Posted by Phillipa on December 30, 2009, at 21:11:42
Seems a lot of bipolar isn't treated til substance abuse treated. Depression longer with abuse and switches to mania. Phillipa
STEP-BD: History of Substance Use Does Not Affect Recovery From Depression in Bipolar Disorder
Pauline Anderson
December 29, 2009 A past or current substance use disorder does not affect recovery time from a depressive episode in patients with bipolar disorder. However, substance use may increase the risk for conversion from depression to mania, hypomania, or mixed states, a new study shows.
The results suggest clinicians should treat substance abuse along with bipolar disorder, lead author Michael J. Ostacher, MD, MPH, assistant professor of psychiatry, Harvard Medical School, and associate medical director, Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, told Medscape Psychiatry.
As it stands, he said, physicians tend to wait until substance abuse has been dealt with before treating bipolar disorder, said Dr. Ostacher. "There has been a long tradition in psychiatry to ask people with drug and alcohol problems to get their drug and alcohol problems fixed before they get treated for their psychiatric problems. It's changing some, but there's still that old tradition," Dr. Ostacher said.
The study was published online December 15 in the American Journal of Psychiatry.
The research was part of the Systemic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a multicenter trial conducted in the United States from 1999 to 2005.
The current analysis included 2154 participants with bipolar disorder who had a major depressive episode and completed at least 1 follow-up visit after becoming depressed. The study was designed to approximate clinical practice, with patients receiving standard-of-care treatment.
Of the 2154 subjects, 1207 (56.0%) had no history of an alcohol use disorder, 693 (32.2%) had a past alcohol use disorder, and 254 (11.8%) had a current alcohol use disorders. As for a drug use disorder, 1528 (70.9%) had no history, 468 (21.7%) had a past disorder, and 158 (7.3%) had a current disorder.
Recovery Time
Median time to recovery from the depressive episode was 182 days for those with a current alcohol use disorder, 201 days for those with a past alcohol use disorder, and 215 days for those with no history of alcohol use disorders. There were no significant differences between those with current vs no history of alcohol use disorder, past vs no history of alcohol use disorder, or current vs past alcohol use disorder.
Median time to recovery was 184 days for those with current drug use disorder, 224 days for past drug use disorder, and 200 days for no history of drug use disorder.
Again, there were no significant differences in time to recovery between those with no current vs no history of drug use disorder, past vs no history of drug use disorder, or current vs past drug use disorder.
Switch to Mania
However, the likelihood of a switch to mania, hypomania, or mixed states before recovery from a major depressive episode was significantly associated with current and past alcohol or drug use disorder compared with no history.
"What's interesting is that this is true whether or not people have a current or past history of drug abuse," said Dr. Ostacher. "From what we can tell, this suggests that switching isn't necessarily a direct effect of drug and alcohol abuse. It may be that people who are prone to developing drug and alcohol problems in bipolar disorder are also those people who are prone to having more cycling in terms of their episodes."
This finding serves as a reminder to physicians that patients who have a current or past history of substance use may switch during a depressive episode, he added.
The results did not appear to be confounded by sociodemographic or clinical features including current Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, anxiety disorder; age at onset; age at study entry; sex; education; or marital status.
No Reason Not to Treat
Although treating a substance abuse disorder in a bipolar patient is important such abuse can lead to health, legal, and workplace problems the presence of such disorders should not be a reason not to treat a psychiatric condition, said Dr. Ostacher. "In other words, people should get whatever treatments you would give to people who don't have drug and alcohol problems."
A limitation of the study was that it did not examine the relationship between the amount of substance use and outcome or include measures of substance use severity or specific types of drug abuse.
People with bipolar disorder are at very high risk for a co-occurring substance use disorder, with estimates of lifetime rates ranging from 40% to 60%. Patients with comorbid bipolar and substance use disorders tend to be excluded from clinical trials, and because of that, many experts believe the results of that research are not generalizable to this population, said Dr. Ostacher.
Interpret With Caution
Stephen M Strakowski, MD, professor of psychology and biomedical engineering and director, Center for Imaging Research, University of Cincinnati in Ohio Academic Health Center, said the findings should be interpreted with caution, as the evaluation of substance abuse was "pretty minimal."
Dr. Strakowski, who was not involved in the research, said that the STEP-BD study was not designed to look at drug and alcohol abuse, so this analysis is essentially "secondary" and had "insufficient instruments" to harvest the information.
"My sense is that this study might suffer from extra noise from the information that was acquired."
However, he added, "if the take-home point is that we treat both substance abuse and bipolar disorder aggressively in people with both, then I agree with that completely."
Dr. Ostacher has received research support from Pfizer; he has served on the advisory/consulting boards of Pfizer, Schering-Plough, and Concordant Rater Systems; he has received speaking fees from AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Company, Forest Pharmaceuticals, GlaxoSmithKline, Janssen Pharmaceutica, Pfizer, and Massachusetts General Psychiatry Academy (whose talks were supported in 2008 through independent medical education grants from AstraZeneca, Eli Lilly, and Janssen). For information on the other authors, see paper.
Am J Psychiatry. Published online December 15, 2009.
poster:Phillipa
thread:931683
URL: http://www.dr-bob.org/babble/20091227/msgs/931683.html