Treating Mental Health Patients with Substance Abuse Disorders
Daniel Headrick, MD Pacific Coast Recovery Center 31872 Coast Highway Laguna Beach, CA 866 633-6787
Bipolar vs. Depression
Himasiri De Silva, MD, DLFAPA Medical Director Behavior Health Service St. Joseph Hospital, Orange, CA
Bipolar Disorder GL 84 yr old male being treated for Bipolar Disorder, Type 1 For 45 yrs, had classical symptoms of mania and depression
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Daughter CL treated for Bipolar Disorder Type II with significant depressions.
Daughter ML treated for Bipolar Disorder Type II. Only mild hypomanic episodes.
Daughter of CL treated for a single episode of Manic Psychosis 14 years ago. No recurrence in mania or episodes of depression during this period.
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Son of ML treated for recurrent episodes of depression and alcohol abuse, diagnosed as Bipolar Type I.
Presentations
Bipolar Disorder, Type 1 in grandfather Bipolar Disorder, Type II in daughter CL Bipolar Disorder, Type II in daughter ML Single episode of Manic Psychosis in GD/CL Bipolar Disorder, Type 1 and Substance Abuse in GS/ML
Criteria for Manic Episode
Pressured speech Hyper verbosity Physical hyperactivity and agitation Decreased need for sleep Hyper sexuality Extravagance
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Mood Symptoms in Mania
Euphoria Irritability Anxiety Hostility
Behavioral Symptoms
Pressured speech Impulsivity Recklessness Diminished need for sleep Elevated libido Violence
Cognitive Symptoms Distractibility Racing thoughts Poor insight Disorganized thinking Inattention Confusion Perceptual symptoms Delusions Hallucinations Sensory hyper acuity
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Criteria for Hypomanic Episode
Periods of persistently elevated, expansive irritable mood lasting at least 4 days, clearly distinct from usual nondepressed mood Inflated selfself-esteem Decreased need for sleep More talkative than usual
Criteria for Hypomanic Episode (cont.)
Raising thoughts Distractibility Increased pleasurable activities No marked impairment in social or occupational functions
11 Nonmanic Markers
Repeated episodes of depression Early age of onset of mood disturbance (before age of 25) Family history of BD, particularly a first degree relative Hyperthymic personality Atypical depression (hypersomnia (hypersomnia,, hyperphagia, hyperphagia, leaden anergy, anergy, rejection sensitivity)
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11 Nonmanic markers (cont.)
Brief episodes of depression lasting less than three months Psychosis Postpartum onset Hypomania when treated with antidepressant medication Loss of patient response to antidepressant agent Three or more antidepressant medications ineffective
National Survey By Depressive and Bipolar Support Alliance
Participant Demographics (N=600)
Females
Never Married
31% 28%
25% 34% 37%
Worked Full Time Completed Some College
23% 29%
66%
Separated or Divorced Married
4141-50 yrs old 5151-60 yrs old
Completed 4 yrs 21% Some Post College Education 27%
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Signs of Depression Before Diagnosis
Prolonged sadness, pessimism Insomnia Guilt, worthlessness Inability to concentrate Loss of energy
Signs of Mania Before Diagnosis
Heightened mood, elation, increased selfself-confidence Erratic sleeping/decreased need for sleep Racing thoughts/increased speech production Increased physical/mental activity Poor judgment
Signs of Depression Before Diagnosis Signs
Experienced
Reported
Prolonged Sadness, Pessimism Insomnia
80%
62%
57%
47%
Guilt, Worthlessness
77%
52%
Inability to Concentrate
75%
53%
Loss of Energy
74%
57%
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Signs of Mania Before Diagnosis Signs Heightened Mood, Elation, SelfSelfConfidence Erratic Sleeping / Decreased Need Racing Thoughts / Increased Speech Increased Physical / Mental Activity Poor Judgment
Experienced
Reported
75%
37%
74%
56%
72%
43%
70%
35%
70%
36%
Time Lapse: From Signs to First Seeking Help
< 6 Months 6 MonthsMonths-1 Year At Least 1 Year— Year—< 5 Years At Least 5 Years— Years—< 10 Years > 10 Years
26% 10% 15% 13% 31%
Common Misdiagnoses
Unipolar Depression Most Common Anxiety Disorder Schizophrenia Alcohol or Substance Abuse Schizoaffective Disorder
60% 26% 18% 14% 11%
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Why Incorrect Diagnosis?
Lack of Understanding Symptoms not taken seriously Lack of communication Patients did not report all symptoms Lack of support from family/friends Did not go to mental health professional Lack of communication among doctors
60% 39% 37% 28% 23% 17% 3%
Prevalence of Misdiagnosis Misdiagnosis Of those misdiagnosed:
69%
Misdiagnosed 11-3 Times Misdiagnosed 44-6 Times
70% 14%
It was necessary to consult four physicians before correct diagnosis
Lapsed Time: Seeking Help to Accurate Diagnosis 1992
2000
Misdiagnosed #
(363)
(411)
< 1 yr
14%
20%
> 1 yr, < 3 yrs
17%
17%
> 3 yrs, < 5 yrs
9%
11%
> 5 yrs, < 10 yrs
15%
16%
> 10 yrs
41%
35%
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BD is commonly misdiagnosed as Unipolar Depression (MDD) Antidepressants unopposed will increase cycling or frequency PCPs wrote 80 million Rxs for antidepressants in 2001, 80% increase from 1996
Depression should not be regarded as an end point Diagnostic workup should follow Possibilities include BP 1, BP11, Mixed BD, Unipolar Depression, Dysthymic Disorder, ADHD, Organic Mood Disorders
Depression no longer should be regarded as a diagnosis
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Consequences of Misdiagnosis
Delay in effective therapy Direct health care cost significantly higher Mood stabilizing therapy less effective after unsuccessful therapy for depression Antidepressants are not more effective than mood stabilizers Antidepressant therapy can have a destabilizing effect Misdiagnosed will not get the benefits of appropriate psychopsycho-education Unrecognized Bipolar Disorder leads to higher rates of hospitalizations and suicidal attempts
Economic Impact of Bipolar Disorder
5 to 10 years delay in diagnosis and effective treatment Actual treatment falls short of established treatment guidelines Only one in 6 patients received medications consistent with national guidelines Only 2/3rd of outpatients received mood stabilizers
Out of 3349 patients in California MediMedi-Cal program from 1994 to 1998, only 42% received a mood stabilizer in the year following their diagnosis of BPD Health care costs were higher among patients who delayed taking mood stabilizers
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Spent $ 44 billion in 1991 Cost of single manic episode is$11,720 Cost of chronic or recurrent manic episodes is $624,780 per person
Thank you
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