The use of effective body armor has dramatically changed the types of wounds and injuries sustained in combat. Kevlar body armor has decreased the frequency of mortal chest and abdominal wounds, leading to an unprecedented proportion of head and neck wounds, including eye injuries. In the war in Iraq and Afghanistan, 22% of evacuated casualties have injuries to the head, neck, and face.¹⁴

At the same time, rapid treatment of open and closed head injuries—often fatal in past wars—has improved survival. As a result, the prevalence of traumatic brain injury in veteran populations is believed to be substantially higher now than in previous conflicts.¹⁵

Mr. L’s story: ‘I forget everything’

Mr. L reports that after he served 8 months in Iraq, his vehicle was destroyed by a roadside bomb. He lost consciousness and was hospitalized briefly before returning to duty and completing his tour.

“I’m having trouble concentrating at work, and it seems like I forget everything,” he says. “My boss has complained about mistakes I make when planning our construction jobs. Could that explosion be causing my problems?”

Mr. L’s loss of consciousness associated with a blast injury and his cognitive complaints suggest possible mild traumatic brain injury. Consider neuropsychological testing and brain imaging studies, along with possible referral to appropriate rehabilitation programs if needed.

Treatment resources

The Iraq War Clinician Guide¹⁶ delineates military approaches to prevention, as well as acute intervention and initial treatment after evacuation from a war zone. This guide also:

• outlines rationales for removing affected service members from combat and eventually returning them to duty or medically retiring them if severe symptoms continue to interfere with ability to function.
  
• describes the biopsychosocial approach used by the Walter Reed Army Medical Center Psychiatric Consultation Service to address the multifactorial needs of the traumatized amputee.
  

Other resources. Detailed analyses of treatment options and their efficacy, along with algorithms for treatment, are available online (Related resources). Because practice guidelines might not apply to all situations, it will be important to develop patient-specific treatment plans.

Related resources

• National Center for PTSD: The War in Iraq. www.ncptsd.va.gov/topics/war.html
  Comprehensive Web site designated by Congress to provide information for military veterans with PTSD. Clinician’s guide available, plus fact sheets for family and patients.
  
• National Center for PTSD. Iraq War Clinician Guide (2nd ed). www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf
  Detailed guide for treating the soldier in combat. Includes treatment options for PTSD and the veteran with amputation.
  
• U.S. Army Center for Health Promotion and Preventive Medicine. Supporting Guidelines. www.pdhealth.mil/clinicians/support.asp
  Collection of guidelines for PTSD, major depression, and medically unexplained symptoms following combat.
  
• Military One Source. www.militaryonesource.com
  Resource for active duty and reserve soldiers and family members. Portal for support services, policies, and education. Brief confidential counseling support for soldiers and family members.
  
• Veterans Administration (VA)/Department of Defense (DOD) Clinical Practice Guideline for Management of PTSD, January 2004. www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm
  Includes list of clinical trials, medication dosing, and evidence basis for treatment with pharmacotherapy and psychotherapy.
  
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
  Background and guidelines for managing PTSD, including treatment recommendations, evidence basis, background, and areas for future research.
  

 

Disclosure

Drs. Lineberry, Bostwick, and Rundell previously served on active duty in the U.S. Air Force for 12, 5, and 23 years, respectively.