Substance use disorders among adolescents with bipolar spectrum disorders

Objective: We set out to examine the prevalence and correlates of substance use disorders (SUD) in a large sample of adolescents with bipolar disorder (BP). Methods: Subjects were 249 adolescents ages 12 to 17 years old who fulfilled DSM‐IV criteria for bipolar I disorder [(BPI), n = 154], or bipolar II disorder [(BPII), n = 25], or operationalized criteria for BP not otherwise specified [(BP NOS), n = 70], via the Schedule for Affective Disorders and Schizophrenia for School‐Aged Children (K‐SADS). As part of the multi‐site Course and Outcome of Bipolar Youth study, demographic, clinical, and family history variables were measured via intake clinical interview with the subject and a parent/guardian. Results: The lifetime prevalence of SUD among adolescents with BP was 16% (40/249). Results from univariate analyses indicated that subjects with, as compared to without, SUD were significantly less likely to be living with both biological parents, and that there was significantly greater lifetime prevalence of physical abuse, sexual abuse, suicide attempts, conduct disorder, and posttraumatic stress disorder among subjects with SUD. Subjects with SUD reported significantly greater 12‐month prevalence of trouble with police, and females with SUD reported significantly greater 12‐month prevalence of pregnancy and abortion. Significant predictors of SUD in a logistic regression model included living with both biological parents (lower prevalence), conduct disorder and suicide attempts (increased prevalence). In logistic regression analyses controlling for demographic differences and conduct disorder, SUD remained significantly associated with trouble with police, whereas the association of SUD with pregnancy and abortion was reduced to a statistical trend. The prevalence of SUD was not significantly different among child‐ versus adolescent‐onset BP subjects. Conclusions: SUD among adolescents with BP is associated with profound hazards including suicide attempts, trouble with police, and teenage pregnancy and abortion.     

Substance use disorders and suicide attempts in bipolar subtypes

Bipolar disorder (BD) is associated with high rates of suicide attempt and completion. Substance use disorders (SUD) have been identified as potent risk factors for suicidal behavior in BD. However, little is known concerning differences between BD subtypes with regard to SUD as a risk factor for suicidal behavior. We studied previous suicidal behavior in adults with a major depressive episode in context of BD type I (BD-I; N = 96) or BD type II (BD-II; N = 42), with and without history of SUD. Logistic regressions assessed the association between SUD and suicide attempt history by BD type, and exploratory analyses examined the effects of other clinical characteristics on these relationships. SUD were associated with suicide attempt in BD-I but not BD-II, an effect not attributable to sample size differences. The higher suicide attempt rate associated with alcoholism in BD-I was mostly explained by higher aggression scores, and earlier age of BD onset increased the likelihood that alcohol use disorder would be associated with suicide attempt(s). The higher suicide attempt rate associated with other drug use disorders in BD-I was collectively explained by higher impulsivity, hostility, and aggression scores. The presence of both alcohol and drug use disorders increased odds of a history of suicide attempt in a multiplicative fashion: 97% of BD-I who had both co-morbid drug and alcohol use disorders had made a suicide attempt. A critical next question is how to target SUD and aggressive traits for prevention of suicidal behavior in BD-I.     

Substance abuse in bipolar disorder

Background: High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized.

Methods: Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted.

Results: Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations.

Conclusions: Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.     

Substance use disorders in individuals with body dysmorphic disorder

BACKGROUND: Little is known about substance use disorders (SUDs) in individuals with body dysmorphic disorder (BDD). Although studies have examined SUD comorbidity in BDD, no previous studies have examined clinical correlates of SUD comorbidity. METHOD: We examined rates and clinical correlates of comorbid SUDs in 176 consecutive subjects with DSM-IV BDD (71% female; mean +/- SD age = 32.5 +/- 12.3 years). Comorbidity data were obtained with the Structured Clinical Interview for DSM-IV. BDD severity was assessed with the Yale-Brown Obsessive Compulsive Scale Modified for BDD, and delusionality (insight) was assessed with the Brown Assessment of Beliefs Scale. Quality of life and social/occupational functioning were examined using the Social Adjustment Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, Medical Outcomes Study 36-Item Short-Form Health Survey, and Range of Impaired Functioning Tool. All variables were compared in BDD subjects with and without lifetime and current SUDs. Data were collected from January 2001 to June 2003. RESULTS: 48.9% of BDD subjects (N = 86) had a lifetime SUD, 29.5% had lifetime substance abuse, and 35.8% had lifetime substance dependence (most commonly, alcohol dependence [29.0%]). 17% (N = 30) had current substance abuse or dependence (9.1% reported current substance abuse, and 9.7% reported current dependence). 68% of subjects with a lifetime SUD reported that BDD contributed to their SUD. There were far more similarities than differences between subjects with a comorbid SUD and those without an SUD, although those with a lifetime SUD had a significantly higher rate of suicide attempts (p = .004). CONCLUSION: These preliminary results suggest that SUDs are very common in individuals with BDD. Subjects with and without a comorbid SUD were similar in most domains that were examined.     

An update on adjunctive treatment options for bipolar disorder

Objectives

Bipolar disorder is a complex illness often requiring combinations of therapies to successfully treat symptoms. In recent years, there have been significant advancements in a number of therapies for bipolar disorder. It is therefore timely to provide an overview of current adjunctive therapeutic options to help treating clinicians to inform their patients and work towards optimal outcomes.

Methods

Publications were identified from PubMed searches on bipolar disorder and pharmacotherapy, nutraceuticals, hormone therapy, psychoeducation, interpersonal and social rhythm therapy, cognitive remediation, mindfulness, e‐Health and brain stimulation techniques. Relevant articles in these areas were selected for further review. This paper provides a narrative review of adjunctive treatment options and is not a systematic review of the literature.

Results

A number of pharmacotherapeutic, psychological and neuromodulation treatment options are available. These have varying efficacy but all have shown benefit to people with bipolar disorder. Due to the complex nature of treating the disorder, combination treatments are often required. Adjunctive treatments to traditional pharmacological and psychological therapies are proving useful in closing the gap between initial symptom remission and full functional recovery.

Conclusions

Given that response to monotherapy is often inadequate, combination regimens for bipolar disorder are typical. Correspondingly, psychiatric research is working towards a better understanding of the disorder's underlying biology. Therefore, treatment options are changing and adjunctive therapies are being increasingly recognized as providing significant tools to improve patient outcomes. Towards this end, this paper provides an overview of novel treatments that may improve clinical outcomes for people with bipolar disorder.     

Substance use disorders in an obsessive compulsive disorder clinical sample

The prevalence and clinical correlates of substance use disorders (SUDs) were examined in a clinical sample of Obsessive Compulsive Disorder (OCD). As part of their intake interview into an observational study of the course of OCD, 323 participants completed a battery of standardized measures. Twenty-seven percent of the sample met lifetime criteria for a SUD. 70% of participants with comorbid SUDs reported that OCD preceded SUD onset by at least one year. Younger age at OCD onset and presence of Borderline Personality Disorder (BPD) were each associated with increased risk of alcohol use disorders but only BPD was associated with increased risk of drug use disorders. SUDs affect more than one-quarter of individuals who seek treatment for OCD. Individuals with a juvenile-onset of OCD or comorbid BPD may be especially vulnerable to SUDs. Further research is needed to identify risk factors for SUDs and to better understand their impact on OCD course.     

Risk of substance use disorders in adolescents with bipolar disorder

OBJECTIVE: Previous work in adults and youths has suggested that juvenile onset bipolar disorder (BPD) is associated with an elevated risk of substance use disorders (SUD). Considering the public health importance of this issue, the authors now report on a controlled study of adolescents with and without BPD to evaluate the risk of SUD. METHOD: Probands with DSM-IV BPD (n=57, mean age +/- SD=13.3 +/- 2.4 years) and without DSM-IV BPD (n=46, 13.6 +/- 2.2 years) were studied. Structured psychiatric interviews and multiple measures of SUD were collected. RESULTS: Bipolar disorder was associated with a highly significant risk factor for SUD (32% versus 7%, Z=2.9, p=.004) that was not accounted for by conduct disorder (adjusted odds ratio=5.4, p=.018). Adolescent-onset BPD (> or =13 years) was associated with a higher risk of SUD compared with those with child-onset BPD (chi1=9.3, p=.002). CONCLUSIONS: These findings strongly indicate that BPD, especially adolescent onset, is a significant risk factor for SUD independently of conduct disorder.     

Women and bipolar disorder: an update

The major clinical challenges facing women with bipolar illness, and the practitioners who care for them, are the management of rapid cycling and of the postpartum period. Among patients with rapid cycling bipolar disorder, the treatment of depression is particularly problematic. The most commonly prescribed mood stabilizers are more potent antimanic than antidepressant agents, and the use of antidepressants may precipitate mania or rapid cycling. The availability of new anticonvulsant medications that may have both mood-stabilizing and antidepressant effects is an important development in this regard. In the postpartum period, women with bipolar illness are at uniquely high risk for relapse. The possible reasons for this high risk, and options for the management of pregnancy and the postpartum period in bipolar women, are discussed.     

Screening for bipolar disorder among outpatients with substance use disorders

BackgroundComorbidity of bipolar disorder and alcohol or substance abuse/dependence is frequent and has marked negative consequences on the course of the illness and treatment compliance. The objective of this study was to compare the validity of two short instruments aimed at screening bipolar disorders among patients treated for substance use disorders.MethodsThe Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32) were tested with reference to the mood section of the Structured Clinical Interview for DSM-IV axis I disorders (SCID) in 152 patients, recruited in two outpatient clinics providing specialized treatment for alcohol and opiate dependence.ResultsAccording to the SCID, 33 patients (21.7%) had a diagnosis within the bipolar spectrum (two bipolar I, 21 bipolar II and 10 bipolar not otherwise specified). The HCL-32 was more sensitive (90.9% vs. 66.7%) and the MDQ more specific (38.7% vs. 77.3%) for the whole sample. The MDQ displayed higher sensitivity and specificity in patients treated for alcohol than for opiate dependence, whereas the HCL-32 was highly sensitive but poorly specific in both samples. Both instruments had a positive predictive value under 50%.ConclusionsCaution is needed when using the MDQ and HCL-32 in patients treated for substance use disorders.     

Association of bipolar and substance use disorders in parents of adolescents with bipolar disorder.

BACKGROUND: We have previously shown that juvenile bipolar disorder (BPD) is a risk for substance use disorders (SUD). Here we examine the expression of both disorders in families of youth with BPD to evaluate the familial risk mechanism. METHODS: We studied 108 adolescent BPD probands with 187 parents (34 with SUD and 58 parents) and 96 control probands with 177 parents with structured interviews. We compared the prevalence of BPD and SUD with Cox proportional hazards models with time to onset of BPD or SUD as the dependent variable and proband diagnosis (Control, BPD, or BPD+SUD) as the independent variable. RESULTS: The parents of the proband youth with BPD (without SUD) and BPD+SUD were more likely to develop BPD than the parents of control subjects [omnibus test chi2=10.18, p=.006]; we found no differences between the two bipolar groups. Parents of proband youth with BPD and with BPD+SUD were more likely than relatives of control subjects to develop SUD [omnibus test chi2=14.69, p<.001]; however, we found no differences between the parents of the two proband bipolar groups. Within the parents of proband youth with BPD+SUD, we found higher risk of SUD in parents with BPD than in those without BPD [chi2=8.39, p=.004], although the frequency of BPD was low in this group of parents. CONCLUSIONS: Bipolar disorder and SUD are prevalent in the first-degree relatives of adolescents with BPD. Adults with BPD were more likely to manifest SUD with preliminary evidence of BPD and SUD cosegregation.     

Personality disorders in recent-onset bipolar disorder

The frequency and types of DSM-III personality disorders (PDs) were investigated in a sample of 26 recent-onset bipolar-disordered (BD) patients. Results showed that 62% of BD patients had PDs according to the Structured Interview for DSM-III Personality Disorders (SIDP). The most frequently diagnosed PDs were the histrionic, borderline, passive-aggressive, and antisocial categories. A comparison between the BD patients and a sample of 35 recent-onset schizophrenic patients showed significant differences for two PDs. Schizotypal PD was more frequently diagnosed in the schizophrenic group, while the BD group had a higher frequency of histrionic PD.     

Anxiety disorders comorbidity in bipolar disorder

High comorbidity between bipolar and anxiety disorders is frequently described in epidemiological and clinical studies. This association has important implications for diagnoses, clinical outcome, therapeutic intervention and prognoses of bipolar disorder that are presented in this review.     

Substance use disorder and personality disorder

Personality disorders (PDs) and substance use disorders (SUDs) frequently co-occur in both the general population and in clinical settings. Literature is reviewed documenting high comorbidity between these two classes of disorders, possible mechanisms of comorbidity, and the clinical implications of this comorbidity. Special emphasis is given to antisocial personality disorder (ASPD) and borderline personality disorder (BPD) as these disorders not only co-occur frequently with SUDs in the clinical populations and present clinical challenges, but also because recent research points to etiologic processes that are common to these specific PDs and SUDs. Although most attention on comorbidity between PDs and SUDs has focused on ASPD and BPD, it is also clear that other PDs (in particular, avoidant PD and paranoid PD) are prevalent among those suffering from SUDs.     

Substance use disorders in patients with posttraumatic stress disorder: a review of the literature

OBJECTIVE: Alcohol use disorders and other substance use disorders are extremely common among patients with posttraumatic stress disorder (PTSD). This article reviews studies pertaining to the epidemiology, clinical phenomenology, and pathophysiology of comorbid PTSD and substance use disorders. METHOD: Studies were identified by means of computerized and manual searches. The review of research on the pathophysiology of PTSD and substance use disorders was focused on studies of the hypothalamic-pituitary-adrenal axis and the noradrenergic system. RESULTS: High rates of comorbidity suggest that PTSD and substance use disorders are functionally related to one another. Most published data support a pathway whereby PTSD precedes substance abuse or dependence. Substances are initially used to modify PTSD symptoms. With the development of dependence, physiologic arousal resulting from substance withdrawal may exacerbate PTSD symptoms, thereby contributing to a relapse of substance use. Preclinical work has led to the proposal that in PTSD, corticotropin-releasing hormone and noradrenergic systems may interact such that the stress response is progressively augmented. Patients may use sedatives, hypnotics, or alcohol in an effort to interrupt this progressive augmentation. CONCLUSIONS: Vigorous control of withdrawal and PTSD-related arousal symptoms should be sought during detoxification of patients with comorbid PTSD and substance use disorders. Inclusion of patients with comorbid PTSD and substance use disorders in neurobiologic research and in clinical trials will be critical for development of effective treatments for this severely symptomatic patient population.     

Substance use disorders and attention-deficit/hyperactivity disorder: A review of recent developments

Despite the increased risk of substance use disorders (SUDs) on individuals with attention-deficit/hyperactivity disorder (ADHD), the mechanism of risk remains unclear. Given the high prevalence of ADHD in patients receiving treatment for addiction, all patients in treatment for SUDs should be screened for ADHD. Clinicians should develop skills in the use of appropriate instruments, including rating scales, as well as the assessment for developmentally appropriate manifestations and impairments associated with adolescent and adult forms of ADHD. Medication should never be provided in isolation from psychosocial treatment directed at the patient’s SUD.     

An update on the role of psychotherapy in the management of bipolar disorder

Recent studies have examined the value of combining structured forms of psychotherapy with medication maintenance for patients with bipolar disorder. These studies have been influenced by the growing body of literature on stress in the elicitation of manic and depressive episodes. Randomized trials published within the past 5 years indicate positive benefits of cognitive-behavioral therapy, interpersonal and social rhythm therapy, family-focused therapy, and group psychoeducation as adjuncts to mood stabilizers in delaying recurrences, stabilizing symptoms, and improving medication adherence. Open trials of family interventions for pediatric-onset bipolar patients also have yielded promising results. Questions remain about the relative advantages of one psychosocial approach over the others, whether there are subgroups of patients who respond to each type of intervention, the impact of psychotherapy on role functioning, mediators of treatment effects, and the potential utility of early intervention as a means of delaying the onset and/or severity of the disorder.