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Principles of Treating Individuals with Complex Co-Morbidit Principles of Treating Individuals with Complex Co-Morbidit

Principles of Treating Individuals with Complex Co-Morbidit - PowerPoint Presentation

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Principles of Treating Individuals with Complex Co-Morbidit - PPT Presentation

Paul E Keck Jr MD Lindner Center of HOPE University of Cincinnati College of Medicine Key Recommendations Realize that comorbidity is the rule not the exception in bipolar disorder BP ID: 298280

morbid psychiatry disorder mood psychiatry morbid mood disorder disorders clin alcohol key treating patients morbidity 2002 anxiety ris arch

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Slide1

Principles of Treating Individuals with Complex Co-Morbidity

Paul E. Keck, Jr., MD

Lindner Center of HOPE

University of Cincinnati College of MedicineSlide2

Key Recommendations

Realize that co-morbidity is the rule, not the exception, in bipolar disorder (BP)2. Assess affective and co-morbid symptoms concurrently

Focus pharmacotherapy on achieving mood stabilization. Use psychological treatments–eg

., patient education or illness management–to address co-morbidity issues.Slide3

Key Recommendations (continued)

Know the evidence–or the lack thereof–for the therapies used to treat BP with co-morbiditiesAvoid prematurely treating co-morbidities with mood-destabilizing agents

Before using antidepressants to treat anxiety disorders co-morbid with BP, consider mood stabilizers and atypical antipsychotics with demonstrated efficacy in anxiety

Rethink requiring active alcoholics to “stop drinking” before treating their BP, and select BP therapies accordinglySlide4

Key Recommendation 1

Realize that co-morbidity is the rule, not the exception, in bipolar disorder (BP)Slide5

National Co-morbidity Survey

1

2

≥ 3

# Lifetime

DSM-III Disorders

21

13

14

% General

Population*

0

100

96

% Sample

With BP I

*N=8098;

Percentage of patients with

euphoric-grandiose subtype of BP I with

comorbidities

(N=29).Kessler RC, et al. Arch Gen Psychiatry.1994;51:8-19; Kessler RC, et al. Psychol Med. 1997;27:1079-1089.Slide6

Prevalence of Selected Co-morbidities with BP I* (N=29)

*Euphoric-grandiose subtype.

Kessler RC, et al. Psychol Med. 1997;27:1079-1089.

Patients (%)Slide7

Odds Ratio for Anxiety Disorders in Bipolar vs Unipolar

Disorders*Epidemiologic Catchment Area (ECA) Survey.†P<.0001.

PD=panic disorder; OCD=obsessive-compulsive disorder.Chen YW, et al. Am J Psychiatry. 1995;152:280-282; Chen YW, et al. Psychiatry Res. 1995;59:57-64.

Odds

Ratio

20.8

PD

OCD

†Slide8

BP and Mental and Medical Disorder Co-morbidity—Clinical Studies

Eating disorders

Impulse control disorders

Tourette

syndrome

Attention-deficit/ hyperactivity disorder

Conduct disorder

Sexual disorders

Migraine

Other chronic pain syndromes?

Obesity

Type II diabetes mellitus

Kruger S et al.

Int

J Eat

Disord

. 1996;19:45-52; McElroy SL et al.

Compr

Psychiatry

. 1996; 37:229-240;

Comings BG et al.

Am J Hum Genet

. 1987;41:804-821;

Biederman

J et al.

Biol

Psychiatry.

2000;48:458-466; Frazier JA et al.

Am J Psychiatry

. 2002;159:13-21; McElroy SL et al.

J

Clin

Psychiatry

. 1999;60:414-420;

Merikangas

KR et al.

Arch Gen Psychiatry

. 1990;47:849-853;

Elmslie

JL et al.

J

Clin

Psychiatry. 2000;61:179-184; McElroy SL et al. J Clin Psychiatry. 2002;63:207-213; Regenold WT et al. J Affect Disord. 2002;70:19-26.Slide9

Key Recommendation 2

Assess affective and co-morbid symptoms concurrentlySlide10

Affective and Comorbid Symptoms of BP

Affective Manic Depressive

Mixed Cycling

Psychotic

Co-morbid

Obsessive-compulsive

Panic/agoraphobia

Generalized anxiety

Phobia

Alcohol use

Substance use

Binge eating Slide11

Key Recommendation 3

Focus pharmacotherapy on achieving mood stabilization. Use psychological treatments–eg, patient education or illness management–to address co-morbidity issues.Slide12

Comorbid BP: Treatment Guidelines

First goal of pharmacotherapy is mood stabilizationStart with medications that might be effective for both BP and the co-morbid disorder(s)Weigh the severity of bipolarity and co-morbidity when considering

monotherapy vs combination therapy

Monitoring patients through daily mood charting helps recognition of mood states, co-morbidities, their relation with one another, Rx response

Freeman MP, et al.

J Affect

Disord

.

2002;68:1-23.Slide13

Goals of Psychotherapy for BP Patients

Modify social risk factors toEnhance protective effects of patient’s social environmentImprove patient’s abilities to manage effects of stressorsEnhance medication adherence

Increase patient’s and family’s willingness to accept the reality of the disorderReduce risk for suicideIdentify, understand, and manage co-morbid disorders

Miklowitz

DJ.

J

Clin

Psychopharmacol

.

1996;16(

suppl

1):S56-S66.Slide14

Psychotherapy for BP Patients:Clinical Trial of Integrated Group Therapy

Integrated group therapy (IGT): manual-based group psychotherapy integrating treatment for 2 disorders6-month pilot study for outpatients (N=45) with BP and substance abuse

Compared outcomes in patients receiving IGT (12 or 20 weekly sessions) or not receiving IGTResults: Patients receiving IGT had

Significantly better outcomes on Addiction Severity Index (

P

<.03), percentage of months abstinent (

P

<.01), likelihood of achieving 3 consecutive abstinent months (

P

<.004)

Significantly greater improvement on YMRS (

P

<.04), but no difference on HAM-D

Weiss RG, et al.

J

Clin

Psychiatry.

2000;61:361-367.Slide15

Key Recommendation 4

Know the evidence–or the lack thereof–for the therapies used to treat BP with co-morbidities Know the evidence–or the lack thereof–for mood stabilizers/atypical antipsychotics in treating conditions commonly co-morbid with BP when those conditions

do not occur with BSlide16

Lithium in Co-morbid Conditions: Randomized Placebo-controlled Trials

Condition

Alcohol

dependence

Anorexia

nervosa

Conduct

disorder

Impulsive

aggression

OCD

Outcome

(# studies)

+

+

+

+

+

+

+

Judd JL, et al.

Am J Psychiatry

. 1984;141:1517-1521; Kline NS, et al.

Am J Med Sci

. 1974;268:15-22;

Fawcett J, et al.

Arch Gen

Psychiatry.

1987;44:248-256;

McDougle

CJ, et al.

J

Clin

Psychopharmacol

.

1991;11:175-184;

Pigott

TA, et al.

J

Clin

Psychopharmacol

.

1991;11:242-248; Gross HA, et al.

J

Clin

Psychopharmacol

. 1981;1:376-381; Campbell M, et al.

J Am

Acad

Child

Adolesc

Psychiatry.

1995;34:445-453; Malone RP, et al.

Arch Gen Psychiatry.

2000;57:649-654;

Sheard

MH, et al.

Am J Psychiatry

. 1976;133:1409-1413;

Dorus

W, et al.

JAMA

. 1989; 262:1646-1652.

The FDA has not approved the use of lithium for any of these disorders.Slide17

Divalproex in Co-morbid Conditions: Randomized Placebo-controlled Trials

Brady KT, et al.

Drug & Alcohol Dependence.

2002;67:323-330;

Lum

M, et al.

Prog

Neuropsychopharmacol

Biol

Psychiatry.

1991;15:269-273; Hollander E, et al.

Neuropsychopharmacology

. 2003;28:1186-1197; Hollander E, et al.

J

Clin

Psychiatry.

2001;62:199-203; Freitag FG, et al. Neurology. 2002;58:1652-1659.

Condition

Alcohol

dependence

(relapse to prevention)The FDA has approved the use of

divalproex for migraine prophylaxis but has not approved any of the other disorders.Panicdisorder

Borderline

personality

disorder

Migraine

(prophylaxis)

Intermittent explosive disorder (modified)

Outcome

(# studies)

+

+

+

+

+

+

+

+

+

Posttraumatic stress disorder (modified)

+

–Slide18

Carbamazepine in Co-morbid Conditions: Randomized Placebo-controlled Trials

Malcolm R, et al.

Am J Psychiatry

. 1989;146:617-621;

Bjorkqvist

SE, et al.

Acta

Psychiatr

Scand

. 1976;53:333-342;

Uhde

TW, et al.

Am J Psychiatry

. 1988;145:1104-1119; Kaplan AS, et al.

Am J Psychiatry

. 1983;140:1225-1226;

Cowdry

RW, et al. Arch Gen Psychiatry. 1988;45:111-119.

Condition

Alcohol withdrawal

The FDA has not approved the use of carbamazepine for any of these disorders.

AlcoholdependenceBorderline

personality disorder

Panic

disorder

Bulimia

nervosa

Outcome

(# studies)

+

+

+

+

+

+

+

–Slide19

Atypical Antipsychotics in Co-morbid Conditions: Placebo-controlled Trials

RIS=

risperidone

; OLZ=

olanzapine

McDougle

CJ, et al.

Arch Gen Psychiatry

. 2000;57:794-801;

Brawman-Mintzer

O, et al. Unpublished data;

Shapira

NA, et al. American College of

Neuropsychopharmacology

; 2002; San Juan, Puerto Rico;

Findling

RL, et al.

J Am

Acad Child Adolesc Psychiatry. 2000;39:509-516; Snyder R, et al. J Am Acad Child

Adolesc Psychiatry. 2002;41:1026-1036; Dion Y, et al.

J Clin Psychopharmacol. 2002;22:31-39; McDougle CJ, et al. Arch Gen Psychiatry. 1998;55:633-641; Grabowski J, et al. J Clin Psychopharmacol. 2000;20:305-310.Condition

OCD

The FDA has not approved the use of olanzapine or risperidone for any of these disorders.

Conduct

disorder

Tourette

syndrome

Autism

+

(RIS)

Cocaine

dependence

Outcome

(Agents)

+

(RIS)

+/–

(OLZ)

+

(RIS)

+

(RIS)

+

(RIS)

(RIS)

GAD

+

(RIS)Slide20

Key Recommendation 5

Avoid prematurely treating co-morbidities with mood-destabilizing agentsSlide21

Co-morbid BP: Treatment Guidelines

Avoid treatments that destabilize moodAntidepressants, stimulants may precipitate hypomania, mania, mixed states, rapid cycling“Uncovering” psychotherapies may increase psychological stress

Destabilization of mood often worsens co-morbid conditionsConcentrate initial therapies on producing mood stability or pure depression; once a patient is depressed, antidepressants usually can be addedSlide22

Key Recommendation 6

Before using antidepressants to treat anxiety disorders co-morbid with BP, consider mood stabilizers and atypical antipsychotics with demonstrated efficacy in anxietySlide23

Mood Stabilizers and Atypical Antipsychotics with Efficacy in Anxiety

Mood stabilizers: valproate/divalproex for

panic disorderAtypical antipsychotics: risperidone for generalized anxiety and obsessive-compulsive disordersSlide24

Key Recommendation 7

Rethink requiring active alcoholics to “stop drinking” before treating their BP, and select BP therapies accordinglySlide25

Treating Co-morbid Alcohol Abuse

Alcoholic, bipolar patients should not be refused treatment for BP Do not postpone therapy until patients achieve sobrietyPatients denied therapy for BP until they stop drinking very often never return for treatmentMany problems of co-morbid alcohol abuse occur with other addictive substances

Consider adjunctive psychological treatment

Bipolar Care OPTIONS Southeast Regional Working Group; June 6-7, 2003; Atlanta, GA.Slide26

Effects of BP Treatments on Comorbid Alcohol Abuse

Divalproex: may be effective in preventing relapseCarbamazepine: effective in alcohol withdrawal

Lithium: may be effective but need to monitor electrolytes and hydration when taken in combination with alcoholSlide27

Topiramate in Alcohol Dependence

Study Weeks

Placebo (n=48)

Topiramate

(n=55)

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

0 4 8 12

Drinks/d

-6.24 ± 1.23

-3.36 ± 1.04

Mean Change ± 95% CI From Baseline on Drinks/Day

P

<.0001

Baseline: 7.78 (

topiramate

)

vs

6.52 (placebo).

Johnson BA, et al.

Lancet

. 2003;361:1677-1685.

The FDA has not approved this use.Slide28

Key Recommendations: Summary

Realize that co-morbidity is the rule, not the exception, in bipolar disorder (BP)Assess affective and co-morbid symptoms concurrently

Focus pharmacotherapy on achieving mood stabilization. Use psychological treatments–eg

, patient education or illness management–to address co-morbidity issues.Slide29

Key Recommendations: Summary

Know the evidence–or the lack thereof–for the therapies used to treat BP with co-morbiditiesAvoid prematurely treating co-morbidities with mood-destabilizing agents

Before using antidepressants to treat anxiety disorders co-morbid with BP, consider mood stabilizers and atypical antipsychotics with demonstrated efficacy in anxiety

Rethink requiring active alcoholics to “stop drinking” before treating their BP, and select BP therapies accordinglySlide30

Q & ASlide31

888-536-HOPE (4673)

lindnercenterofhope.org