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5/18/2010 DISCLAIMER Chemical Ch mic l dependency d p nd nc in Bipolar Bip l Disorder Dis d Thanks to Dr. Henson Disclosure Statement of Unapproved/Investigative Use I, Kamran Hayel, M.D. do not anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation. NEITHER THE PUBLISHER NOR THE AUTHORS ASSUME ANY LIABILITY FOR ANY INJURY AND OR DAMAGE TO PERSONS OR PROPERTY ARISING FROM THIS WEBSITE AND ITS CONTENT. Q: A patient with an alcohol problem is ambivalent about starting Acamprosate. The psychiatrist explores the patient’s thought about the advantages and disadvantages of taking and not taking the medication, attempting to tip the patient’s decisional balance in favor of taking the medication. Which of the following techniques is the physician using? A) cognitive reframing B) Contingency Management C) Motivational enhancement D) Pessimistic anticipation E) Rational emotion 1 5/18/2010 Q: A 15‐year‐old girl is brought in for an emergency evaluation because she has been out all night and refuses to tell her parents where she has been. The parents report that for several months the girl has been irritable and oppositional with sever mood swing. She has been leaving home and school without permission. The girl admits that she has been somewhat moody but insist that her parents are making a big deal about nothing. A preliminary i i h h ki bi d l b hi A li i diagnosis of bipolar disorder is made. Which of the following is the most common co‐morbid condition with bipolar disorder? A) Conduct disorder B) Generalized Anxiety disorder C) Oppositional Defiant Disorder D) Posttraumatic Stress Disorder E) Substance Use Disorder Introduction In Bipolar Disorder: Substance abuse is the rule rather than the exception 60% of f patients p ti nts with ith BPD have h a co-occurring in lifetime lif tim substance use disorder (SUD) Bipolar D/O Type I has the highest rate of co morbid substance use among psychiatric disorders Comorbid Bipolar Disorder and SUD Alcohol is the most common of substance abuse (46%) Followed by Marijuana ( 30%- 50%), Amphetamines, h i cocaine( i ( 20%20% 35%) sedatives and opioids are less frequently abused Worse prognosis Poorer response to Lithium Slower stabilization in hospital Suicide S i id attempts tt t more frequent f t Higher risk for relapse to substance abuse than with SUD alone 2 5/18/2010 Co-morbid BPD and SUD continue Increased risk for eg, Financial problems, Family problems, homelessness, violence, incarceration More M Tx T noncompliance li & More M Hospitalization Problems making a diagnosis in dual disorders Substance abuse? Self-medication? Difficulty to differentiate substance-induced syndromes from other psychiatric disorders Often incomplete and/or inaccurate information Substance abuse states that can mimic other psychiatric disorders Depression can be caused by the use of depressants (EToH, Sedative) Mania can be caused by stimulants Psychosis can be caused by Marijuana , Amphetamines, cocaine and hallucinogens Substance abuse states that can mimic other psychiatric disorders Continue: Early recovery as depression Sx of Withdrawal such Mood swings < 1 year during recovery Impulsivity common feature of substance-use conditions are also symptoms of other disorders ( ADD, Mania, personality disorder) 3 5/18/2010 Psychiatric disease caused by substance abuse Reasons to differentiate Unclear whether this occurs Dual diagnosis may need additional services More likely expedites illnesses More severe pathology May have reduced resources and/or support Combined with alcohol reduces efficacy and compliance Alcohol may make prognosis worse Making the diagnosis Self-medication Hypothesis Chronologic history Reduce anxiety Are psychiatric symptoms present during periods Blunt or control affect of abstinence Where Wh there th mood d symptoms t before b f the th onsett of f substance abuse Sleep Pain Other somatic symptoms Attention Relieve withdrawal 4 5/18/2010 Associations between specific substance and conditions BPD More common in those with cocaine dependence than alcohol dependence Depression more often associated with alcohol and opioid use of Mood and Anxiety Disorders, Mania associated with highest probability of drug dependence Lifetime occurrence of Bipolar Disorder in drug abuser is 3%- 11% ( excluding ETOH) Drug abuser (Exclude etoh) BPD Risk Factors for developing drug abuse in Bipolar Patients Males Lower education Social supports cocaine BPD Axis I Disorders ETOH Earlier onset of mood symptoms More mania than depression Rapid cycling or mixed state 5 5/18/2010 Treatment Compliance in SUDs Associated with better compliance + Employment Older Age Education + Social Supports Treatment Compliance in SUDs (cont’) Associated with poor compliance Co-morbidity Severity S it of f psychiatric ps hi t i symptoms s mpt ms Cognitive impairment Poor support systems Disulfiram (eg, Antabuse) FDA approved for alcoholism Inhibits liver enzyme function Causes accumulation of toxic precursor Flushing, nausea, and vomiting if combined with alcohol Decreases frequency of drinking Not associated with long-term improvement Patient requires liver function tests Increased risk for psychosis 6 5/18/2010 Disulfiram (cont’) More affective with impulsive drinkers or in high risk situations Use in addition with psychological treatment Can C be b used d with ith alcohol l h l by b a small ll percentage t without ill effects Take in the presence of a witness Naltrexone Naltrexone FDA approved for alcoholism Lower craving, lower alcohol consumption, and decreased reward Monthly M thl injection i j ti Disadvantages - blocks opioid receptors Early trials v. Large multicenter trial Trials in population with Bipolar Disorder and Alcoholism Fewer studies Medication M di ti well ll tolerated t l t d Might indirectly improve mood symptoms Improved self-esteem and compliance with medication regimens Removing effects of alcohol consumption 7 5/18/2010 Naltrexone and Disulfiram combination Study of each agent individually Each agent with placebo Combination of Naltrexone and Disulfiram Double placebo Improvement found in all groups Acamprosate FDA approved for use in treating alcoholism 7 European trials – abstinence increased if with psychosocial h i l interventions i t ti United States trials showed most effective in Highly motivated cases 8 5/18/2010 Valproate Topiramate Small trial Significantly lower number of drinking days Improved affect Decrease in GGT In theory it could help control compulsivity but no data available Carbamazepine Lithium Some evidence of efficacy with Bipolar Disorder and co-morbid cocaine abuse Little or no data available 9 5/18/2010 Psychological Treatment Outcome better when treatment of Bipolar Disorder and substance use disorder are integrated Self-help Self help groups Social stability Adherence to treatment A patient with an alcohol problem is ambivalent about starting Acamprosate. The psychiatrist explores the patient’s thought about the advantages and disadvantages of taking and not taking the medication, attempting to tip the patient medication attempting to tip the patient’s decisional s decisional balance in favor of taking the medication. Which of the following techniques is the physician using? A) cognitive reframing B) Contingency Management C) Motivational enhancement D) Pessimistic anticipation E) Rational emotion Cognitive Behavorial Therapy (CBT) Medical management plus CBT increased number of patients who completed treatment compared with groups receiving medical management alone Improvement in mood seen Treatment well liked by patients A patient with an alcohol problem is ambivalent about starting Acamprosate. The psychiatrist explores the patient’s thought about the advantages and disadvantages of taking and not taking the medication, attempting to tip the patient’s decisional balance in favor of taking the medication. Which of the following techniques is the physician using? A) cognitive reframing B) Contingency Management C) Motivational enhancement D) Pessimistic anticipation E) Rational emotion 10 5/18/2010 Motivational enhancement therapy is a form of psychotherapy that has been shown to be effective in the treatment of substance use disorder. It uses directive, empathic, patient directive empathic patient‐centered techniques to centered techniques to address ambivalence and denial. Mark AH, Franklin JE, Frances RJ: Substance use disorder, in The American psychiatric Press textbook of clinical Psychiatry. Edited By Hales RE, Yudofsky SC. Washington DC, American Psychiatric Publishing, 2003, P 353 Polcin DL, Galloway GP, Palmer J, Mains W: The case for high‐dose motivational enhancement therapy. Substance Use Misuse 2004; 39:331‐334 A 15‐year‐old girl is brought in for an emergency evaluation because she has been out all night and refuses to tell her parents where she has been. The parents report that for several months the girl has been irritable and oppositional with sever mood swing. She has been leaving home and school without permission. The girl admits that she has been somewhat moody but insist that her parents are making a big deal about nothing. A preliminary diagnosis of bipolar disorder is made. Which of the following is the most common co‐morbid condition with bipolar disorder? p A) Conduct disorder B) Generalized Anxiety disorder C) Oppositional Defiant Disorder D) Posttraumatic Stress Disorder E) Substance Use Disorder A 15‐year‐old girl is brought in for an emergency evaluation because she has been out all night and refuses to tell her parents where she has been. The parents report that for several months the girl has been irritable and oppositional with sever mood swing. She has been leaving home and school without permission. The girl admits that she has been somewhat moody but insist that her parents are making a big deal y p g g about nothing. A preliminary diagnosis of bipolar disorder is made. Which of the following is the most common co‐morbid condition with bipolar disorder? A) Conduct disorder B) Generalized Anxiety disorder C) Oppositional Defiant Disorder D) Posttraumatic Stress Disorder E) Substance Use Disorder Substance use or abuse is an important diagnosis to consider in adolescents who present with symptoms consistent with bipolar disorder, both as a possible cause of the symptoms and as an important potential co‐existing problem. This diagnosis has significant implications for treatment planning. Sadock BJ, Sadock VA (eds): Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed. Philadelphia, Lippincott & Williams & Wilkins, 2005, P 3277 Lewis M (ed): Child and Adolescent Psychiatry : A Comprehensive Textbook, 3rd ed. Philadelphia, Lippincott & Williams & Wilkins, 2002, pp 783‐786 11 5/18/2010 Conclusions SUDs and Bipolar Disorder highly associated and have increased risks for poor outcomes Essential to integrate treatment for both Addiction Addi ti pharmacotherapies h th i and d CBT shown h to t be beneficial Additional research needed Treatment compliance essential Questions and Comments? Thank you for your time 12