Among the psychiatric disorders seen in persons with opioid de-pendence, antisocial personality disorder is one of the most com-mon. Diagnostic studies of persons with opioid dependence have typically found rates of antisocial personality disorder ranging from 20 to 50%, as compared with less than 5% in the general population. PTSD is also seen with increased frequency.
Opioid dependent persons are especially at risk for the development of brief depressive symptoms, and for episodes of mild to moderate depression that meet symptomatic and dura-tion criteria for major depressive disorder or dysthymia. These syndromes represent both substance-induced mood disorders as well as independent depressive illnesses. Brief periods of de-pression are especially common during chronic intoxication or withdrawal, or in association with psychosocial stressors that are related to the dependence. Insomnia is common, especially during withdrawal; sexual dysfunction, especially impotence, is common during intoxication. Delirium or brief, psychotic-like symptoms are occasionally seen during opioid intoxication.
The data on psychiatric comorbidity among opioid addicts and its negative effect on outcome have stimulated research on the effect of combining psychiatric and substance abuse treat-ment. Studies have shown that tricyclic antidepressants can be useful for chronically depressed opioid dependent persons who are treated with methadone maintenance and that profes-sional psychotherapy can be useful for psychiatrically impaired, methadone-maintained opioid addicts. The main result in most pharmacotherapy and psychotherapy studies with methadone-maintained addicts has usually been a reduction in psychiatric symptoms such as depression, although some have shown reduc-tions in substance use as well.
Less than 5% of persons with opioid dependence have psy-chotic disorders such as bipolar illness or schizophrenia; how-ever, these patients can present special problems since programs typically have few psychiatric staff. As a result, these patients are sometimes excluded from methadone treatment because they cannot be effectively managed within the constraints of the avail-able resources. Others are treated with methadone, counseling and the same medications used for nonaddicted patients with similar disorders. Women with opioid dependence can present special challenges because many have been sexually abused as children, have other psychiatric disorders, and are involved in difficult family/social situations. Abusive relationships with ad-dicted males are common, sometimes characterized by situa-tions in which the male exerts control by providing drugs. These complex psychiatric and relationship issues have emphasized the need for comprehensive psychosocial services that include psy-chiatric assessment and treatment, and access to other medical, family and social services.