MENTAL HEALTH & ADDICTION
A concurrent bipolar disorder is a huge risk factor for the development of an addiction. In fact, it rates at around an eleven-time risk modifier. That means you are eleven times more likely to develop a substance use disorder as compared to the general population if you have bipolar disorder.
Diagnosis is not Simple
That’s about as simple as we get for looking at bipolar in addiction. Everything beyond that seems to get more and more complicated. Especially that of the diagnostic clarification for someone, say addicted to cocaine, and having a questionable bipolar disorder history. It is important for clinicians to actively address bipolar disorder, not just because a dual diagnosis is the standard of care, but because of the relative weight, we would assign different conditions for a person with such a severe mental illness. A diagram to break down weights or ‘ratios’ of mental illness and addictive disorder blends would look like this:
This is a theoretical construct we use to clarify people in treatment and is not ‘sanctioned’ by any significant addiction treatment body – I’m basically saying this is the way I conceptualize people, as it helps guide me in working with them. Another way of looking at it is through comparing different potential dual diagnosis issues and their life magnitude. A depressive disorder in a stable mother of three is massively different than a schizophrenia diagnosis for a 20-year-old who is withdrawing from college. Using this metaphor, I would divide the conditions into general columns as follows:
Severe Mental Illness (70-80% weighted towards mental health)
- Bipolar disorder – Type 1
- Combined Borderline Personality Disorder with Narcissistic Features
- Balanced Dual Diagnosis Pictures (50/50 Blend)
Post-Traumatic Stress Disorder
- Moderate and Severe Major Depression
- Eating Disorders
- Panic Disorder
- Generalized Anxiety Disorder
Addiction Weighted (60-70% Emphasis on Addictive Disorder)
- Mild Major Depression
- Social Anxiety Disorder
So accuracy for a true bipolar diagnosis is critical in designing a treatment package. We would use the term positive predictive value in this situation, as the diagnosis can become complex and confusing. It also is very common for clinicians to disagree about diagnosing bipolar in addiction, setting up for conflicting recommendations.
That may sound confusing because it is. If we take a standard clinician and have them interview a person to see if that person has bipolar disorder, there’s a percentage of the time that the clinician is correct and incorrect if you follow that person forward. We start with the available diagnostic criteria for mania:
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
- During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree.
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments
People who are actively using stimulants such as cocaine or meth or actively withdrawing from downers such as alcohol or heroin can present with some or multiple of the above mania features. It is also common for people who are in a manic state to abuse substances, especially ‘uppers’ such as cocaine. Just diagnosing a ‘manic-appearing’ person in a treatment setting with bipolar in addiction may be a premature mistake that could alter this person’s treatment (and future treatments as diagnostic labels such as bipolar disorder very often stick with a person in their medical chart).
We care about the accuracy of this diagnosis for a few reasons, including the following:
- Better outcomes by starting the appropriate med
- Avoiding unnecessary side effects by starting the wrong person on a med
- Addressing recovery rates through the ‘ratio of responsibility’
Medication for Stabilization
Bipolar people, especially those in actively manic and mixed mood states, require medication support to stabilize. These medications include such compounds as lithium, Depakote, or Zyprexa – all of which carry significant side effect burdens. Improperly placing a ‘non-bipolar’ patient on these meds would be a mistake and potentially harmful. Finally, we need to have some sense of the culprit for a poor outcome – was it a function of under-medication or of more needed recovery skills?
Revisiting the person who is sitting face-to-face with the clinician, we can actually increase the positive predictive value in that diagnosis. That basically means that a few target traits, when found positive, are more suggestive that the seemingly manic person has bona fide bipolar instead of just mania secondary to cocaine. These factors include:
- A prior history of a suicide attempt
- A prior history of psychotic thought
- A first-degree relative with bipolar disorder
If all three of these traits are positive, and the person presents with symptoms of mania, a diagnosis of bipolar disorder should be given. The positive predictive value, in this case, can exceed 90% accuracy.
So to summarize, I use a common sense partition when working with dual diagnosis people, as I’m appreciating the relative contribution to functioning different diagnoses can give. The more severe, chronic mental illness diagnoses can overrun the entire case if not well-addressed. As many people with severe drug use can appear manic, we need to have some additional screening tools to increase our positive predictive value in assigning the right people the right diagnosis. These above-listed traits are useful in making these assessments and will align people to more appropriate treatment paths. Better accuracy, better outcomes.