Part I Presentation Slides no background

							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%
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
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
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%
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
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
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%
Comorbidity in Clinical
Populations
   Outpatients with bipolar disorder
    – 65% at least one comorbid lifetime Axis I
      disorder
    – 42% comorbid substance use disorders
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
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
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
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
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
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
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
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
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
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%
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
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
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
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
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
       Common Medical Conditions in
 100
  90
       VA Patients with Bipolar Disorder
  80
  70
  60
% 50
  40   35
  30        23
  20             17   15   16
  10                            11   11
                                          6
   0
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