A challenging comorbidity in adolescents

The challenge of treating adolescents with substance use disorders (SUDs) can be significant by itself. Yet when factoring in an illness such as bipolar disorder and other comorbid disorders such as attention-deficit/hyperactivity disorder (ADHD), formulating treatment plans becomes more complicated and requires strict attention to multiple etiologic factors. In recent years a focus on mood disorders in youths with substance abuse or dependence has emerged as a major clinical and public health concern, particularly given what we know about the ability to address SUDs, delinquency and mood symptoms with treatment.1

In discussing these comorbidities, Gabrielle Carlson, MD, Professor of Psychiatry and Pediatrics and Director of Child and Adolescent Psychiatry at the State University of New York at Stony Brook School of Medicine, said in the March 2005 issue of The Brown University Child and Adolescent Psychopharmacology Update (Vol. 7, No. 3), “People with bipolar disorder often abuse substances, especially during manic and depressive episodes. When you have an age of onset that is high during adolescence and young adulthood, which is the highest risk time for onset for substance abuse problems, you can imagine that the risk for bipolar teens would be very high.”

It is imperative for clinicians working with adolescents with bipolar disorder to understand that comorbidity occurs more often than not in pediatric and adolescent bipolar disorder, and the high incidence of comorbidity makes diagnosis of the underlying disorder difficult and also affects treatment.

Careful assessment

Careful attention should be paid to differential diagnosis, including medical, psychiatric and neurological conditions whose symptoms may overlap with bipolar disorder (schizophrenia, hyperthyroidism) or be a result of SUD (protractive withdrawal, hyperactivity). Current psychosocial factors contributing to the clinical presentation need to be explored thoroughly. No specific guidelines exist for evaluating the patient with bipolar disorder and an active SUD, but at least a few days of abstinence might be useful in the effort to assess for bipolar symptoms.

Semi-structured psychiatric interviews are invaluable aids for the systematic diagnostic assessment of this group of patients. The aforementioned article in The Brown University Child and Adolescent Psychopharmacology Update cites several helpful diagnostic instruments and scales, such as the school-age children's version of the Schedule for Affective Disorders and Schizophrenia (K-SADS), the Addiction Severity Index (ASI) and the Child Behavior Checklist (CBCL). Heavy, intermittent, binge use of substances is a tip-off to the possible existence of bipolar disorder in youths who are abusing substances.

Treatment considerations

When approaching treatment of comorbid conditions such as bipolar disorder and SUD, clinicians should consider a simultaneous treatment approach. Given limited, albeit important, data on the effects of psychotropic medication treatment in reducing SUD in bipolar youths, both psychosocial and medication strategies should be considered in these adolescents.

It is important to review with the patient and family the fact that medication is one aspect of the treatment plan and is more likely to be effective when used in conjunction with other treatments.

The American Academy of Child and Adolescent Psychiatry's (AACAP's) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder2 lists these among the potentially beneficial psychosocial treatments:

• Psychosocial education therapy. This is where information should be provided to both patients and their families on the disorders' symptoms and course, treatment options, and potential impact on psychosocial and family functioning.

• Cognitive-behavioral therapy. This addresses cognitions and emotions of mania and depression, and has proven to be efficacious with clients with bipolar disorder.3

• Relapse prevention. Education should be provided to the adolescent and family on the impact of noncompliance with medications, the recognition of emergent relapse symptoms, and other factors that may promote relapse (e.g. sleep deprivation, substance abuse, medication noncompliance).

• Family-focused treatment. Family environmental factors are correlated with the course of recurrent mood disorders, because adolescents are generally more dependent on their families of origin than are young or older adults. Negative relationships with parents have a great potential to influence the course of the disorder. Various models of family intervention have been shown to be powerful adjuncts to pharmacotherapy among adolescent bipolar I patients.4

The response to treatment might vary according to certain factors related to the relative onsets of SUD and affective symptoms. In a prospective follow-up study of alcohol use disorders and bipolar disorders, participants with bipolar disorder beginning prior to the SUD exhibited affective episodes and alcohol use symptoms for longer periods compared with individuals who presented with alcohol-related problems prior to the onset of bipolar symptoms.5

It is always important to keep in mind that comorbidity poses a major clinical concern, as patients with both psychiatric disorders and SUDs have more complicated treatment courses and higher rates of relapse.6

References

1. Riggs PD, Mikulich SK, Coffman LM, et al. Fluoxetine in drug -dependent delinquents with major depression: an open trial. J Child Adolesc Psychopharmacol 1997; 7:87-95.
2. American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder. J Amer Acad Child Adolesc Psychiatry 1997; 36:Supplement.
3. Basco MR, Rush AJ. Cognitive-Behavioral Therapy for Bipolar Disorder (2nd Edition). New York City:The Guilford Press; 2005.
4. Miklowitz DJ, Craighead WE. Bipolar affective disorder: does psychosocial disorder add to the efficacy of drug therapy? Econ Neurosci 2001; 3:58-64.
5. Strakowski SM, DelBello MP, Fleck DE, et al. Effects of co-occurring alcohol abuse on the course of bipolar disorder following a first hospitalization for mania. Arch Gen Psychiatry 2005 Aug; 62:851-8.
6. Buckstein OG, Brent DA, Kaminer Y. Comorbidity of substance abuse and other psychiatric disorders in adolescence. Am J Psychiatry 1989; 146:1131-41.