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 1
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. 2
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 3
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 4
Criteria for Hypomanic Episode Periods of persistently elevated, expansive irritable mood lasting at least 4 days, clearly distinct from usual nondepressed mood Inflated self-esteem 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, leaden anergy,, rejection sensitivity) 5
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 66% 41-50 yrs old 31% 51-60 yrs old 28% Never Married 25% Separated or Divorced 34% Married 37% Worked Full Time 23% Completed Some College 29% Completed 4 yrs 21% Some Post College Education 27% 6
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 self-confidence Erratic sleeping/decreased need for sleep Racing thoughts/increased speech production Increased physical/mental activity Poor judgment Signs of Depression Before Diagnosis Signs Prolonged Sadness, Pessimism Insomnia Guilt, Worthlessness Inability to Concentrate Loss of Energy Experienced 80% 57% 77% 75% 74% Reported 62% 47% 52% 53% 57% 7
Signs of Mania Before Diagnosis Signs Heightened Mood, Elation, Self- Confidence Erratic Sleeping / Decreased Need Racing Thoughts / Increased Speech Increased Physical / Mental Activity Poor Judgment Experienced 75% 74% 72% 70% 70% Reported 37% 56% 43% 35% 36% Time Lapse: From Signs to First Seeking Help < 6 Months 26% 6 Months-1 1 Year 10% At Least 1 Year < < 5 Years 15% At Least 5 Years < < 10 Years 13% > 10 Years 31% Common Misdiagnoses Unipolar Depression Most Common 60% Anxiety Disorder 26% Schizophrenia 18% Alcohol or Substance Abuse 14% Schizoaffective Disorder 11% 8
Why Incorrect Diagnosis? Lack of Understanding 60% Symptoms not taken seriously 39% Lack of communication 37% Patients did not report all symptoms 28% Lack of support from family/friends 23% Did not go to mental health professional 17% Lack of communication among doctors 3% Prevalence of Misdiagnosis Misdiagnosis 69% Of those misdiagnosed: Misdiagnosed 1-31 3 Times 70% Misdiagnosed 4-64 6 Times 14% It was necessary to consult four physicians before correct diagnosis Lapsed Time: Seeking Help to Accurate Diagnosis Misdiagnosed # < 1 yr > 1 yr, < 3 yrs > 3 yrs, < 5 yrs > 5 yrs, < 10 yrs > 10 yrs 1992 (363) 14% 17% 9% 15% 41% 2000 (411) 20% 17% 11% 16% 35% 9
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 10
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 psycho-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 Medi-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 11
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 12