Objectives

1
Objectives

• The importance of identifying and treating
  bipolar disorder among patients with SUDs as
  early as possible
• Ways to address and treat bipolar patients' SUDs
  through psychosocial interventions, integrated
  care, or other treatment models
• Psychopharmacologic treatment of patients with
  bipolar disorder SUDs

2
Early Identification of Bipolar Disorderin
Substance Use Disorder (BD-SUD)

• 7- to10-year lag diagnosing BD in the general
  population
• Clinical Barriers
• Substances as triggers ? more episodes
• Episodes as triggers ? substance use
• Diagnostic dilemmas and dismissals
• Its all due tosubstances.
• Its all due tobipolar disorder.

3
Early Identification in BD-SUD

• System Barriers
• Financing
• Healthcare Organization
• Training and Culture
• SAMHSAs No Wrong Door Policy
• VHA Advantage There is no wrong door
• theoretically

4
Principles of BD-SUD Treatment

• Parallel (not serial) treatment
• Goals of Parallel Treatment
• Get substances off the table for dealing with
  illness and life
• Stabilize symptoms to allow participation in
  substance treatment

5
Principles of BD-SUD Treatment

• Look for and seek out complications
• Depression
• Mania
• Subtle Psychosis
• Anxiety
• Perseverance
• Sometimes the 17th times a charm
• Collaboration beats confrontation

6
Paternalistic Medicine
Thus I say
Yes I shall!
Fix me up!
Maternalistic Medicine
Load em on.
7
Collaborative Practice
Values Expert Athlete
Technical Expert Coach
8
Examples of Collaborative Interventions for BD-SUD

• Motivational Interviewing
• Miller Rollnick and others
• Integrated Group Therapy
• Weiss
• Life Goals Program Collaborative Chronic Care
• VA Cooperative Study 430

9
Purposes of Psychosocial Interventions

• Supplement (not replace) pharmacologic treatment
• Enhance illness management skills
• Address independent determinants of disease
  outcome (stressors, comorbidities)
• Enhance social role function and quality of life
• Reduce depression

10
Types of PsychosocialInterventions

• Psychotherapies Add-on
• Integrated Treatment Models Multimodal Packages

11
Types of Individual Psychotherapy

• Psychodynamic (Past life events)
• Supportive (Current life events)
• Interpersonal (Social relationships)
• Cognitive Behavioral (Thought habits)
• Social Rhythm (Stabilizing social rhythms)
• Psychoeducation (Knowledge and coping strategies)

12
Group Psychotherapy

• Mutual support
• Shared experiences
• Work on personal goals
• Stigma reduction

13
Other Psychotherapy

• Family Therapy
• Challenges in relationships between family
  members-conflict resolution
• Increase supportive family relationships
• Self-help Groups

14
Integrated Treatment Models

• Intensive Case Management
• Recovery-Oriented Programs
• Collaborative Chronic Care Models

15
Intensive Case Management

• Involves mobile community outreach,
  rehabilitative services via provider teams
• Examples ACT, MHICM
• Effective for SMI and co-occurring SUD
• High start-up costs impede dissemination into
  routine care

16
Recovery-Oriented Programs

• Mental health recovery is a journey of healing
  and transformation enabling a person with a
  mental health problem to live a meaningful life
  in a community of his or her choice while
  striving to achieve his or her full potential.
  SAMHSA 2005
• Include peer support, vocational training, family
  involvement, and other services

17
Collaborative Chronic Care Models

• Clinic-based tools to promote self-management and
  continuity of care for chronic illnesses
• VA CSP 430
• Self-management (Life Goals Program - group
  sessions)
• Delivery system/clinical information system
  redesign
• Decision support (Clinical Practice Guidelines)

18
VA CSP 430 Chronic Care Model for Bipolar
Disorder
Decision Support (Guidelines)
Self-Management (Life Goals)
Delivery System (Care Manager)
19
Life Goals Program

• Education, group interaction and support
• Personal symptom profile(s), warning signs
• Triggers and coping resources
• Personal cost-benefit analysis
• Action plan / personal care plan
• Destigmatization

20
Responding to Depression/Stress by Drinking
Alcohol
Good Effects
Bad Effects

• I can finally sleep
• I dont get panic attacks
• I dont feel so down
• It gets me out of the house, and when I
  socialize, I forget my troubles

• My wife gets mad at me
• Sometimes, it makes me not care feel like
  killing myself
• I feel terrible the next morning

21
Medications for the Management of Bipolar Disorder

• Lithium
• Anticonvulsants
• Antipsychotics
• Antidepressants
• Benzodiazepines

22
Medications for the SUD Treatment

• Acamprosate
• Amantadine
• Buprenorphine/Naloxone
• Bupropion

23
Medications for SUD Treatment

• Disulfiram
• Methadone
• Naltrexone
• Nicotine replacement

24
Inadequacy of Treatment

• Only 59 of patients with BD-SUD were on adequate
  mood stabilizing regimens
• Only 0.4 were receiving substance abuse-specific
  medications

25
Reasons for Non-Response

• Non-adherence
• Inadequate dosing
• Relapse to substance use
• Incorrect diagnosis/indication
• Drug interactions
• Adverse drug reactions

26
Strength of Evidence

• Study design
• Randomized controlled trials
• Open-label trials
• Retrospective studies
• Case series/reports
• Outcome measures

27
Lithium

• 2 open-label 12 week studies
• Cocaine dependent patients
• N16
• 3/16 decreased craving
• N10
• 5/10 decreased craving
• 3/10 cocaine free x 3 wks

28
Lithium

• 6 wk, Randomized, Double Blind, Placebo
  Controlled, Parallel group
• Adolescent outpts (BD I, II or MD N25)
• Alcohol, marijuana, inhalant, cough syrup
• Percentage of positive urine drug screens
  decreased in the lithium group (p0.028)

29
Valproate

• 24 wk, open-label study in alcohol, cocaine or
  SUD outpts (N9)
• Decreased days of substance used (plt0.005)

30
Valproate

• 24 wk, RCT, in BD I pts with alcohol dependence
  receiving lithium (N59)
• Fewer heavy drinking days (p0.02)
• Higher serum concentration correlated with
  improved alcohol use outcomes
• No significant changes in mood symptoms

31
Lithium and Valproate

• 24 wk, open-label, in 56 with alcohol, cannabis,
  and/or cocaine dependent outpts
• 14 pts met DSM-IV criteria for full remission of
  alcohol or drug use disorder after 6 months

32
Carbamazepine

• 12 wk, placebo controlled, outpts with cocaine
  dependence (N139)
• N57 cocaine dependent with mood d/o
• N82 without mood d/o
• Decreased drug craving
• Significantly longer time to first cocaine use in
  pts with mood disorders
• No difference in cocaine use in pts without mood
  disorders

33
Gabapentin

• 43 pts with bipolar disorder resistant to
  standard treatment received gabapentin
  adjunctively for 8 wks (case series)
• 18/43 (42) responded
• Alcohol abuse was associated with positive
  response

34
Lamotrigine

• 12 wk, open-label, in 30 cocaine dependent outpts
• Decreased craving and NS decrease days of use and
  money spent on cocaine
• No change in positive urine drug screens

35
Aripiprazole

• 20 antipsychotic-treated pts with bipolar or
  schizoaffective d/o and substance abuse switched
  to open-label aripiprazole for 12 wks
• 17 with alcohol dependence showed a reduction in
  dollars spent (p0.042) and craving (p0.003)
• 9 with cocaine-related d/o showed a reduction in
  craving (p0.014) but not in use

36
Quetiapine

• 12 wk, open-label, outpts with cocaine dependence
  (N17)
• Decreased craving and NS decrease in days of
  cocaine use and money spent on cocaine
• Slight increase in positive urine drug screens
• Subset with alcohol use (N14)
• Decrease in craving
• Decrease in days of alcohol use/wk but not
  drinks/wk

37
Ongoing RCTs

• Quetiapine vs risperidone in bipolar disorder
  with stimulant dependence
• Divalproex ER vs risperidone in BD-SUD

38
Summary of Medications for Management of Bipolar
Disorder

• Few randomized controlled trials
• Most data with valproate and carbamazepine
• Trials are short duration (no long term trials)
• Small samples
• Comorbid substances vary in studies
• Definition of response
• Further research is needed

39
Use Caution When Treating BD-SUD

• Impulsivity/Toxicity
• Tricyclics
• MAOIs
• Abuse
• Opiates
• Stimulants
• Barbiturates
• BZDs

40
VANTS Call

• May 30, 2006
• 200 pm Eastern
• 1-800-767-1750
• Access Code 14945