Bipolar disorder and substance abuse

Bryan K. Tolliver, MD, PhD, Assistant professor, Clinical neuroscience division, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

The high prevalence of substance use disorders (SUDs) in persons with bipolar disorder (BD) is well documented. Up to 60% of bipolar patients develop an SUD at some point in their lives. Alcohol use disorders are particularly common among BD patients, with a lifetime prevalence of roughly 50%. Recent epidemiologic data indicate that 38% of persons with bipolar I disorder and 19% of those with bipolar II disorder meet criteria for alcohol dependence. Comorbid SUDs in patients with BD are associated with:

• poor treatment compliance
• longer and more frequent mood episodes
• more mixed episodes
• more hospitalizations
• more frequent suicide attempts.

The impact of co-occurring SUDs on suicidality is particularly high among those with bipolar I disorder. Frequently referred to as “dual diagnosis” conditions, co-occurring BD and SUDs may be more accurately envisioned as multi-morbid, rather than comorbid, illnesses.

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Adolescents who self-harm

John Peterson, M, Director, child and adolescent psychiatry, Denver Health Medical Center, Associate professor, Department of psychiatry, University of Colorado School of Medicine, Denver, CO

Stacey Freedenthal, PhD, Associate professor, Graduate School of Social Work, University of Denver, Denver, CO

Adam Coles, MD, Resident Department of psychiatry, University of Colorado School of Medicine, Denver, CO

Josh, age 16, gets poor grades in school and occasionally smokes marijuana and abuses inhalants. After his girlfriend breaks up with him, he cuts his wrist with a hunting knife. While bleeding profusely, Josh calls his mother at work, who calls 911. The cut is deep and requires sutures. Josh says he did not try to kill himself; he only wanted to carve his girlfriend’s initials into his wrist to show his love for her.

When treating teenagers with self-harming thoughts and behavior, it may be difficult to distinguish suicide attempts from self-injury without intent to die. Understanding adolescent self-harm, suicide risk assessment, and treatment options guides clinicians to appropriate interventions. Recognizing the need for aggressive treatment—including psychiatric hospitalization—is essential to keeping self-harming teenagers safe.

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Depression in older adults

Nabil Kotbi, MD, Assistant professor of psychiatry, Weill Medical College of Cornell University, New York-Presbyterian Hospital, White Plains, NY

Nahla Mahgoub, MD, Instructor in psychiatry, Weill Medical College of Cornell University, New York-Presbyterian Hospital, White Plains, NY

Anna Odom, PhD, Instructor of psychology in psychiatry, Weill Medical College of Cornell University, New York-Presbyterian Hospital, White Plains, NY

Depression in older adults (age ≥65) can devastate their quality of life and increase the likelihood of institutionalization because of behavioral problems. Depression is a primary risk factor for suicide, and suicide rates are highest among those age ≥65, especially among white males. The burden of geriatric depression can extend to caregivers. Prompt recognition and treatment of depression could help minimize morbidity and reduce suffering in older adults and their caregivers.

Although geriatric depression varies in severity and presentation, common categories include:

• major depressive disorder (MDD)
• vascular depression
• dysthymia
• depression in the context of dementias, psychosis, bipolar disorder, and executive dysfunction.

Diagnoses in this population generally correspond with DSM-IV-TR criteria, but geriatric depression has distinct clinical manifestations.

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Treat the patient, not the disease

Henry A. Nasrallah, MD
Editor-in-Chief

Personalized care is at the heart of good medical care. It is an indispensable ingredient for optimal clinical outcomes because each patient is unique, as an individual and as a patient, and requires customized treatment.

If 10 patients with depression walk into a psychiatrist’s office on any given day, each will be different and should be treated accordingly. Their symptoms may be similar thematically but they differ widely in presentation and content. Their medical and psychiatric histories and social, educational, religious, ethnic, socioeconomic, and attitudinal diversity can be stunning in complexity and disparity. Just as patients’ symptoms can be similar yet different, so can their response to a specific antidepressant or psychotherapy. Their clinical and functional outcomes will vary widely in degree and valence. Every psychiatrist expects (and enjoys) the richness of patient backgrounds and manages each individually.

Given these individual differences among our psychiatric patients, why are practitioners being barraged by various entities to abandon the traditional medical approach to their patients? Why is there a push to transform personalized clinical care to an assembly-line system, where patients are defined by their disease and are managed like “human widgets” as though they can be “processed” in an identical, protocolized, mechanical manner? This is completely antithetical to the magnificent personal approach inherent in the classic and highly effective doctor-patient relationship.

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