Bipolar Disorder and Comorbid Disorders

1. Bipolar Disorder and Comorbid Disorders Kurt Weber, PhD Mental Health America – Brown CountyBemis International Center St Norbert College May 13, 2008

2. Many disorders have been shown to be comorbid with bipolar disorder • Some conditions are treated by treating BPD first • Others more clearly show the BD when the comorbid problem is cleared up…

3. AODA • many factors may contribute to these substance abuse problems, including • Self-medication of mood-related symptoms • mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders. • Treatment of one does not resolve the other, but controlled bipolar disease usually leads to the diminishing of AODA symptoms.

4. 23.6% of bipolar clients have an alcohol use disorder • 12.9% have a drug abuse disorder • 37% have nicotine dependence (NESARC)

5. Bipolar clients are unreliable reporters of AODA use • They also underreport psychiatric symptoms. • Nonetheless, substance abuse complicates bipolar disorder, of course…

6. Stimulants may precipitate a manic episode. • Chronic use of CNS stimulants like amphetamine and cocaine cause • euphoria • decreased appetite • increased energy • grandiosity • sometimes paranoia that mimics mania

7. The incidence of “revolving door” clients is higher with concurrent substance abuse • Substance abuse is associated with a relatively poor response to lithium.

8. Hallucinations are more refractory (resistant to treatment or cure) in clients with substance abuse • Substance abuse is related to higher mortality by suicide (15-19%) and other causes.

9. from about.com • "I made a serious commitment to quit all drug use (street & rx) when I was pregnant (7 years ago) which actually led to my diagnosis of BP, as I could no longer hide my illness without the drug use.“ • "I stopped alcohol 5 years ago and street drugs four. Of course, this is when my depression (possibly BP with no formal dx) and OCD really began to peek out from beneath the foggy cover of my substance abuse camouflage.“

10. hard to identify comorbidity at first • One study found that of those with a substance problem among severely mentally ill patients seen in a university hospital emergency room -- only 2 percent were detected. • The state hospital did only slightly better, detecting 15 percent

11. why? • Emergency rooms are just not often able to do structured interviews about drug and alcohol use • Patients tend to underestimate the problems caused by the drugs, and they rarely disclose that they have a problem with substance abuse • Practitioners should also keep in mind that illicit drugs and alcohol can cause the development, the reemergence, or even worsen the severity of mental disorders • These drugs can also present symptoms that parallel those of mental disorders or even cover them up.

12. Polcin • Issues in the Treatment of Dual Diagnosis Clients Who Have Chronic Mental Illness • poor treatment response • high rates of rehospitalization • aggravated psychotic thoughts • changes in neurophysiology

13. Polcin, continued • notes that those dually diagnosed are often less responsive to medications than those who do not abuse substances, specifically stating that cocaine users have problems with lithium • systems have not been well designed with this population in mind • community may have treatment services for people with mental illness in one agency and treatment for substance abuse in another • clients are referred back and forth between them in what some have called 'ping -pong' therapy" (NAMI).

14. Often the very treatment approach of one service may cause problems for the other side of the condition. • substance abuse workers traditionally consider the use of medications to be a crutch for those struggling with addiction • psychiatrists rely on prescriptions to treat the mental illness • while psychiatrists rarely give much credence to spiritual or self-help approaches, those working with addictions place a great deal of emphasis here

15. poor communication between practitioners • Those struggling to reach stability with their mental illness and to achieve sobriety are, more often than not, shuffled between different practitioners. • Even when these counselors and doctors work within the same facility, there is seldom good, if any, communication between offices

16. HHS plan • first area relates to decision-making with regard to treatment plans. • Second is the use of psychotropic medications. • Accurate diagnostic tools is another area greatly needing research • currently no good instrument for detecting or classifying substance use disorders in the mentally ill, in that those available were developed for use in the general population

17. outlook for those with dual diagnosis seems grim • What is the long-term prognosis? Is there any hope for stability and sobriety? • lifetime prevalence of substance use disorders is as much as seven times greater for those with bipolar disorder than those in the general population • however, there are successes… • "My life is quite manageable today with the proper medication, therapy, a wonderful support program and recovery program. And no booze ... not a drop. Works the best I have ever had it."

18. Anxiety • the first 500 patients with bipolar I or bipolar II disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder • Lifetime comorbid anxiety disorders were common, occurring in over one-half of the sample • were associated with • younger age at onset • decreased likelihood of recovery • poorer role functioning and quality of life • less time euthymic • greater likelihood of suicide attempts. • comorbid anxiety appeared to exert an independent, deleterious effect on functioning, including history of suicide attempts

19. highlighting the need for greater clinical attention to anxiety in this population, particularly for enhanced clinical monitoring of suicidality. • In addition, it is important to determine whether effective treatment of anxiety symptoms can • lessen bipolar disorder severity • improve response to treatment of manic or depressive symptoms • reduce suicidality

20. The interaction between anxiety disorders and substance use goes both ways: patients with bipolar disorder have a higher rate of substance use and anxiety disorder, and vice versa. • Bipolar disorder is also associated with borderline personality disorder and ADHD, and to a lesser extent with weight gain. • As more than 40% of bipolar patients have anxiety disorder, it is indicated that while diagnosing bipolar patients, systematic enquiry about different anxiety disorders is called for

21. therapeutic challenge, since agents that effectively treat anxiety disorders are associated with the risk of induced mania. • the treating psychiatrist needs to carefully evaluate the potential benefit of treating the anxiety against the potential cost of inducing a manic episode • possible solution would be to use, when possible, a non-pharmacological intervention, such as a cognitivebehavioural approach • clinician may attempt to ensure that the patient receives adequate treatment with mood stabilizers before slowly and carefully attempting the addition of anti-anxiety compounds with a relatively lower risk of mania induction

22. social phobia • Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2.9), dysthymia (2.7) and bipolar disorder (5.9). • Odds ratios increase in magnitude with number of social fears. • Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases.

23. Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition • adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. • Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

24. Axis II personality disorders– study A • association of mood disorders with personality disorders (PDs) is relevant from a clinical, therapeutic and prognostic point of view • avoidant PD, borderline PD and obsessive-compulsive PD were the most prevalent axis II diagnoses among patients with depressive disorder • in bipolar disorder group, patients showed more frequently obsessive-compulsive PD, followed by borderline PD and avoidant PD • different pattern of PDs emerges between depressive and bipolar patients.

25. Axis II personality disorders – study B • Axis II disorders can be rated reliably among bipolar patients who are in remission. Co-diagnosis of personality disorder occurred in 28.8% of patients. • Cluster B (dramatic, emotionally erratic) and cluster C (fearful, avoidant) personality disorders were more common than cluster A (odd, eccentric) disorders. • Bipolar patients with personality disorders differed from bipolar patients without personality disorders in the severity of their residual mood symptoms, even during remission.

26. When structured assessment of personality disorder is performed during a clinical remission, less than one in three bipolar patients meets full syndromal criteria for an axis II disorder. • Examining rates of comorbid personality disorder in broad-based community samples of bipolar spectrum patients would further clarify the linkage between these sets of disorders.

27. Axis II personality disorders– study C • Thirty-eight percent of the bipolar patients met criteria for an axis II diagnosis. • Two (4%) met criteria for (only) a Cluster A disorder, four (8%) for (only) a Cluster B, and six (12%) for (only) a Cluster C disorder. • One (2%) bipolar patient met criteria a disorder in both Clusters A and B, and one (2%) for a disorder in Clusters B and C. • Five (10%) met criteria for at least one disorder in Clusters A and C, and one met criteria for disorders in Clusters A, B, and C.

28. The presence of a personality disorder was significantly associated with a lower rate of current employment, a higher number of currently prescribed psychiatric medications, and a higher incidence of a history of both alcohol and substance use disorders compared with the bipolar patients without axis II pathology. • results extend previous findings of an association between comorbid personality disorder in bipolar I patients and factors that suggest a more difficult course of bipolar illness.

29. Axis I • authors assessed comorbid lifetime and current axis I disorders in 288 patients with bipolar disorder and the relationships of these comorbid disorders to selected demographic and historical illness variables • 65% of the patients with bipolar disorder also met DSM-IV criteria for at least one comorbid lifetime axis I disorder • no differences in comorbidity between patients with bipolar I and bipolar II disorder • patients with bipolar disorder often have comorbid anxiety, substance use, and, to a lesser extent, eating disorders • axis I comorbidity, especially current comorbidity, may be associated with an earlier age at onset and worsening course of bipolar illness

30. diabetes mellitus • Several papers have reported higher prevalence of diabetes mellitus (DM) type 2 in patients suffering from bipolar disorder (BD) • possible links between these disorders include treatment, lifestyle, alterations in signal transduction, and possibly, a genetic link • prevalence of DM in sample -- 11.7% (n = 26)

31. Diabetic patients • were significantly older than nondiabetic patients • had higher rates of rapid cycling • chronic course of BD • scored lower on the Global Assessment of Functioning Scale • were more often on disability for BD • had higher body mass index • increased frequency of hypertension • Lifetime history of treatment with antipsychotics was not significantly associated with an elevated risk of diabetes (P = 0.16); however, the data showed a trend toward more frequent use of antipsychotic medication among diabetic subjects • diagnosis of DM in BD patients is relevant for their prognosis and outcome

32. obesity • Obesity is more prevalent in patients than in the general population. • Obesity prevalence is clearly related to the administration of antipsychotic drugs…

33. migraine headaches • association between migraine and affective disorders, but the information is sparse concerning the prevalence of migraine in subgroups of the affective disorders • present study was undertaken to investigate the prevalence of migraine in unipolar depressive, bipolar I and bipolar II disorders

34. striking difference between the two diagnostic subgroups • prevalence of 77% in the bipolar II group • 14% in the bipolar I group • “These results support the contention that bipolar I and II are biologically separate disorders and point to the possibility of using the association of bipolar II disorder with migraine to study both the pathophysiology and the genetics of this affective disorder."

35. age of onset • 320 subjects with a diagnosis of BP I or BP II • significantly earlier AAO in subjects • with anxiety disorders • rapid cycling course • more frequent suicidal ideation/attempts • Axis I comorbidity • substance use disorders • “Overall, these results suggest a role of early AAO as a significant predictor of poor outcome in BP and, if replicated, they may have important clinical implications."

36. “Assessment of bipolar disorder must include careful attention to comorbid disorders and predictors of compliance. • “Randomized trials are needed to further evaluate the efficacy of medication, psychosocial interventions, and other health service interventions, particularly as they relate to the management of acute bipolar depression, bipolar disorder co-occurring with other disorders, and maintenance prophylactic treatment."