The link between bipolarity and substance use: A controlled clinic based study.

Youth with depression may be at a higher risk of developing bipolar disorder (BD). Self-reported, dimensional measures, like the Bipolar Spectrum Diagnostic Scale (BSDS), aim to assess for BD in these groups. We explored properties of this instrument within a cohort of depressed, help-seeking youth. We used baseline data from two randomized controlled trials for depressed youth (aged 15-25years) who had no history of BD or psychosis and who completed the BSDS (n=240; mean Age=19.9years, SD=2.7; Female=57%). Structured diagnostic assessments were repeated at 26-weeks to detect new-onset BD. We examined false-positive rates for concurrent BD using established thresholds on the BSDS, utilised factor analyses to determine its underlying structure, and explored associations between the BSDS and demographic, clinical, and personality variables using linear regressions. False-positives rates were high. Most (60%) participants scored above BSDS thresholds at baseline, though none developed BD over the 26-week study period. A three-factor model best fit BSDS items, representing depression, mania, and lability factors. BSDS total, mania and lability sub-scale scores were associated with similar characteristics, with a different pattern of association for the BSDS depression subscale. With no long-term follow-up of the current sample nor a separate bipolar youth sample, we were unable to determine the overall discriminant validity, sensitivity, or longer-term predictive validity of the BSDS. At recommended thresholds, BSDS has high false positive rates for detecting current BD in youth with moderate to severe depression, especially with mental state or personality disorder comorbidities.

Back to table of contents Previous article Next article Education & TrainingFull AccessResource Document Calls for Improved Residency Training on SUDsMark MoranMark MoranSearch for more papers by this authorPublished Online:26 Apr 2021https://doi.org/10.1176/appi.pn.2021.5.23AbstractTrainees need to see patients in a wide variety of settings, over time, with supervisory training that focuses on a patient’s addiction.When trainees are exposed to patients who recover from a substance use disorder, it is humanizing, destigmatizing, and unforgettable, said Shelly F. Greenfield, M.D., M.P.H., a member of APA’s Council on Addiction Psychiatry, at the virtual meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT).“When trainees have that opportunity to work with a patient with a substance use disorder over time and see the patient get better in a real-world setting, it is incredibly gratifying,” says Shelly F. Greenfield, M.D., M.P.H.Residents and fellows need more of those experiences. Greenfield cited data from surveys of program directors and from an October 2020 APA Resource Document on Education and Training for Substance Use Disorders (see section below) indicating that trainees generally do not receive sufficient training in the treatment of substance use disorders (SUDs), including faculty supervision focused specifically on treatment of SUD patients over time. Additionally, too few residents receive training in prescribing buprenorphine and other medications approved for treating SUDs.“When trainees graduate as early career psychiatrists—no matter where they practice—they will see a very high proportion of patients with an SUD either alone or co-occurring with another psychiatric disorder,” Greenfield said. “Yet they have very little training in their four years overall. There have been some positive changes in addiction training in residency, but most studies and the APA resource document demonstrate that training for diagnosing and treating patients with substance use disorders is inadequate for graduating residents in 2021.”She noted that the requirement of the Accreditation Council for Graduate Medical Education for just four weeks of dedicated training in addiction has not been changed since 2001. A 2012 survey of 104 program directors supported by the APA Council on Addiction Psychiatry found that only 19% of program directors reported that trainees were paired with supervisors for addiction, and 68% said patients with SUDs were sent elsewhere for treatment. Most did not provide opportunity for long-term treatment for patients with SUDs.In comments to Psychiatric News after the meeting, Greenfield emphasized four areas in which training in addiction falls short:Lack of supervision that is specifically focused on treatment of patients with SUD. Greenfield cited a 2018 survey of 84 program directors by the Addiction Task Force of AADPRT that found that in many programs addiction training takes place only on general psychiatry units in which co-occurring disorders are evaluated and treated, but the extent to which addiction-trained supervisors are available or addiction is the focus of the training is unclear. In that survey, 41.6% of program directors indicated there was a limited number of faculty with expertise in co-occurring conditions to provide trainee supervision.Greenfield said one approach for programs that lack faculty expertise in addiction is collaboration with other programs, an opportunity made possible by the widespread use of video technology in medicine and psychiatry during the pandemic.Failure to see patients over time. Trainees need to see the progress and recovery of patients with SUD over time. “Longitudinal experience with patients having SUD usually happens in outpatient settings where the trainee can treat patients with SUD, receive supervision, and be able to follow them beyond just a four-week experience on an inpatient unit,” Greenfield said.Lack of training in using buprenorphine and other medications approved for addiction and SUD. “If residents have eight-hour waiver training in buprenorphine, they learn a lot about the medication and about opioid use disorder,” Greenfield said. “Data show that if you get just eight hours of training in residency, you are much more likely to prescribe this medication in your practice after residency. And yet we don’t have a requirement to complete that training.”The tendency of residents to see patients with SUD only in the emergency department. “If you mostly expose trainees to patients who present to the emergency department with SUD, this can contribute to stigma and therapeutic nihilism—the belief that this condition never gets better,” Greenfield told Psychiatric News. “Most patients with SUDs are never seen in emergency departments.”Psychiatrists should learn how to care for patients presenting in the emergency department with acute withdrawal or intoxication, she said, but most will graduate to practice in other settings—outpatient practices, community health settings, inpatient services, and residential and partial hospital settings. “Psychiatrists will routinely encounter patients in these settings who have substance use disorders including those with co-occurring psychiatric disorders, and it is imperative that they feel competent in providing that care.”In addition to the APA resource document, Greenfield cited a number of resources for trainees and training programs. They include the Opioid Response Network and the Providers Clinical Support System, of which APA is a partner. This program offers training and mentoring in evidence-based prevention and treatment of opioid use disorders and treatment of chronic pain.When trainees are expose to patients who recover from an SUD, it can be an experience the trainee will never forget.“We have an apprentice system of learning in graduate medical education—as a resident you have a supervisor, but you are treating the patient yourself,” she said. “What we know is that when trainees have that opportunity to work with a patient with a substance use disorder over time and see the patient get better in a real-world setting—it’s incredibly gratifying.” ■The APA Resource Document on Education and Training for Substance Use Disorders is posted here.APA Resource Document Offers Recommendations for Medical Students, Residents, and Lifelong Learners“Medical schools, physician training (residency) programs, and continuing education programs for physicians in practice provide limited training in the treatment of SUDs,” according to the APA Resource Document on Education and Training in Substance Use Disorders. “The scope of training on SUDs is disproportionate to the population health need to address these problems, and many with SUDs go undiagnosed and untreated.”The resource document is a product of APA’s Council on Addiction Psychiatry, the Council on Medical Education and Lifelong Learning, and the Council on Healthcare Systems and Financing. The document offers recommendations for medical schools, residencies, and continuing medical education for physicians in practice, as well as strategies for change.Recommendations for medical student rotations and residency programs include the following:Addiction and co-occurring disorders should be incorporated into all aspects of psychiatry residency training since patients with SUD are seen at all levels of care.Supervision and discussion of SUD cases should occur at inpatient and outpatient levels of care and should include an addiction psychiatrist.Programs should ensure they have access to resources to help them incorporate enhanced training in SUD with the goal of bolstering resident competencies in assessing and treating patients for these conditions.All psychiatry residents should complete the buprenorphine waiver training or its equivalent.Residents should be trained to treat patients with alcohol use disorder, stimulant use disorder, opioid use disorder, sedative/hypnotic use disorder, cannabis use disorder, tobacco use disorder, and other substances.Training experience should include various levels of patient acuity and corresponding care including outpatient and residential treatment.Residents should receive training in the use of FDA-approved medications for opioid, alcohol, and tobacco use disorder (and others as developed and approved by the FDA).Training on SUD treatments should include knowledge of the range of evidence-based behavioral therapies and competency to practice at least one. This might include, but is not limited to, the ability to integrate motivational interviewing concepts and techniques into patient assessments and sessions. ISSUES NewArchived

Objective This study aimed to develop a machine learning-based classification model to differentiate bipolar disorder from major depressive disorder using self-report scales, including the Mood Disorder Questionnaire (MDQ), Bipolar Spectrum Diagnostic Scale (BSDS), and Anger Coping Scale (ACS).Methods A total of 122 bipolar and 67 depressive patients participated. Recursive feature elimination with 1,000 iterations was used to identify the most informative features. Machine learning classifiers assessed combinations of MDQ, BSDS, and ACS items for classification performance.Results The AUC values for MDQ and BSDS were 0.8212 and 0.7934, respectively. Combining MDQ and BSDS increased the AUC to 0.8477, which improved further to 0.8548 when ACS was included. For MDQ, the best performance was achieved when all 13 items were included. In contrast, the combined model of MDQ, BSDS, and ACS showed optimal performance when BSDS items 18 (conflicts with colleagues or police), 19 (alcohol or substance use), and ACS item 15 (beating others) were excluded.Conclusion Integrating anger coping styles with mood symptoms enhanced diagnostic accuracy, particularly when items related to undesirable behaviors were excluded. This machine learning approach shows potential for effectively evaluating bipolarity and underscores the importance of refining self-report scales to optimize diagnostic tools. Future research should incorporate clinical and objective data to enhance classification models.

The coronavirus disease 2019 (COVID-19) pandemic has had an impact on patients with substance use disorder (SUD). We aimed to investigate factors associated with confidence and adherence to governmental policies against COVID-19 (social desirability) among patients with SUD. This cross-sectional study was conducted during 2020 to 2021. Patients with SUD and healthy controls were recruited. The severity of sleep disturbance, social desirability, drug dependence, vaccine worries, other psychological burdens and demographic variables were collected through self-administrated questionnaires. Differences between the SUD and control groups were estimated. Hierarchical regression analysis was used to identify significant relationships between social desirability and other factors. In total, 58 of patients with SUD and 47 healthy controls were recruited. The patients with SUD had a lower level of social desirability and more severe sleep disturbance than the control group. Older age, more severe sleep disturbance, lower level of drug dependence, and lower level of vaccine worries were significantly associated with a higher level of social desirability among the patients with SUD. Our results show the importance of timely interventions for drug dependence and to address vaccine worries in patients with SUD.

Circadian functioning and quality of life in substance use disorder patients with and without comorbid schizophrenia

To estimate the treated prevalence of mental illness, substance use disorder (SUD) and dual diagnosis and the association between dual diagnosis and fatal and non-fatal overdose among residents of British Columbia (BC), Canada. A retrospective cohort study using linked health, income assistance, corrections and death records. British Columbia (BC), Canada. A total of 921 346BC residents (455 549 males and 465 797 females) aged 10years and older. Hospital and primary-care administrative data were used to identify a history of mental illness only, SUD only, dual diagnosis or no history of SUD or mental illness (2010-14) and overdoses resulting in medical care (2015-17). We calculated crude incidence rates of non-fatal and fatal overdose by dual diagnosis history. Andersen-Gill and competing risks regression were used to examine the association between dual diagnosis and non-fatal and fatal overdose, respectively, adjusting for age, sex, comorbidities, incarceration history, social assistance, history of prescription opioid and benzodiazepine dispensing and region of residence. Of the 921 346 people in the cohort, 176 780 (19.2%), 6147 (0.7%) and 15 269 (1.7%) had a history of mental illness only, SUD only and dual diagnosis, respectively; 4696 (0.5%) people experienced 688 fatal and 6938 non-fatal overdoses. In multivariable analyses, mental illness only, SUD only and dual diagnosis were associated with increased rate of non-fatal [hazard ratio (HR)=1.8, 95% confidence interval (CI)=1.6-2.1; HR=9.0, 95% CI=7.0-11.5, HR=8.7, 95% CI=6.9-10.9, respectively] and fatal overdose (HR = 1.6, 95% CI=1.3-2.0, HR=4.3, 95% CI=2.8-6.5, HR=4.1, 95% CI=2.8-6.0, respectively) compared with no history. In a large sample of residents of British Columbia (Canada), approximately one in five people had sought care for a substance use disorder or mental illness in the past 5years. The rate of overdose was elevated in people with a mental illness alone, higher again in people with a substance use disorder alone and highest in people with a dual diagnosis. The adjusted hazard rates were similar for people with substance use disorder only and people with a dual diagnosis.

Association of Bipolar and Substance Use Disorders in Parents of Adolescents With Bipolar Disorder

Our aim was to evaluate the impact of direct-acting antivirals (DAAs) on decompensated cirrhosis (DCC) and HCC in patients with chronic HCV and substance use disorder (SUD) compared with those without an SUD. This retrospective cohort study used the MarketScan database (2013-2018) to identify 29,228 patients with chronic HCV, where 22% (n=6,385) had≥1 SUD diagnosis. The inverse probability of treatment weighted multivariable Cox proportional hazard models were used to compare the risk of developing DCC and HCC. Among the those who were noncirrhotic, treatment reduced the DCC risk among SUD (adjusted hazard ratio [aHR] 0.13; 95% CI, 0.06-0.30) and non-SUD (aHR 0.11; 95% CI, 0.07-0.18), whereas the risk for HCC was not reduced for the SUD group (aHR 0.91; 95% CI, 0.33-2.48). For those with cirrhosis, compared with patients who were untreated, treatment reduced the HCC risk among SUD (aHR, 0.33; 95% CI, 0.13-0.88) and non-SUD (aHR, 0.40; 95% CI, 0.25-0.65), whereas the risk for DCC was not reduced for the SUD group (aHR, 0.64; 95% CI, 0.37-1.13). Among patients with cirrhosis who were untreated, the SUD group had a higher risk of DCC (aHR, 1.52; 95% CI, 1.03-2.24) and HCC (aHR, 1.69; 95% CI, 1.05-2.72) compared with non-SUD group. Among the HCV SUD group, DAA treatment reduced the risk of DCC but not HCC for those who were noncirrhotic, whereas DAA treatment reduced the risk of HCC but not DCC for those with cirrhosis. Among the nontreated, patients with an SUD had a significantly higher risk of DCC and HCC compared with those without an SUD. Thus, DAA treatment should be considered for all patients with HCV and an SUD while also addressing the SUD.

BackgroundDual diagnosis is common in Borderline Personality Disorder (BPD), one of the most common being Substance Use Disorder (SUD). Previous studies have shown that general psychiatric management (GPM) was effective in reducing borderline symptoms.In the present study, we tested whether the short GPM was as effective in the BPD + SUD as in the BPD group.MethodsWe analysed a group of 99 patients presenting a BPD. 51 of these patients presented a SUD. The BPD group and the BPD + SUD group received a manual-based short variant of the GPM treatment. Previous studies have shown that a 10-session version of GPM was effective in reducing borderline symptoms at the end of the treatment (Psychother Psychosom 83:176–86, 2014).ResultsWe found no significant difference in the reduction of general symptoms, which diminished in both groups. The specific borderline symptoms were also reduced in both groups, but there was a slightly higher reduction of the borderline symptoms in the SUD group. The therapeutic alliance progressed positively in all groups. Moreover, the alliance increased more over time in the SUD group.ConclusionThe short variant of GPM seems to be effective in BPD treatment independently from the presence of SUD. Therefore, this treatment could be an effective entry-level treatment for patients with dual diagnosis as well as patients with BPD only. Further studies are needed to confirm efficacy and long-term outcome.Trial registrationThe trial was registered at ClinicalTrial.gov (identifier NCT01896024).

Granulocyte colony–stimulating factor (G-CSF) has raised much interest because of its role in cocaine addiction in preclinical models. We explored the plasma concentrations of G-CSF in patients diagnosed with substance use disorder (SUD) and highly comorbid psychiatric disorders. In particular, we investigated the association between G-CSF concentrations and comorbid major depressive disorder (MDD) in patients with cocaine and alcohol use disorders (CUD and AUD, respectively). Additionally, patients with MDD but not SUD were included in the study. Three hundred and eleven participants were enrolled in this exploratory study: 136 control subjects, 125 patients with SUD (SUD group) from outpatient treatment programs for cocaine (N = 60, cocaine subgroup) and alcohol (N = 65, alcohol subgroup), and 50 patients with MDD but not SUD (MDD group) from primary-care settings. Participants were assessed based on DSM-IV-TR criteria, and a blood sample was collected to examine the plasma concentrations of G-CSF. G-CSF concentrations were negatively correlated with age in the entire sample (r = − 0.233, p < 0.001) but not in the patients with MDD. G-CSF concentrations were lower in patients with SUD than in controls (p < 0.05), specifically in the cocaine subgroup (p < 0.05). Patients with SUD and comorbid MDD had lower G-CSF concentrations than patients with SUD but not comorbid MDD or controls (p < 0.05). In contrast, patients with MDD but not SUD showed no differences compared with their controls. The negative association between G-CSF concentrations and age in the sample was not observed in patients with MDD. G-CSF concentrations were decreased in patients with SUD and comorbid MDD but not in patients with MDD. Therefore, G-CSF may be useful to improve the stratification of patients with dual diagnosis seeking treatment. Further investigation is needed to explore the impact of sex and type of drug on the expression of G-CSF.

BackgroundScreening scales for bipolar disorder including the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) have been plagued by high false positive rates confounded by presence of borderline personality disorder. This study examined the accuracy of these scales for detecting bipolar disorder among patients referred for eating disorders and explored the possibility of simultaneous assessment of co-morbid borderline personality disorder.MethodsParticipants were 78 consecutive female patients who were referred for evaluation of an eating disorder. All participants completed the mood and eating disorder sections of the SCID-I/P and the borderline personality disorder section of the SCID-II, in addition to the MDQ and BSDS. Predictive validity of the MDQ and BSDS was evaluated by Receiver Operating Characteristic analysis of the Area Under the Curve (AUC).ResultsFifteen (19%) and twelve (15%) patients fulfilled criteria for bipolar II disorder and borderline personality disorder, respectively. The AUCs for bipolar II disorder were 0.78 (MDQ) and 0.78 (BDSD), and the AUCs for borderline personality disorder were 0.75 (MDQ) and 0.79 (BSDS).ConclusionsAmong patients being evaluated for eating disorders, the MDQ and BSDS show promise as screening questionnaires for both bipolar disorder and borderline personality disorder.

OBJECTIVE: Substance use disorders (SUD) are among the most important public health problems throughout the world. We investigated whether COMT (Val108/158Met), CNR2 (rs2501432 and rs2229579), UCP2 (rs659366), and IL-17 (rs763780) gene variants were associated with SUD and its clinical parameters in a Turkish population.METHODS: We conducted a case–control study among 136 subjects with SUD and 100 healthy controls. Six variants were analysed by the PCR-RFLP method.RESULTS: The CNR2 rs2229579 T/T genotype and T allele increased in SUD groups than controls while the C/C genotype and C allele were more prevalent in the control group compared to the SUD group (p = 0.000 and p = 0.001, respectively). The COMT Val108/158Met Val/Val genotype and Val allele were significantly associated with polysubstance abuse (p < 0.05). There was no significant difference between the SUD group and control group regarding genotype and allele frequencies of COMT (Val108/158Met), CNR2 (rs2501432), UCP2 (rs659366) and IL-17 (rs763780) variants.CONCLUSIONS: This is the first study that discussed the relation of these variants and SUD patients in the Turkish population. The results of the analysis indicated that the CNR2 rs2229579 variant has an effect on susceptibility to SUD, suggesting that this variant might play a role in the physiopathology of SUD. The COMT Val108/158Met variant might be an important factor affecting polysubstance use.

Dual disorders (substance use and mental illness comorbidity) are a condition that has been strongly associated with severe symptomatology and clinical complications. The study of circadian characteristics in patients with Severe Mental Illness or Substance Use Disorder (SUD) has shown that such variables are related with mood symptoms and worse recovery. In absence of studies about circadian characteristics in patients with dual disorders we examined a sample of 114 male participants with SUD and comorbid Schizophrenia (SZ+; n = 38), Bipolar Disorder (BD+; n = 36) and Major Depressive Disorder (MDD+; n = 40). The possible differences in the sample of patients according to their psychiatric diagnosis, circadian functioning with recordings of distal skin temperature during 48 h (Thermochron iButton®), circadian typology and sleep-wake schedules were explored. MDD+ patients were more morning-type, while SZ+ and BD+ had an intermediate-type; the morning-type was more frequent among participants under inpatient SUD treatment. SZ+ patients had the highest amount of sleeping hours, lowest arousal and highest drowsiness followed by BD+ and MDD+, respectively. These observed differences suggest that treatment for patients with dual disorders could include chronobiological strategies to help them synchronize patterns with the day-light cycle, since morning-type is associated with better outcomes and recovery.

Historically, recovery from substance use disorders (SUD) has focused exclusively on the use or non-use of the addictive substance(s). More recently, SAMSHA [1] has defined recovery in a more holistic way, using quality of life (QoL) as a measure of recovery for individuals with substance use and mental health disorders. However, little is known about the myriad experiences that inform and affect QoL for individuals with substance use disorders. Using an attachment informed stress-buffering framework, the purpose of this study was to examine the contribution of parental warmth and recovery support to QoL among women in substance abuse treatment. Linear regression and bootstrapping were used to examine direct and mediated effects of parental warmth and recovery support on QoL among 318 women recruited from three inner-city women-only addiction treatment programs. Relationships were assessed across three domains of quality of life: physical, psychological, and social. Parental warmth and recovery support were directly associated with psychological and social QoL, when controlling for the influence of trauma symptoms. Recovery support mediated the relationship between parental warmth and QoL across psychological and social QoL domains. Findings suggest that interventions that focus on attachment-related constructs to enhance recovery support may improve quality of life among women with SUD.

During the COVID-19 pandemic, US emergency department (ED) visits for psychiatric disorders (PDs) and drug overdoses increased. Psychiatric disorders and substance use disorders (SUDs) independently increased the risk of COVID-19 hospitalization, yet their effect together is unknown. To assess how comorbid PD and SUD are associated with the probability of hospitalization among ED patients with COVID-19. This retrospective cross-sectional study analyzed discharge data for adults (age ≥18 years) with a COVID-19 diagnosis treated in 970 EDs and inpatient hospitals in the United States from April 2020 to August 2021. Any past diagnosis of (1) SUD from opioids, stimulants, alcohol, cannabis, cocaine, sedatives, or other substances and/or (2) PD, including attention-deficit/hyperactivity disorder (ADHD), anxiety, bipolar disorder, major depression, other mood disorder, posttraumatic stress disorder (PTSD), or schizophrenia. The main outcome was any hospitalization. Differences in probability of hospitalization were calculated to assess its association with both PD and SUD compared with PD alone, SUD alone, or neither condition. Of 1 274 219 ED patients with COVID-19 (mean [SD] age, 54.6 [19.1] years; 667 638 women [52.4%]), 18.6% had a PD (mean age, 59.0 years; 37.7% men), 4.6% had a SUD (mean age, 50.1 years; 61.7% men), and 2.3% had both (mean age, 50.4 years; 53.1% men). The most common PDs were anxiety (12.9%), major depression (9.8%), poly (≥2) PDs (6.4%), and schizophrenia (1.4%). The most common SUDs involved alcohol (2.1%), cannabis (1.3%), opioids (1.0%), and poly (≥2) SUDs (0.9%). Prevalence of SUD among patients with PTSD, schizophrenia, other mood disorder, or ADHD each exceeded 21%. Based on significant specific PD-SUD pairs (Q < .05), probability of hospitalization of those with both PD and SUD was higher than those with (1) neither condition by a weighted mean of 20 percentage points (range, 6 to 36; IQR, 16 to 25); (2) PD alone by 12 percentage points (range, -4 to 31; IQR, 8 to 16); and (3) SUD alone by 4 percentage points (range, -7 to 15; IQR, -2 to 7). Associations varied by types of PD and SUD. Substance use disorder was a stronger predictor of hospitalization than PD. This study found that patients with both PD and SUD had a greater probability of hospitalization, compared with those with either disorder alone or neither disorder. Substance use disorders appear to have a greater association than PDs with the probability of hospitalization. Overlooking possible coexisting PD and SUD in ED patients with COVID-19 can underestimate the likelihood of hospitalization. Screening and assessment of both conditions are needed.