Drug abuse in schizophrenia and bipolar disorder

Developmental trajectories in psychiatric disorders: does substance/alcohol use moderate the effects of affective temperaments as moderators of age at onset? A study in post-acute, hospitalized patients with psychotic or DSM-5 bipolar or major depressive disorders

BACKGROUND

Age-at-onset (AAO) affects psychiatric disorder outcome; substance (SUDs) or alcohol use disorders (AUDs) may influence their onset. Affective temperaments may affect early AAO and drug-use proneness. Objectives: To investigate whether SUD/AUD moderated temperamental effects in determining AAO of mental disorders. Methods: We included 300 post-acute inpatients with schizophrenia-spectrum and other psychotic (SSOPDs), major depressive (MDD) or bipolar (BD) disorders (168 men; mean age, 40.63 years ± 11.82 men, 43.21 years ± 12.69 women) with (N = 110) or without (N = 190) SUD/AUD. Patients completed cross-sectionally TEMPS-A. We carried moderation analysis with each regression-significant TEMPS temperament as independent variable, SUD/AUD presence/absence as dichotomous moderator, and AAO as dependent variable. Significance was set at p < 0.05. Results: AAO was lower in patients with SUD/AUD diagnosis than in patients without (23.74 ± 10.09 vs. 27.73 ± 10.35, respectively, p = 0.001, η2 = 0.034). SUD/AUD patients scored higher on the hyperthymic (10.22 ± 4.08, p < 0.001, η2 = 0.069) and irritable (8.26 ± 4.69, p < 0.01, η2 = 0.026) temperaments than nonSUD/AUD patients. Moderation analysis showed only direct effects of irritable (β = -0.55, p < 0.005) and hyperthymic (β = -0.95, p < 0.001) temperaments on AAO and no significant SUD/AUD and interaction effects. Limitations. Cross-sectional design. Conclusions: When irritable and hyperthymic traits prevail over other temperaments, AAO is earlier in SSOPDs, MDD, and BD. SUD/AUD presence/absence does not moderate the relationship between temperament and AAO.

Is “cannabis psychosis” a distinct category?

Forty-five cases of psychotic patients with admission urinalysis positive for cannabis were compared with psychotic controls without evidence of cannabis use. Cases and controls were matched for age, sex and year of admission, and were compared for socio-demographic data, circumstances of admission, diagnosis, and symptoms at admission. Three differences were found: cases were more likely to be Afro-Caribbean than white (P = 0.01), to manifest incoherence of speech (P= 0.02) and agitation (P= 0.01). In other respects the case and control groups were indistinguishable, and no pattern of symptoms characterised the “cannabis psychosis“group. These findings do not support the view that “cannabis psychosis” has a distinct psycho-phenomenological pattern Epidemiological studies are required to further clarify the association for psychotic patients between Afro-Caribbean ethnic groups and the likelihood of having a positive urine test for cannabis.

Benzodiazepine abuse, misuse, dependence, and withdrawal among schizophrenic patients: A review of the literature

Patients diagnosed with schizophrenia are at least three times more likely to develop a substance use disorder than controls. These patients are frequently prescribed benzodiacepines as a coadjuvant drug, which have a high potential for addiction. We performed a literature review aiming to gather evidence on various topics concerning the use of benzodiacepines in schizophrenia, with a focus on possible abuse: 1) Prevalence of prescripted and non-prescripted benzodiacepine use among patients, 2) Prevalence of abusers, 3) Effects of long-term benzodiacepine abuse in schizophrenia prognosis, 4) Possible management strategies for benzodiacepine abuse in this population. Our search revealed there is a high variability (up to 20%) in benzodiacepine abuse among patients, with cannabis and stimulants being more frequent, and no clear demographic traits have been identified among these patients. Patients with affective symptoms are more likely to abuse benzodiazepines. Its long-term effects on prognosis have been debated, with some papers hinting at a higher mortality rate. Tapering benzodiacepines has been associated with an improvement in some cognitive functions. Management strategies for potential abuse do not differ greatly for this population, and no specific pharmacological aid can be indicated, but an integral approach is proposed.

Psychoactive substance use among outpatients with severe mental illness: A comparative study

Background

Despite several studies on the prevalence and pattern of substance use in Nigeria, there is little information on substance use in patients diagnosed with serious mental illness (SMI) such as schizophrenia and bipolar affective disorder (BD).

Aim

The aim of the study was to compare the pattern of psychoactive substance use among outpatients with BD and schizophrenia.

Setting

The study was conducted in a neuropsychiatric hospital in Nigeria.

Methods

Seventy five consecutive patients with a MINI-PLUS diagnosis of BD were compared with an equal number of patients obtained by systematic random sampling with a MINI-PLUS diagnosis of schizophrenia.

Results

The respondents with schizophrenia were aged 18–59 years (37.2 ± 9.99) and were predominantly young adult (49, 65.3%), men (46, 61.3%), who were never married (38, 50.7%). Overall, lifetime drug use prevalence was 52%, while for current use, overall prevalence was 21.3%. Participants with BD were aged 18–63 years (36.7 ± 10.29) and were predominantly young adult (53, 70.7%), women (44, 58.7%), who were married (32, 42.7%), with tertiary education (31, 41.3%). Overall, lifetime drug use prevalence was 46.7%, while current overall prevalence was 17.3%. These rates (lifetime and current) for both diagnostic groups are higher than what was reported by the World Health Organization in the global status report of 2014 (0% – 16%). The statistically significant difference between the two diagnostic groups was related to their sociodemographic and clinical variables and psychoactive substance use.

Conclusion

Psychoactive substance use remains a burden in the care of patients diagnosed with schizophrenia and BD. Future policies should incorporate routine screening for substance use at the outpatient department with a view to stemming the tide of this menace.

The impact of mood symptomatology on pattern of substance use among homeless

BACKGROUND

Homeless individuals are an extremely vulnerable and underserved population characterized by overlapping problems of mental illness and substance use. Given the fact that mood disorders are frequently associated with substance use disorders, we wanted to further highlight the role of excitement in substance abuse. Patterns of substance abuse among homeless suffering from unipolar and bipolar depression were compared. The "self-medication hypothesis" which would predict no-differences in substance preference by unipolar (UP) and bipolar (BP) depressed homeless was tested.

METHODS

Homeless individuals from the Vancouver At Home/Chez Soi study were selected for lifetime UP and lifetime BP depression and patterns of substances abused in the previous 12 months were identified with the Mini-International Neuropsychiatric Interview. Differences in substance use between BP-depressed homeless and UP-depressed homeless were tested using Chi-square and logistic regression techniques.

RESULTS

No significant differences were observed between UP and BP homeless demographics. The bipolar depressed homeless (BDH) group displayed a higher percentage of Central Nervous System (CNS) Stimulants (χ 8.66, p=0.004) and Opiates (χ 6.41, p=0.013) as compared to the unipolar depressed homeless (UDH) group. CSN Stimulant was the only predictor within the BDH Group (χ(2) 8.74 df 1 p<0.003).

LIMITATIONS

Data collected are self-reported and no urinalyses were performed.

CONCLUSIONS

The results support the hypothesis that beyond the self-medication hypothesis, bipolarity is strictly correlated to substance use; this correlation is also verified in a homeless population.

A randomized, double-blind, placebo-controlled, trial of lamotrigine therapy in bipolar disorder, depressed or mixed phase and cocaine dependence

Bipolar disorder is associated with very high rates of substance dependence. Cocaine use is particularly common. However, limited data are available on the treatment of this population. A 10-week, randomized, double-blind, placebo-controlled trial of lamotrigine was conducted in 120 outpatients with bipolar disorder, depressed or mixed mood state, and cocaine dependence. Other substance use was not exclusionary. Cocaine use was quantified weekly by urine drug screens and participant report using the timeline follow-back method. Mood was assessed with the Hamilton rating scale for depression, quick inventory of depressive symptomatology self-report, and young mania rating scale. Cocaine craving was assessed with the cocaine-craving questionnaire. Data were analyzed using a random regression analysis that used all available data from participants with at least one postbaseline assessment (n=112). Lamotrigine and placebo groups were similar demographically (age 45.1±7.3 vs 43.5±10.0 years, 41.8% vs 38.6% women). Urine drug screens (primary outcome measure) and mood symptoms were not significantly different between groups. However, dollars spent on cocaine showed a significant initial (baseline to week 1, p=0.01) and by-week (weeks 1-10, p=0.05) decrease in dollars spent on cocaine, favoring lamotrigine. Few positive trials of medications for cocaine use, other than stimulant replacement, have been reported, and none have been reported for bipolar disorder. Reduction in amount of cocaine use by self-report with lamotrigine suggests that a standard treatment for bipolar disorder may reduce cocaine use. A study limitation was weekly assessment of urine drug screens that decreased the ability to detect between-group differences.

Mood stabilizers in the treatment of substance use disorders

Individuals suffering from drug addiction may also manifest features of bipolar spectrum disorders. Hyperthymic and cyclothymic temperaments may render individuals vulnerable to later development of substance abuse. Bipolar disorders themselves may be altered or precipitated by substance use, most notably by stimulants (amphetamines), alcohol, and cannabinoids. The clinical usefulness of mood stabilizers, particularly antiepileptics, has been established as safe and effective in substance abusers with and without comorbid mood disorders. Most studies on this issue have been of short duration and focused on the resolution of a currently manifest period of illness. Few studies have been conducted on the usefulness of these drugs on the long-term longitudinal course of these diseases, such as frequently encountered recurrent relapses into states of agitation, impulsivity, and/or dissatisfaction. As opposed to the clinical experience with traditional antidepressants and neuroleptics, antiepileptics do not induce counter-polar states (depressed patients abruptly turning manic or hypomanic; nor patients currently hypomanic or manic turning abruptly depressed). Many clinicians consider antiepileptic mood stabilizers to be the preferred category of medications for the treatment of such patients. Valproate appears to be a potentially fruitful medication to study in these dual diagnosis patients due to preliminary evidence demonstrating its anticraving efficacy.

Affective temperaments in alcoholic patients

Ninety-four consecutive responders to treatment alcoholics, 39 with and 55 without psychiatric comorbidity, were compared, regarding affective temperaments, according to the formulation of Akiskal and Mallya, with 50 healthy volunteers displaying the same social characteristics and belonging to the same environment. No differences were observed between alcoholics and controls on the hyperthymic scale. Significant discrepancies were measured on the depressive, cyclothymic, and irritable scales, where alcoholics scored higher, regardless of the presence or absence of dual diagnosis. In a multivariate discriminant analysis, mainly cyclothymic, but also depressive traits to a lesser degree, make it possible to distinguish between alcoholics and controls, but not between alcoholics with and without a dual diagnosis. The present study shows the main ways in which alcoholics can be distinguished from controls in terms of cyclothymic traits, with a depressive component, and why these characteristics are unrelated to the presence of dual diagnosis.

Toward a unitary perspective on the bipolar spectrum and substance abuse: opiate addiction as a paradigm

Bipolar spectrum disorders and addiction often co-occur and constitute reciprocal risk factors that the authors believe are best considered under a unitary perspective. In particular, we submit that patients whose disorders fall under the bipolar spectrum - and its hyperthymic and cyclothymic temperamental substrates are at increased risk for substance use, possibly moving towards addiction through exposure to intrinsically dependence-producing substances. In our experience, the contribution of bipolar spectrum disorders to the addictive process is often clinically missed, because attenuated and subclinical expressions of such mood disorders as bipolar II and cyclothymia are not adequately appreciated by our current formal diagnostic system (e.g. DSM-IV, as well as research and clinical practice based on it). The use of agonist treatment in dual diagnosis heroin addicts has allowed us to gather valuable knowledge about the intrinsic, and historically and clinically documented mood-regulating effects of opiates. From the therapeutic point of view, the challenge of double diagnosis requires double competence from clinicians. The combination of opiate agonists and mood stabilizers often produces results difficult to obtain with the use of the two types of drugs separately. We therefore submit that the present conceptualization of the link between bipolar spectrum and addictive disorders has not only heuristic and scientific values, but also an important message for the clinician.

Cannabis use and mood disorders: patterns of clinical presentations among adolescents in a developing country

Notwithstanding the increase use of cannabis among adolescents in both developing and developed countries, few studies have looked at cannabis use and mood disorders. In a series of case studies, this research project seeks to investigate patterns of clinical presentations seen among cannabis users in psychiatric outpatients in Trinidad. Five clinical patterns of presentations are identified among cannabis users and abusers based on variables of dosing, age of initial use, duration of use, tolerance and reverse tolerance and poly-drug abuse. All patients in these case studies were standardized for method of use and potency of cannabis used. Patients were screened by urine tests to determine co-morbid use of other substances. Other variables such as environmental factors and genetic vulnerability were reviewed as far as possible from historical accounts of family members. The five patterns described are low, controlled use with mild euphoria and heightened awareness, moderate use with mixed depressive symptoms and suicidal behaviour, heavy, short term use with manic symptoms, long term incremental use with psychotic symptoms due to the trumping of depressive symptoms and cannabis mixed with other substances resulting in florid psychosis. Mood disorders appear to be a common finding among adolescents using cannabis. Sensitization to symptomatic presentation and early detection of cannabis use in young adolescents are necessary. Further research is needed on the effect of cannabinoids on emotions, behaviour and thinking and its relationship to mental disorders. This study is useful as a guideline for the implementation of public health strategies and legislation concerning the use of cannabis in youths.

Cannabinoids in bipolar affective disorder: a review and discussion of their therapeutic potential

Bipolar affective disorder is often poorly controlled by prescribed drugs. Cannabis use is common in patients with this disorder and anecdotal reports suggest that some patients take it to alleviate symptoms of both mania and depression. We undertook a literature review of cannabis use by patients with bipolar disorder and of the neuropharmacological properties of cannabinoids suggesting possible therapeutic effects in this condition. No systematic studies of cannabinoids in bipolar disorder were found to exist, although some patients claim that cannabis relieves symptoms of mania and/or depression. The cannabinoids Delta(9)-tetrahydrocannabinol (THC) and cannabidiol (CBD) may exert sedative, hypnotic, anxiolytic, antidepressant, antipsychotic and anticonvulsant effects. Pure synthetic cannabinoids, such as dronabinol and nabilone and specific plant extracts containing THC, CBD, or a mixture of the two in known concentrations, are available and can be delivered sublingually. Controlled trials of these cannabinoids as adjunctive medication in bipolar disorder are now indicated.

Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder

BACKGROUND

Recent data indicate high prevalence of both anxiety and substance comorbidity in bipolar disorder. However, few studies have utilized public sector samples, and only one has attempted to separate contributions of each type of comorbidity.

METHODS

328 inpatient veterans with bipolar disorder across 11 sites were assessed using selected Structured Clinical Interview for DSM-IV modules and self-reports.

RESULTS

Comorbidity was common (current: 57.3%; lifetime: 78.4%), with multiple current comorbidities in 29.8%. Substance comorbidity rate was comparable to rates typically reported in non-veteran inpatient samples (33.8% current, 72.3% lifetime). Selected anxiety comorbidity rates exceeded those in other inpatient samples and appeared more chronic than episodic/recurrent (38.3% current, 43.3% lifetime). 49% of PTSD was due to non-combat stressors. Major correlates of current substance comorbidity alone were younger age, worse marital status, and higher current employability. Correlates of current anxiety comorbidity alone were early age of onset, greater number of prior-year depressive episodes, higher rates of disability pension receipt, and lower self-reported mental and physical function. Combined comorbidity resembled anxiety comorbidity.

LIMITATIONS

This is a cross-sectional analysis of acutely hospitalized veterans.

CONCLUSIONS

Distinct patterns of substance and anxiety comorbidity are striking, and may be subserved by distinct neurobiologic mechanisms. The prevalence, chronicity and functional impact of anxiety disorders indicate the need for improved recognition and treatment of this other dual diagnosis group is warranted. Clinical and research interventions should recognize these divergent comorbidity patterns and provide individualized treatment built "from the patient out."

Bipolar disorder and substance abuse

Substance use disorders are overrepresented in individuals with bipolar and bipolar spectrum disorders. Although awareness of this phenomenon has increased over the past 20 years, few empirically based treatment strategies have been developed for this challenging patient population. This review examines the relationship between bipolar and substance use disorders and treatment options that have been studied in this patient population. First, we examine the high prevalence rates of substance use disorders in individuals diagnosed with bipolar disorder, the common problems associated with establishing a bipolar disorder diagnosis in individuals who abuse substances, the possible explanations for the frequent coexistence of bipolar and substance use disorders, and the negative effect of substance abuse on the course of and treatment outcomes for bipolar disorder. The review then focuses on treatment approaches for this patient population, including integrated group therapy for co-occurring bipolar and substance use disorders and pharmacotherapies that target both disorders. Finally, we present suggestions for medications that might be tested for their efficacy in treating both disorders in specific subgroups of patients with bipolar and substance use disorders.

Exploring the association between cannabis use and depression

AIM

To examine the evidence on the association between cannabis and depression and evaluate competing explanations of the association.

METHODS

A search of Medline, Psychinfo and EMBASE databases was conducted. All references in which the terms 'cannabis', 'marijuana' or 'cannabinoid', and in which the words 'depression/depressive disorder/depressed', 'mood', 'mood disorder' or 'dysthymia' were collected. Only research studies were reviewed. Case reports are not discussed.

RESULTS

There was a modest association between heavy or problematic cannabis use and depression in cohort studies and well-designed cross-sectional studies in the general population. Little evidence was found for an association between depression and infrequent cannabis use. A number of studies found a modest association between early-onset, regular cannabis use and later depression, which persisted after controlling for potential confounding variables. There was little evidence of an increased risk of later cannabis use among people with depression and hence little support for the self-medication hypothesis. There have been a limited number of studies that have controlled for potential confounding variables in the association between heavy cannabis use and depression. These have found that the risk is much reduced by statistical control but a modest relationship remains.

CONCLUSIONS

Heavy cannabis use and depression are associated and evidence from longitudinal studies suggests that heavy cannabis use may increase depressive symptoms among some users. It is still too early, however, to rule out the hypothesis that the association is due to common social, family and contextual factors that increase risks of both heavy cannabis use and depression. Longitudinal studies and studies of twins discordant for heavy cannabis use and depression are needed to rule out common causes. If the relationship is causal, then on current patterns of cannabis use in the most developed societies cannabis use makes, at most, a modest contribution to the population prevalence of depression.

Marijuana use among adolescents

More than half of US adolescents will experiment with marijuana. Of those who try marijuana more than once, approximately one third will subsequently use marijuana regularly, although most will have stopped by their late 20s. Although genetic predisposition plays the most important role in determining who will develop dependence, environmental factors influence who will initiate marijuana use. One of the challenges for prevention and treatment programs is that the immediate adverse effects of marijuana use are not extreme, and many adolescents have difficulty in making decisions based on future risks. Therefore, the consequences of leaving school early, having unprotected sex, and driving while intoxicated are often insufficient to deter adolescents from using marijuana. Thus, it is not surprising that current prevention and treatment programs have had limited success in decreasing the rates of initiation and regular use of marijuana among adolescents. However, the accumulation of data about marijuana use in adolescents has the potential to enable the development of more effective prevention and treatment programs.

Substance abuse among patients with schizophrenia

Substance use in the general population is a significant public health problem. Problems associated with substance use are aggravated by concomitant psychiatric illness, particularly schizophrenia and schizoaffective disorder. Although there is a general agreement on the need to address this problem, a wide range of opinions exists on exactly what is the best modality. In this article, we provide a brief overview of the etiology and consequences of substance use in individuals with schizophrenia, followed by a more detailed review of pharmacological and psychotherapeutic trends in the treatment of this population. Research studies indicate that, while some evidence supports the self-medication hypothesis, individuals with schizophrenia or schizoaffective disorder frequently use substances for the same reasons and in the same manner as the general population. In the pharmacotherapy section, we briefly discuss the rationale for current medication strategies, their efficacy, and directions for future research. This is followed by an assessment of current psychotherapeutic interventions, their limitations, and potential modifications to improve treatment outcome. The research literature suggests that integrated treatment and well-tailored interventions that take into account psychosocial factors and motivation offer the most promise for the future. More controlled trials are necessary to validate this hypothesis.

A comparative study on schizophrenic patients with dual diagnosis

As indicated in the literature, substance abuse is a significant yet complex variable in schizophrenic disorder. We evaluated hospital charts of 86 schizophrenic patients with comorbid substance use disorder and of 56 patients suffering from schizophrenia-only. We surmised that among the former group there will be a substantial proportion of patients abusing opiates and that there will be differences between schizophrenic patients abusing different drugs. Both hypotheses could be confirmed. Among our dual patients, 18 patients with alcohol, 18 patients with cannabis, and 50 patients with "hard drugs" (opiates, cocaine) use disorder were identified and several significant differences were found between the individual groups of patients in respect to basic sociodemographic and clinical variables; in particular, schizophrenic patients with alcohol use disorder (and patients suffering from schizophrenia-only) were older and better socially adjusted than schizophrenic patients with "illegal" drug use disorder. The particularities of schizophrenic patients suffering from different kinds of substance use disorder should be considered when creating individualized therapeutic programs.

Comparison of four groups of substance-abusing in-patients with different psychiatric comorbidity

OBJECTIVE

Comparisons of different groups of dual patients are rare, yet potential differences could have therapeutic implications. In this study, four groups of psychiatric in-patients with substance use disorder were compared to each other: patients with no psychiatric comorbidity, patients with comorbid schizophrenia and patients with affective and personality disorder.

METHOD

Apart from sociodemographic, therapy-related variables and a detailed survey of their substance use, all subjects were assessed with BPRS and SCL-90-R.

RESULTS

No differences were found in the patients' demography, psychosocial adjustment and substance consumption career. Significant differences were found in regard to some therapy variables reflecting adherence to treatment and global outcome and to the level of psychopathology.

CONCLUSION

Both substance use and comorbid psychiatric disorder have a variable impact on distinct areas of patients' general condition and functioning. The group with comorbid affective disorder appeared to be the most difficult to treat and the therapeutic approach to this disorder deserves reconsideration.

Drug abuse and bipolar disorder: comorbidity or misdiagnosis?

Bipolar disorder is a common, severe and cyclic psychiatric illness. A strong association between alcohol dependence and bipolar disorder has been reported in numerous studies. The abuse of other drugs including cocaine, amphetamines, opiates, cannabis, and prescription medications in bipolar patients is also an important public health concern and has been less extensively investigated. This review examines the abuse of drugs other than alcohol or nicotine in people with bipolar disorder. The high rates of milder affective symptoms but not mania observed in patients in drug abuse treatment settings suggests the symptoms may in many cases be associated with the drug use. However, such patients presenting in psychiatric settings might be suffering from cyclothymic and related attenuated bipolar disorders (type II). Substance abuse may be associated with medication non-compliance, more mixed or dysphoric mania and possibly an earlier onset of affective symptoms and more hospitalizations. The pharmacotherapy of patients with bipolar disorder and drug abuse is examined, including evidence on the use of mood stabilizers, neuroleptics and the newer atypical antipsychotics in this population.

The co-occurrence of mania with medical and other psychiatric disorders

OBJECTIVE

The co-occurrence of mania with other medical and psychiatric disorders has been little studied. The authors reviewed the literature in order to clarify the current state of knowledge of this subject and to identify possible areas of future research.

METHODS

Published articles which specifically addressed associations of mania with medical disorders and other psychiatric syndromes were identified using the Paperchase medical literature search system and by cross-referencing from other published work. The articles were then organized into three categories: 1) medical disorders associated with secondary mania; 2) medical comorbidity in bipolar disorder; and 3) psychiatric comorbidity in bipolar disorder.

RESULTS

The review of medical illness and secondary mania supports the hypothesis that injuries involving right-side and mid-line brain structures are associated with so-called secondary mania. Additionally, an association between bipolar disorder and migraine is identified. Several psychiatric disorders appear to occur with mania at rates higher than expected including obsessive-compulsive disorder, bulimia nervosa, panic disorder, impulse control disorders, and substance abuse.

CONCLUSIONS

The authors discuss the potential implications of these findings and suggest research approaches to further examine the relationships between mania and other medical and psychiatric syndromes.

Substance misuse, offending and mental illness: a review

The literature concerning the associations between violence, mental disorder, comorbidity and substance misuse are discussed in this review, which focuses on the findings of several international studies that demonstrate significantly higher rates of violence in substance misuse and dual diagnosis (when compared with 'single' diagnosis groups). The need for the development of an effective psychiatric nursing response in terms of assessment, liaison and joint clinical management approaches to those with a dual diagnosis is discussed in the context of United Kingdom Government legislation and policy in both forensic mental health services, and in statutory substance misuse services.

Impact of substance abuse on the course and treatment of bipolar disorder

OBJECTIVES

The objectives of this article are to review the prevalence, natural history, pathophysiology, and treatment of comorbid bipolar disorder with alcoholism and other psychoactive substance use disorders (PSUDs).

METHODS

All identified bibliographies through a literature search of all Medline files and bibliographies of selected articles focusing on the prevalence, natural history, course, prognosis, inter-relationship, and treatment of bipolar disorder with comorbid alcoholism and other PSUDs were reviewed.

RESULTS AND CONCLUSIONS

Comorbidity of bipolar disorder and alcoholism and other PSUDs is highly prevalent. The presence of this so called 'dual diagnoses' creates a serious challenge in terms of establishing an accurate diagnosis and providing appropriate treatment interventions. The inter-relationship between these disorders appears to be mutually detrimental. The course, manifestation, and treatment of each condition are significantly compounded by the presence of the other condition. Substance abuse and alcoholism appear to significantly complicate the course and prognosis of bipolar disorder resulting in increased suffering, disability, and costs. On the other hand, bipolar disorder may be a risk factor for developing PSUDs. Although, there are a number of hypotheses explaining the pathophysiological mechanism involved in such comorbidities, our understanding of the exact nature of such neurobiological mechanisms is still limited. While the antikindling agents and targeted psychotherapeutic techniques may be useful intervention strategies, there is still a significant lack of empirically based treatment options for these patients.

Lifetime prevalence of substance or alcohol abuse and dependence among subjects with bipolar I and II disorders in a voluntary registry

OBJECTIVE

To evaluate the prevalence of substance abuse dependence and/or alcohol abuse dependence among subjects with bipolar I versus bipolar II disorder in a voluntary registry.

METHOD

One hundred randomly selected registrants in a voluntary case registry for bipolar disorder were interviewed, using the Structured Clinical Interview for DSM-IV Axis I Disorders, to validate the diagnosis of this registry. Corroborative information was obtained from medical records, family members and the treating psychiatrist. Eighty-nine adults (18-65 years) met criteria for bipolar disorder (bipolar I = 71, bipolar II = 18) and were included in this analysis.

RESULTS

Forty-one (57.8%) subjects with bipolar I disorder abused, or were dependent on one or more substances or alcohol, 28.2% abused, or were dependent on, two substances or alcohol, and 11.3% abused or were dependent on three or more substances or alcohol. Nearly 39% of bipolar II subjects abused or were dependent on one or more substances, nearly 17% were dependent on two or more substances or alcohol, and 11% were dependent on three or more substances or alcohol. Alcohol was the most commonly abused drug among either bipolar I or II subjects.

CONCLUSIONS

Consistent with other epidemiologic and hospital population studies, this voluntary bipolar disorder registry suggests a high prevalence of comorbidity with alcohol and/or substance abuse dependence. Bipolar I subjects appear to have higher rates of these comorbid conditions than bipolar II subjects; however, as the number of bipolar II subjects was rather small, this suggestion needs confirmation.

Substance abuse and bipolar comorbidity

Bipolar disorder and substance abuse commonly co-occur. In fact, as many as 50% of individuals with bipolar disorder have been found to have a lifetime history of substance abuse or dependence. This article discusses the very important comorbidity of bipolar disorder as it is complicated by substance abuse, focusing on the prevalence, course, diagnostic considerations and treatment.

A relapse prevention group for patients with bipolar and substance use disorders

Although bipolar disorder is the Axis I disorder associated with the highest risk of having a coexisting substance use disorder, no specific treatment approaches for this dually diagnosed patient population have thus far been developed. This paper describes a 20-session relapse prevention group therapy that the authors have developed for the treatment of patients with coexisting bipolar disorder and substance use disorder. The treatment uses an integrated approach by discussing topics that are relevant to both disorders and by highlighting common aspects of recovery from and relapse to each disorder.

Very long-term users of marijuana in the United States: a pilot study

The authors recruited a sample of 37 Americans, aged 30-74, who had smoked marijuana on at least 5,000 separate occasions. These subjects were found to span a wide range of ethnic groups, educational backgrounds, occupations, and annual income; they did not display any obvious features which distinguished them from the population as a whole. They typically began smoking in the 1960s or early 1970s, and then continued to smoke heavily into middle adulthood because they felt that marijuana relieved unpleasant feeling states such as anxiety or depression. To our knowledge, individuals of this type have not previously been examined; further studies of older, long-term American marijuana users are needed.

Use of potentially abusive psychotropic substances in psychiatric inpatients

A series of 417 consecutively admitted psychiatric inpatients were studied with regard to their use of potentially abusive psychotropic substances in the last 3 months preceding admission. In all patients face-to-face interviews were performed; in 354 of them urine specimens could also be tested. Alcohol and benzodiazepines belonged to the most frequently used substances followed by cannabis, opiates and cocaine. Barbiturates, hallucinogens and amphetamine derivatives were only exceptionally reported. The most important finding of the study is that every fifth patient regularly used "hard" drugs (opiates and/or cocaine), every fourth patient illegal drugs and every third patient alcohol. Substances were found in 54% of all urine specimens; methadone, opiates and cocaine were hardly found alone. For the latter substances excellent agreement was found between interview reports and urine exams. Excluding patients diagnosed as substance-use disorders, there were no statistically significant differences between schizophrenic, affective, neurotic/stress/somatoform and other disorders with regard to the use of "hard" drugs and illegal drugs. Regular substance use correlated with much worse psychosocial adjustment. Substance use has to be explored and considered in every individual psychiatric inpatient.

Schizophrenia and substance abuse

BACKGROUND

Recent research from North America has demonstrated higher than expected rates of drug and alcohol abuse among the seriously mentally ill. Schizophrenics appear to be particularly susceptible to the negative effects of substance abuse. These include psychiatric and social complications, with antisocial behaviour, particularly violence emerging as one of the most worrying features. This review examines the strength of the association and explores the possible explanations for the apparent link between schizophrenia, substance abuse and violence.

METHOD

The literature was searched using Medline, supplemented with a manual literature search.

RESULTS

Very few articles specifically approached the problem of violence among substance abusing schizophrenics, but over 80 papers were identified which were helpful in exploring the link between dangerous behaviour and substance abuse by schizophrenics.

CONCLUSIONS

While there is circumstantial evidence to support the hypothesis that schizophrenics who abuse drugs or alcohol are at an increased risk of behaving violently, longitudinal studies are required to facilitate a better understanding of the mediating mechanisms.

Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder

The relationship between history of specific types of substance abuse (alcohol, stimulants, cannabis, hallucinogens, narcotics) and demographic and diagnostic variables was evaluated in a large (n = 263) sample of schizophrenic, schizoaffective, major depression and bipolar disorder patients. Prevalence rates were also compared with rates observed in a previous study (1983-1986) conducted using the same methods. Demographic characteristics (gender, age, race, educational level) were strong predictors of type of substance abuse. Patients with a history of cocaine abuse had fewer prior hospitalizations, suggesting that less impaired psychiatric patients may be more prone to illicit substance abuse. Diagnoses were not related to most types of substance abuse, although there was a trend for bipolar patients to have a history of alcohol abuse. The results demonstrate the importance of matching groups on demographic characteristics when exploring diagnostic differences in preference to abuse specific types of substances.

Outpatient treatment of adults with coexisting substance use and mental disorders

This study examined the six-month and one-year treatment statuses of 118 patients admitted to an abstinence-oriented, outpatient facility serving dually disordered adults. Findings revealed that persons who have been underserved by the mental health and substance abuse fields can be engaged in treatment and will respond favorably to it. Overall, demographic characteristics, admission diagnoses, and past treatment history did not predict treatment outcomes. Rather, patients who participated more fully in treatment had better recoveries than did those who did not engage in treatment. In addition, patients who complied and responded to treatment during their first six months in treatment were more likely to comply and respond to treatment during the second six months of treatment. These results should encourage other clinicians to develop innovative services that meet the needs of dually disordered adults.