# Presentation: 239298

## Objectives

- Epidemiologic data
- The risks and consequences of co-occurring bipolar disorders and SUD (BP-SUD)
- The scope of general medical problems associated with bipolar disorder and SUD
- Importance of selecting appropriate methods to identify and assess SUD among people with bipolar disorder

## Prevalence of Bipolar Disorders

- Type I Bipolar Disorder
- 12 month DSM-IV bipolar I disorder	2.0%
- Lifetime DSM-IV bipolar I disorder 		3.3%
- (Rates are higher than 1-2% previously thought)
- Type II Bipolar Disorder
- 0.5%

**Notes:**
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results From the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.

Grant JE, Levine L, Kim D et al. Impulse Control Disorders in Adult Psychiatric Inpatients. Am J Psychiatry 2005;162:2184-2188. 

Bebbington and Ramana 1995; Regier et al. 1990

## Prevalence of SUDs

- Lifetime prevalence of substance use disorders in general population
- Alcohol dependence/abuse	17%
- Other substances		  6%
- Prevalence of problematic substance use may increase
- Changes in drug use and patterns
- Aging of “baby boom” cohort

**Notes:**
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results From the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.

Grant JE, Levine L, Kim D et al. Impulse Control Disorders in Adult Psychiatric Inpatients. Am J Psychiatry 2005;162:2184-2188. 

Bebbington and Ramana 1995; Regier et al. 1990

## Co-occurring BD and SUD

- Rates of SUDs are substantially higher
- Co-occurring SUD & bipolar disorder has negative impact on course, treatment & prognosis of both disorders
- Comorbid substance use problematic and common among those with bipolar disorder

**Notes:**
Bauer MS, Altshuler L, Evans DR, et al. VA Cooperative Study #430 Team. Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder. J Affect Disorders 2005;85:301-15. 

McElroy SL, Altshuler LL, Suppes T, et al. Axis I Psychiatric Comorbidity and Its Relationship to Historical Illness Variables in 288 Patients With Bipolar Disorder. Am J Psych 2001;158:420-426. 

## Co-occurring BD and SUD

- Compared to those with other Axis I disorders, individuals with bipolar diagnosis have highest lifetime rates of alcohol use disorders
- Bipolar I Disorder
- Substance use disorder in lifetime: 61%
- Alcohol use disorders: 46%
- Drug use disorders: 41%
- Bipolar II Disorder
- Substance use disorder in lifetime: 48%

**Notes:**
(Reiger et al., 1990)

## Risk for SUDs

- Compared to the general population, individuals with mania
- 9.7 times more likely to have lifetime alcohol dependence
- 8.4 times more likely to have lifetime drug dependence
- 8.2 times more likely to have drug dependence in last year

**Notes:**
(Kessler et al., 1996)

## Comorbidity in Clinical Populations

- 14 studies of patients with bipolar disorder in inpatient & outpatient settings found lifetime rates of substance use disorders ranging from 14-65%
- Settings
- Definitions and Criteria

**Notes:**
Baethge C, Baldessarini RJ, Khalsa MNK, et al. Substance Abuse in First-Episode Bipolar I Disorder: Indications for Early Intervention. Am J Psychiatry 2005; 162:1008-1010. 

Bauer MS, Altshuler L, Evans DR, et al. VA Cooperative Study #430 Team. Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder. J Affect Disorders 2005;85:301-15. 

Brown, TA, Campbell LA, Lehman CL, e al. Current and Lifetime Comorbidity of the DSM-IV Anxiety and Mood Disorders in a Large Clinical Sample. J Abnorm Psychology 2001; 110:585-599. 

McElroy SL, Altshuler LL, Suppes T, et al. Axis I Psychiatric Comorbidity and Its Relationship to Historical Illness Variables in 288 Patients With Bipolar Disorder. Am J Psych 2001;158:420-426. 

Sbrana et al., 2005

## Success in Identifying SUDs

- Nationwide, less than 25% of Veterans with bipolar disorder receive a SUD diagnosis
- Less than would be expected
- Less than half of those identified received tx
- But better than in non-VA population

## Comorbidity in Clinical Populations

- Inpatients with bipolar disorder
- Comorbid substance use disorder
- Current 33-46%; Lifetime: 72.3%
- Psychiatric comorbidity common
- Current 57.3%; Lifetime: 78.4%
- Multiple current psychiatric comorbidities: 29.8%

**Notes:**
Baethge C, Baldessarini RJ, Khalsa MNK, et al. Substance Abuse in First-Episode Bipolar I Disorder: Indications for Early Intervention. Am J Psychiatry 2005; 162:1008-1010. 

Bauer MS, Altshuler L, Evans DR, et al. VA Cooperative Study #430 Team. Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder. J Affect Disorders 2005;85:301-15. 

Brown, TA, Campbell LA, Lehman CL, e al. Current and Lifetime Comorbidity of the DSM-IV Anxiety and Mood Disorders in a Large Clinical Sample. J Abnorm Psychology 2001; 110:585-599. 

McElroy SL, Altshuler LL, Suppes T, et al. Axis I Psychiatric Comorbidity and Its Relationship to Historical Illness Variables in 288 Patients With Bipolar Disorder. Am J Psych 2001;158:420-426. 

Sbrana et al., 2005

## Comorbidity in Clinical Populations

- Outpatients with bipolar disorder
- 65% at least one comorbid lifetime Axis I disorder
- 42% comorbid substance use disorders

**Notes:**
Baethge C, Baldessarini RJ, Khalsa MNK, et al. Substance Abuse in First-Episode Bipolar I Disorder: Indications for Early Intervention. Am J Psychiatry 2005; 162:1008-1010. 

Bauer MS, Altshuler L, Evans DR, et al. VA Cooperative Study #430 Team. Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder. J Affect Disorders 2005;85:301-15. 

Brown, TA, Campbell LA, Lehman CL, e al. Current and Lifetime Comorbidity of the DSM-IV Anxiety and Mood Disorders in a Large Clinical Sample. J Abnorm Psychology 2001; 110:585-599. 

McElroy SL, Altshuler LL, Suppes T, et al. Axis I Psychiatric Comorbidity and Its Relationship to Historical Illness Variables in 288 Patients With Bipolar Disorder. Am J Psych 2001;158:420-426. 

Sbrana et al., 2005

## Alcohol Use

- In recent study, patients with bipolar disorder and active alcohol use reported in past month
- 18.4 out of 30 drinking days
- 9.9 drinks per drinking day
- 169.4 total standard drinks

**Notes:**
McKowen JW, Frye MA, Altshuler LL, Gitlin MJ. Patterns of alcohol consumption in bipolar patients comorbid for alcohol abuse or dependence. Bipolar Disorders 2005; 7:377-381. 

## Alcohol Use

- Significant differences in the number of drinks per drinking day between those diagnosed with:
-  rapid cycling than non-rapid cycling bipolar disorder
- new diagnosis versus established diagnosis of bipolar disorder

**Notes:**
McKowen JW, Frye MA, Altshuler LL, Gitlin MJ. Patterns of alcohol consumption in bipolar patients comorbid for alcohol abuse or dependence. Bipolar Disorders 2005; 7:377-381. 

## Explanations of Comorbidity

- “Self-medication”
- Substance abuse and bipolar disorder have overlapping symptomotology (agitation, depression, restlessness, euphoria)
- Bipolar disorder may lead to substance abuse due to impulsivity, poor judgment, risk taking

**Notes:**
(APA 2000; Feinman and Dunner 1996; Hahesy et al., 2002; Khantzian 1985; Sonne et al., 1994;
Strakowski et al., 1998; Winokur et al., 1995)

## Risk Factors for the Development of BD-SUD

- Common risk factors
- Genetic influences
- Environmental / familial factors
- History of childhood abuse
- These factors are also related to co-occurrence
- SUD associated with earlier age of onset of bipolar disorder

**Notes:**
Brown et al., 2005; Dalton et al., 2003; Feinman and Dunner, 1996; Strakowski et al., 2005; 
Winokur et al., 1995, 1998)

## Influence of SUDs on Bipolar Disorder

- SUD + psychiatric illness =
- more severe symptoms
- increased suicidality
- poor adherence to treatment and medications
- negative mental health outcomes
- SUD negatively impacts presentation, course, and prognosis of bipolar disorder

**Notes:**
(Hasegawa et al., 1990; Feinman and Dunner, 1996; Schuckit et al., 1997; Sonne and Brady, 2002; Tsuang et al., 1995

## Influence of SUDs on Bipolar Disorder

- Effect of substance use disorder appears to be additive
- Shared symptom clusters more severe in individuals with both disorders vs. those with either disorder alone

**Notes:**
(Hasegawa et al., 1990; Feinman and Dunner, 1996; Schuckit et al., 1997; Sonne and Brady, 2002; Tsuang et al., 1995)

## Symptoms and Course

- More rapid cycling, dysphoria, and mixed mood states
- Slower remissions from acute manic episodes
- Shorter latency between episodes
- Delayed recovery
- Frequent relapses
- More episodes

**Notes:**
(Brady et al., 1991; Cassidy et al., 2001; Feinman and Dunner, 1996; Golderberg et al., 1999; 
Himmelhoch et al., 1976; Keller et al., 1986; Reich et al., 1974; Salloum and Thase, 2000; 
Salloum et al., 2002; Sonne et al., 1994)

## Symptoms and Course

- Higher total number of manic symptoms, increased mood lability, impulsivity, violence
- Increased utilization of health services including:
- Emergency department visits
- Psychiatric hospitalizations

**Notes:**
(Brady et al., 1991; Cassidy et al., 2001; Feinman and Dunner, 1996; Golderberg et al., 1999; 
Himmelhoch et al., 1976; Keller et al., 1986; Reich et al., 1974; Salloum and Thase, 2000; 
Salloum et al., 2002; Sonne et al., 1994)

## Symptoms and Course

- Substance use levels (drinks per drinking day, marijuana use) are related to clinical course
- Associations
- Alcohol dependence with depressive symptoms
- Cannabis dependence with manic symptoms
- Stimulants may be used to prolong manic episodes

**Notes:**
(Baethge et al., 2005; Feinman and Dunner, 1996; McKowen et al., 2005; Salloum et al., 2005; 
Strawkowski et al., 2005)

## Clinical and Treatment Outcomes

- Substance use associated with poorer treatment outcomes among bipolar patients
- Patients with bipolar disorder using two or more substances have worse outcomes
- Impedes recovery & functioning
- Full remission of SUD: 73%
- Relapse within one year of remission: 36%

**Notes:**
(Baethge et al., 2005; Drake et al., 2004; Salloum and Thase 2000; Strawkowski et al., 2005; Weiss et al., 2005; Winokur et al., 1995)

## Clinical and Treatment Outcomes

- Patients with co-occurring disorders cycle in and out of treatment
- Patients have significantly fewer psychiatric outpatient visits and shorter psychiatric inpatient stays
- Worse continuity of care
- Stable recovery from bipolar disorder less likely among patients with current SUD

**Notes:**
(Baethge et al., 2005; Drake et al., 2004; Salloum and Thase 2000; Strawkowski et al., 2005; Weiss et al., 2005; Winokur et al., 1995)

## Medication Adherence

- Patients have poorer medication adherence
- Forgetting to take medications
- Lose medications
- Discontinue medications
- Medications can be less effective in combination with substance use
- Medical dangers of combining BD medications with alcohol and other drugs

**Notes:**
(Goldberg et al., 1999; Keck et al., 1998; Maarbjerg et al., 1988; Sajatovic et al., 2006; Verduin et al., 2005)

## Quality of Life Outcomes

- Compared to bipolar patients without SUD, those with bipolar disorder and current or past substance use disorders report
- Significantly lower quality of life
- Poorer role functioning
- Severity of alcohol dependence worsens quality of life and psychosocial outcomes
- Even moderate use of alcohol can impact quality of life

**Notes:**
(Bauer et al., 2005; Friedman et al., 2005; Salloum and Thase, 2000; Singh et al., 2005; 
Sonne et al., 1994; Tohen et al., 1990; Weiss et al., 2005)

## Psychosocial Outcomes

- Psychosocial factors associated with comorbidity
- Worse marital status
- Lower levels of education
- Additional Axis I disorders and medical problems
- Increased disability and mortality
- Greater criminal history
- More homelessness

**Notes:**
(Bauer et al., 2005; Friedman et al., 2005; Salloum and Thase, 2000; Singh et al., 2005; 
Sonne et al., 1994; Tohen et al., 1990; Weiss et al., 2005)

## Suicide

- Patients with comorbid bipolar disorder and SUDs are more likely to attempt suicide
- Odds of attempting suicide are 2 to 3 times higher for individuals with comorbid               BD + Alcohol dependence vs. BD only
- Individuals with comorbid BD-SUDs are significantly more likely to be suicidal compared   to those with either disorder alone

**Notes:**
(Comtois et al., 2004; Dalton et al., 2003; Feinman and Dunner 1996; Goldberg et al., 1999; Morrison 1974; 
Potash et al., 2000; Tondo et al., 1999; Verduin et al., 2005; Weiss et al., 2005; Winokur et al., 1995)

## Common Medical Conditions in VA Patients with Bipolar Disorder 

**35**

**23**

**Hypertension**

**Hyperlipidemia**

**%**

**Notes:**
Kilbourne AM, Cornelius JR, Han X et al. Burden of general medical conditions among individuals with bipolar disorder. Bipolar Disord. 2004; 6:368-373. 

## Contributing Factors to Comorbidities

- Patient
- Family hx, Health behaviors, Stress
- Treatment
- Side effects, Weight gain
- Provider
- Competing priorities, Lack of resources, information
- Health System
- Access to care, Fragmentation

## BD-SUD and Medical Care

- Bipolar disorder presents a unique challenge because of its cyclical nature
- Bipolar disorder can lead to
- Little contact with health care
- Lack of motivation to seek medical care
- This can lead to an increased risk of medical comorbidity

## BD-SUD and Medical Care

- Mania has been linked to binge eating
- Mania leads to sleep problems -- which are self-medicated by substance use
- Depressive episodes exacerbate the risk of CVD through sedentary lifestyle, overeating, smoking, and subsequent weight gain

## BD-SUD and Risky Behaviors

- Substance use can also lead to risky and impulsive behaviors
- Risky sexual behaviors
- Increased risk of STIs (e.g., Hep C, HIV)
- Injuries

## Red Flags to Identify BD-SUD

- Medical conditions/Physical signs
- Hepatitis C, HIV
- Missed appointments
- Critical encounters
- Hospitalizations, ER, arrest
- New manic/depressive episodes
- Anxiety symptoms
- Not refilling prescriptions
- Multiple requests for prescriptions

## SUD Assessment 

- Brief, practical screeners (e.g., AUDIT-C)
- Address quantity, frequency, binge use
- Formal assessment to confirm extent of use as needed
- Repeat assessments

## New Initiatives 

- VA performance measures
- NCQA adopted Washington Circle measures (identification, management)
- Integrated Care Initiatives
- “No Wrong Door” to treatment

## VANTS Call

- May 23, 2006
- 2:00 pm Eastern
- 1-800-767-1750
- Extension 14945