Download Co-Occurring Disorders

Co-Occurring Disorders
J. H. Shale, MD, JD
Psychiatric Director Serenity House, Abilene, TX
Clinical Prof. UCSD School of Medicine, San Diego, CA
Overview
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Definitions of terms
Propositions
Statistics
Diagnosis v. Misdiagnosis
Treatment
Definitions 1
• Dual Diagnosis (DD) was an early term used for the
presence of a mental disorder and a SADO
• DD has been used interchangeably with Co-occurring
disorders and co-morbidity.
• But DSM IV TR also uses co-morbidity to describe
two mental disorders in the same person
• And DSM IV TR does not define any of these terms
• Here we use any of these terms in the original sense
Mental DO + SADO
Definitions 2
• Serious persistent mental illness
• Public systems often have a limited spectrum of
disorders that qualify for treatment
• LA and SD County and MHMR here in TX
• SCZ, SczAff DO, Bipolar DO and MDD, maybe
BPDO and less often Anxiety DO’s
• SADO are usually treated in a parallel system if at all
• This has a huge impact on the quality of DX
Definitions 3
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DSM Axis I = clinical disorders and SADO
DSM Axis II = MR and PDO’s
DSM III = general medical conditions
DSM IV = Psychosocial/environmental problems
DSM V = GAF
This has a huge impact on the quality of DX
Proposition 1
Persons with SADO are at increased risk to develop
mental disorders.
Persons with mental disorders are at increased risk to
develop SADO
There is a clear consensus on this proposition, the only
controversy is about the magnitude
Proposition 2
There is a major tendency to misdiagnose these cooccurring disorders.
This results in both over and under diagnosis
Statistics
The mark of a truly educated man is to be
moved deeply by statistics.
Geo. B. Shaw
There are lies, damn lies and statistics
Mark Twain
Problems getting good data
• Denial
– Folks with SADO don’t tend to admit it
• Poor History taking
– don’t ask, don’t tell
• Lack of experience and training in SADO
• Politics
• Confusion on rules for Dx
– Tendency to over Dx
– Rule of parsimony
Schizophrenia
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Lifetime Prevalence 1% - 1.5%
Alcohol abuse/dep 24%
Drug abuse/dep 14%
Life expectancy 20% less than Gen pop
Suicide rates > 15%
Smoking 80 %
Diabetes rates 1.5 times matched controls
Schizophrenia Dx
• A. Sx’s
– delusions (bizarre), hallucinations, disorganized thinkng
(speech/behavior, includes catatonia) neg sx’s of flat affect
alogia, avolition. Active sx’s for at least a month
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B. social/occupational dysfunction
C. Duration at least 6 months
D. Exclusions: MDD, BPDO1, SczAffective DO
E. Exclusions: SADO, gen med condition
F. Relation to Autism/ Pervasive DDO
– prominent Hallucination/Delusion for at least a month
Major Depressive Disorder
• Lifetime Prevalence 18%
• Early use of ETOH, tobacco, drugs increases risk of
MDD and may cause earlier onset of MDD
• “former drinkers” at 4 fold risk of MDD in the period
measured ( 1-4 yrs abstinent)
• Question is to what extent A causes B
– Texas Sharpshooter Fallacy
Major Depressive Disorder Dx
• Sx’s 5 or more of following and 1 or 2 must be among them:
1.depressed mood, 2. Diminished interest
– wgt change >5% in a month, insomnia/hypersomnia, psychomotor
agitation/retardation, decreased energy, guilt/worthlessness,
decreased concentration, recurrent thoughts of death/ SI/SA
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Exclude mixed episode (Dx of BPDO1)
Sig interfere with major area of life function
Not due to SADO, meds or med. Condition
Sx’s are not form bereavement
Sx’s duration > 2 month
Bipolar Disorder I Mania
• Distinct period at least a week of persistently
elevated or expansive or irritable mood
• Sx’s 3 or more of: grandiosity/inflated self-esteem,
decreased sleep, increased talk/pressured speech,
thoughts racing/flgt of ideas, distractable, can’t focus,
increase goal directed activity, psychmotor agitation,
excessive involvement in sex, spending, or risk taking
with potential for harm (poor jusdgment)
• exclude mixed episode (sx’s of both mania and dep)
• Sig interferes with major area of life function
• Excludes SADO or meds or Med condition
Bipolar Disorder in Clinical Populations
Patients Treated for Depression in Community Psychiatry
602 outpatients
receiving treatment
for unipolar
depression with at
least 1 failed
antidepressant trial
19% screened
positive* for
bipolar
disorder
• The average number of failed antidepressants was 2.9
• No significant differences seen in rate of positive MDQ screens
based on # of failed antidepressants
*Using the Mood Disorder Questionnaire (MDQ)
Calabrese JR, et al. MedGenMed. 2006;8.
Bipolar Disorder Symptoms Are
Chronic and Predominantly Depressive
1% 2%
9%
6%
53%
50%
32%
146 bipolar I patients
followed 12.8 years
% of Weeks
Asymptomatic
Depressed
Manic/hypomanic
Cycling/mixed
Judd LL, et al. Arch Gen Psychiatry. 2002;59:530-537.
Judd LL, et al. Arch Gen Psychiatry. 2003;60:261-269.
46%*
86 bipolar II patients
followed 13.4 years
*%s do not add to 100 due to rounding
Epidemiology
• Bipolar disorder is estimated to
affect approximately 3.7% of the US
population1
• Disease onset at 15 to 24 years of age,
but accurate diagnosis may take 5 to
10 years1,2
• Equal incidence in men and women2
1
Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64:53-59.
2 Evans DL. J Clin Psychiatry. 2000;61(suppl 13):26-31.
Epidemiology
• 15% to 20% of untreated patients
succeed in committing suicide1
• High recurrence rate of bipolar
disorder2
• High economic burden2
• Bipolar is a multidimensional
disease1,3
1
Evans DL. J Clin Psychiatry. 2000;61(suppl 13):26-31.
2 Woods SW. J Clin Psychiatry. 2000;61(suppl 13):38-41.
3 Goodwin FK, et al. In: Goodwin FK, Jamison KR, eds. ManicDepressive Illness.
New York, NY: Oxford University Press; 1990:74-84.
Bipolar Disorder:
Unrecognized and Underdiagnosed
Mood Disorders Questionnaire
Positive Rates (US Population)
Prevalence of bipolar I and II disorder*
3.7%†
Correctly diagnosed by a doctor as having
bipolar disorder
20%
Incorrectly diagnosed as unipolar depression
31%
Not diagnosed as bipolar disorder or
unipolar depression
49%
*Weighted to match national demographics
†When adjusted for frequency of bipolar disorder in nonresponders
Hirschfeld RMA, et al. J Clin Psychiatry.
2003;64:161-174.
Cross Addiction
The APA Glossary, 8th Ed. 2003 defines crossdependence: “ A drug’s ability to suppress
physical manifestations of substance
dependence produced by another drug and to
maintain the physically dependent state. It
provides the rationale for the treatment of
dependence on one substance, such as
alcohol, by the short-term substitution of a
less dangerous and more controllable
substance that is cross-dependent with
alcohol (e.g. Librium, [chlordiazepoxide]) to
treat the symptoms of alcohol withdrawal.”
Cross Addiction
It has become a staple of teaching in
addiction medicine that one should not
use potentially addicting medications in
patients with a history of substance
abuse or dependence if it can be
avoided.
Reasons For Misdiagnosis
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Problems getting good data
Statistical issues and definitions of terms
Payment mis-incentives
Changing roles of “mental health professionals”
Ignorance and sloth, maybe greed
– TDPS: Harris county docs rank first in prescribing a combo
of three highly addictive meds that give a “heroin high”
– hydrocodone, alprazolam and carisoprodol
– C.M. Schade, MD past president of TX Pain Society: No
legitimate medical reason for this combo. (Temple Sentinel,
B1, 6/1/10)