Substance Abuse and Mood Disorders: The Chicken or the Egg?
Presented at the US Psychiatric Congress, Las Vegas, 2011
Manuel Mota-Castillo, M.D. - Assistant Clinical Professor at University of Central Florida and St. Matthews University Medical Schools, Orlando, Florida.
Gustavo Vazquez, M.D. - Professor of Psychiatry at University of Palermo, Argentina.
Daniel Pistone, M.D. - Staff Psychiatrist at Evergreen Behavioral Manageme nt In North Carolina
For decades the controversy about a possible self-medicating benefit from the abuse of sedative med ications to individuals with bipolar spectrum disorders have been the subject of multiple scientific papers. 1,3 Merikangas et al found that "Individuals having manic symptoms were at significantly greater risk for the later onset of alcohol abuse/dependence, cannabis use and abuse/dependence, and benzodiazepine use and abuse/dependence. Bipolar II disorder predicted both alcohol abuse/dependence and benzodiazepine use and abuse/dependence. In contrast, major depression was predictive only of later benzodiazepine abuse/dependence."
We aim to follow 100 individuals that have come to an inpatient facility or outpatient practice with a Chief Complaint of substance abuse and were found to have an undiagnosed bipolar spectrum disorder. Our objective is to investigate the relationship between the presence of an underlying (undiagnosed) bipolar spectrum disorder, and evidence of self-medication with illicit substances or abuse of prescribed medication.
This is an observational study that seeks to monitor the outcome of the subjects (50 men and 50 women) that will be followed for 12 months to assess response to treatment with mood stabilizers, length of sobriety and either they still have craving for the drug (s) of choice after mood stabilization has been achieved. Each volunteer is screened with a 7-questions instrument developed by the authors which has not been validated yet but we plan to do so . Subjects with four "yes" answers or more are further screened with the Bipolar Spectrum Diagnostic Scale 2 to advance the possibility of assigning or ruling out the diagnosis of a mood disorder. A final diagnosis is established with a structured clinical interview. 867 patients were approached but many of them were unwilling or unable (i.e. homeless transient) to participate. Of the 98 patients that consented to participate only 31 have been able to stay in treatment and to report their outcomes.
This is a preliminary report of an ongoing study. In 7 months of investigation we have found evidence suggestive of statistically significant correlation (P value: 0.005) in the 31 patients already enrolled in this study between undiagnosed and untreated bipolar spectrum disorder and abuse of a psychoactive substance with sedative effects. Most patients were abusing cannabis, benzodiazepines, opiates or alcohol. So far we have encounter 2 cases of pure alcohol dependence, 3 of PTSD and alcohol/opiates abuse among those excluded with the structured clinical interview. Of note, we found an unsuccessful overuse of trazodone as sleep aid , which in most cases induced an increase in racing thoughts, in many patients misdiagnosed as "co -morbid" depression and anxiety . Remarkably these 31 patients have maintain sobriety while taking mood stabilizers and deny cravings for drug or alcohol.
Our preliminary data seems to indicate that clinicians should search for the possibility of a baseline bipolar spectrum disorder in patient s presenting with a history of sedatives abuse. We would like to infer that treating a mood disorder will increase the possibilities of maintaining sobriety after a rehabilitation treatment but the number of patients at this time is too small to have a predictive value. We believe these preliminary findings warrant further investigation regarding the effect of treating the underlying BP disorder upon maintaining sobriety and we hope to motivate researchers to replicate this study .
The heterogeneous nature of this population (i.e., from a practicing physician to a homeless construction worker) makes certain settings (Veteran Affairs, Department of Defense, police forces, etc.) advantageous because they could have "captive audiences." Ideally, in any of those institutions a randomized study could be adjusted for age, gender and length of substance abuse . Should our findings prove to be true in future studies it could mean a significant saving in money for the insurance companies and states budgets (Medicaid) as well and less pain and
suffering for thousands of patients.
This is a preliminary report of what should be a larger study, but the diagnosis at the heart of this investigation (bipolar disorder) has been found to have a dropout rate ranging from so to 80% 4 in multiple studies reviewed by Dr. Ghaemi and several other researchers.
Funding and disclosures: Self-funded . The authors have no conflict of interest to disclose.
Merikangas KR, Herrell R, Swendsen J, Rossle r W, Ajdacic-Gross V, Angst J. ; Specificity of bipolar spectrum conditions in the comorbidity of mood and susbstance use disorders: results from the Zurich cohorts study; Arch Gen Psychiatry, 2008, Jan; 65 (1) : 4 7-52
Ghaemi, S.N., Miller, C.J., Berv, D.A., Klugman, J., Rosenquist, K., Pies, R.W.; Sensitivity and specificity of o new bipolar spectrum diagnostic scale, Journal of Affective Disorders; Vol. 84, Issues 2·3, Feb 2005:273-2 77.
Rothe et al., Are the Media and the Public Still Missing the Clues ? Psychiatric Times' blog Couch in Crisis, August 18th 2011
Ghaemi, S. N.; A Clinician 's Guide to Statistics and Epidemiology in Mental Health, 2009; Cambridge University Press.