Bipolar Disorder & Adolescent Substance Use Disorder

Bipolar Disorder & Adolescent Substance Use Disorder Elham Shirazi M.D. Board of General Psyciatry Board of Child & Adolescent Psychiatry

Manic symptoms: Elevated, expansive, or irritable mood Inflated self-esteem, grandiosity Decreased need for sleep Pressured speech Flight of ideas, racing thoughts Distractibility Increased goal directed activity, or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences

The topic of BD + SUD is beginning to develop. • BD shares the strongest association with SUD. • There is an increase in morbidity & mortality among adults with comorbid BD & SUD. • It is imperative to improve methods of early identification & treatment of both disorders.

Youth with BD are at greatly increased risk of SUD as a complication of their mood disorder. • Both epidemiologic & clinical studies have shown the exceedingly high rate of SUDs among BDs. • Subtreshold substance use is highly prevalent among BD youth (Strober, 1995). • There is a markedly increased prevalence of BD in studies of youth with SUD.

When SUD occurs with BD: • Recovery is delayed • Relapse is hastened • Symptoms are greater in number • Symptoms persist between episodes • Disability & mortality are increased (Cassidy, 2001)

Combination of : • Early identification & treatment of BD among adolescents • Facilitation & organization of aftercare May decrease the development of SUD secondary to BD (Wilens, 1999; Strober, 1995).

Compared to BD (without SUDs), those with SUDs + BD demonstrate : • Increased impulsivity (Swann, 2004) • Increased suicidality (Dalton, 2003) • Decreased medication compliance (Weiss, 1998) • Decreased quality of life (Singh, 2005) • Impaired role functioning even in those who recover from SUDs (Weiss, 2005). • Even moderate alcohol use may be associated with increased severity of illness in BD (Goldstein, 2006)

SUD increases the burden of BD including: Chronicity Cyclicity Service utilization Morbidity & mortality

The attenuation & remission of SUD is of paramount importance to BD outcome. Preventive efforts are crucial for youth with BD who have not yet manifested SUD.

Screen for SUDs among youth with even subsyndromal symptoms of BD. • Subsyndromal BD is associated with an equally high prevalence of SUDs. • There is also a high prevalence of SUD among the families of both BD & subsyndromal BD patients(Lewinsohn, 2000).

The substances of abuse are most commonly alcohol & marijuana. Cigarette smoking in early adolescence is a significant predictor of marijuana dependence in later adolescence (Coffey, 2003). The association between age and substance of choice among BD youth requires further study.

Given the susceptibility of youth with BD for SUD Given the risks involved in this population (i.e., triggering mania, depression, or psychosis) Therefore youth with BD should be: Regularly screened for cigarette smoking Smoking cessation interventions should be instituted urgently.

In adolescents the prevalence of SUD in BD-I = BD-II (Wilens,1997). In adults the prevalence of SUD in BD-I > BD-II (Chengappa, 2004).

Future studies are needed to examine the impact of cardinal symptoms of BD (euphoria & grandiosity vs irritability) on the prevalence of SUDs. Comorbid SUD is most strongly associated with history of suicide attempt in BD(Goldstein, 2005). SUD is a significant predictor of suicide attempts in multivariate analyses.

Impulsivity may confer a diathesis to both SUD & suicidality(Swann, 2004, 2005). Antecedent BD may be a risk factor for the later development of SUD among youth(Biederman, 1997). BD confers a distinct risk for SUD, over & above that conferred by externalizing disorders(Wilens, 1997, 2004).

Subsyndromal mood flactuation, co-occuring with SUD, among offspring or younger siblings of adults with BD, may be a harbinger of later BD. Family members of BD youth: • Have elevated rates of SUD • SUD onset tends to occur at a younger age. • A high index of suspicion for SUD is indicated for adolescent relatives of BD youth.

SUDs are extremely common among parents of BD youth. BD youth who have parents with SUD should be considered for family-focused interventions. SUD among offspring of adults with BD may be a strong & specific correlate of offspring BD.

Youth with BD may present with symptoms that they seek to self-medicate with substances: Excessive euphoria Irritability Dysphoria Psychosis Anxiety ...

Youth experiencing mania or hypomania as an enjoyable mood state may turn to substance use to prolong this mood state. Particularly if depressive episodes follow closely after manic or hypomanic episodes.

Bipolar depression is difficult to treat. • Therefore such episodes may serve as a trigger for increased substance use • They search for an escape from: Depression-related boredom • Guilt-ridden or self-critical thoughts • Aversiveness of sadness • Mania & psychosis are often accompanied by poor insight • Self-report of substance use may be unreliable when mania & psychosis are prominent.

Panic attacks: Panic disorder is strongly associated with BD among youth. Panic disorder confers its own risk of substance use in BD (Goodwin, 2002). Inquiring about anxiety & panic attacks is central to assessment of patients with BD + SUD.

Mood charting is a commonly used approach to characterizing longitudinal patterns in mood dysregulation & related symptoms. Have the patient retrospectively describe longitudinal patterns in mood flactuations & changes in substance use.

1. This allows the clinician to appreciate: The relative burden of mood symptoms & of substance use Their impact on the patient’s functioning. Because part of the clinical challenge is the discrimination between primary mood symptoms & those that are secondary to ongoing substance use.

It is important to weigh the risks & benefits of aggressively treating mood symptoms occurring in BD+SUD. There must be a balance between optimizing the treatment of BD without “chasing” substance-induced symptoms with multiple psychotropics.

2. Provides the opportunity to demonstrate to the patient the association between substance use & mood-related difficulties. Psychoeducation regarding the dynamic between BD symptoms & substance use is a crucial part of ongoing treatment. This starts with assessment.

Patients believe that substances can do what no pharmacotherapy can: Don’t debate the short-term psychological benefits of substance use. Present the argument that substance use serves to destabilize mood.

The reason for substance use vary dramatically between patients: • Craving is central for some & is chronic & independent of mood state • For some, impulsivity which may be independent of mood state among BD youth, results in a positive feedback loop of escalating substance use. • For some, substances are used to self-medicate (therefore is not a problem during periods of euthymic mood). This heterogeneity in reasons has direct implications for treatment.

Youth with comorbid BD & SUD are at exceedingly high risk of: Suicidality Impulsive behavior (e.g. driving intoxicated, sexual indiscretions, inconsistent medication use,...)

Mood-stabilizing medications (with or without antidepressant), are the mainstay of treatment of BD. (Lithium, Valproate, Quetiapine, Lamotrigine, Naltrexone, Gabapentin) Few studies have examined the impact of pharmacological or nonpharmacological treatments on BD + SUD among adolescents.

Only lithium has evidence for use with adolescents with BD + SUD. Individuals with BD + SUD may be at high risk of antidepressant-induced mania(Goldberg, 2002).

It is important to document the burden of subsyndromal substance use (“hazardous” use), and identify persons at risk. Even moderate substance use may confer a risk of mood destablization in BD The risks of experimentation & recreational substance use (normative substance use) in BD adolescents should be considered.

Safety comes first Decide whether the treatment plan is meeting the safety needs of the youth

Bipolar Disorder & Adolescent Substance Use Disorder