A GP's Approach to the Identification and Treatment of Three Important Symptom Groupings in Conjunction with Substance Abuse
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 33
Concurrent mood disorders and substance use often involve a complex situation in which an individual’s depression may have a bipolar component and may also co-exist with symptoms known as Cluster B and C symptoms (defined below). When mood disorder combines with substance abuse and these other groups of symptoms, this leads to a complex medical situation in general practice. Clarification of symptoms of these three states (i.e. depressive symptoms; manic/hypomanic symptoms; and Cluster B and C symptoms) is necessary for effective treatment. Abstinence from drugs of abuse coupled with the use of mood stabilizing medicines, antidepressants, and/or broad-spectrum psychotropic medications are the key first steps to consider in the resolution of this situation.
When the patient is more stable, stress resolution can be attempted. Helpful approaches from a psychological point of view include cognitive therapy (for example using the helpful ideas of David Burns and Albert Ellis). Recommending writing exercises may also be helpful. To a patient who is fragile, this could be too upsetting, but writing could be helpful for people with some sense of stability and those who are able to discuss aspects of their past with the physician or therapist. In selected cases, it can be very interesting and helpful to consider a metaphorical approach for dreams. In my own clinical practice, I’ve found it very helpful to have a patient ‘read’ a dream as if it were a poem, describing and providing insights into the individual’s own situation. An exercise program is most helpful and is critically important as well for the relief of fatigue. These facets to treatment address both the biological and psychological aspects of our nature.
A person’s experience of themselves develops over time. Various symptoms can be troubling and eventually unmanageable, prompting the individual to seek help. They may feel that it is ‘the situation’ and not themselves at all. They may be crying a lot or just ‘feeling lousy.’ They may be using alcohol, marijuana, cocaine, cigarettes and such to try to feel better. It is a tragic situation, but this dysfunction can continue for 10-15 years before a diagnosis is made. This is the subjective confusion the patient brings to the doctor.
Objective clarity begins by noting the symptoms and determining how long they have been present. This leads to a diagnosis and then suitable treatment. The essential diagnostic categories to search for and identify, if present, include (1) depressive symptoms (2) manic or hypomanic symptoms and (3) Cluster B and C symptoms (defined below).
Ideally, for the patient who is abusing substances, a three to six month period free of drugs of abuse is desirable and necessary before assessment is possible. It should be kept in mind that withdrawal can mimic symptoms of de pression, bipolar disorder and Cluster symptoms. Another complication in the assessment picture is, for example, that emotional upset can be caused by bingeing on weekends. Abstinence is a difficult process and there are some strategies to help a person realize this goal so that an accurate assessment can be made. Time is required for social recovery from addiction. Searching for a period of abstinence in the patient’s history and finding out what that period of time was like can also be helpful.
Risk for psychiatric illness can be clarified by looking at the personal history and the family history. Two key points in the personal history are the patient’s experience of childhood and periods of abstinence. Important family history includes history of alcoholism and any mental health issue.
By helping the patient maintain a period of abstinence and keeping the above guidelines in mind, the risk of overdiagnosis (and overuse of medications) can be minimized.
Depression (and anxiety)
When looking for the presence of depression (with or without co-occurring anxiety) in the general practice setting, the doctor needs to separate the symptoms of anxiety and depression from other physical disorders that may possibly exist. Disturbed sleep, appetite and weight change, depressed mood, irritability, fatigue and diminished sexual interest which appear together and have gradually appeared over time are generally symptoms of depression, rather than a physical health issue.
Similarly, symptoms of anxiety may also include somatic (or bodily) manifestations present in the same time period. These symptoms include muscular pain of any kind including tension headache, blurred vision, ringing in the ears, light-headedness, dry mouth, a sensation of a lump in the throat, shortness of breath, palpitations or racing heartbeat. Gastrointestinal symptoms of anxiety include nausea, vomiting, diarrhea, constipation or change of bowel habit, for example as may be seen in irritable bowel syndrome. A person may experience urinary frequency. There may be aggravation of premenstrual symptoms and neurodermatitis (a psychosomatic skin condition). There may be psychological symptoms of anxiety: for example, claustrophobia or intellectual manifestations that include the inability to concentrate or a sense that memory is being affected. Various stressors may coincide with these symptoms of anxiety and de pression. It is also true that obvious stressors cannot always be found.
This typical presentation in the context of the rest of the history allows the doctor to set aside other diagnostic possibilities. These symptoms of anxiety usually clear when the depression resolves with appropriate antidepressant treatment. (In this population of patients, for completeness, the medical screen should include thyroid stimulating hormone, hemoglobin, HIV, and hepatitis status).
Manic or Hypomanic Symptoms
Secondly, the co-existence of symptoms that may be periodically present may suggest the occurrence of manic or hypomanic symptoms. I find DSM criteria cumbersome to work with but the Mood Disorder Questionnaire (online at: www.bipolar.com/mdq.htm) is a most helpful tool in ruling in or ruling out a coexisting bipolar pattern. Hirschfeld states that seven out of ten people with bipolar spectrum disorder are correctly identified by this questionnaire and nine out of ten who do not have bipolar spectrum disorder would be successfully screened out.
Cluster B and C Symptoms
Thirdly, and finally, an important symptom grouping to be considered is the presence of Cluster B and C symptoms, which are commonly present in people who have substance use and depression-related problems. These Cluster B and C symptoms serve as a type of shorthand to the presence of what the DSM DSM IV would identify as one or more of the personality disorders.
Zarate and Tohen2 speak to the frequency of co-occurring Axis 1 (primary psychiatric diagnoses) and Axis 2 disorders (in this case, personality disorders or Cluster symptoms) and tell us that these comorbid conditions are common and often difficult to diagnose and treat. They state that the literature provides little guidance for the clinician on how to diagnose and treat these co-occurring conditions. In my experience, I have found the Cluster-based approach a helpful way to assess and deal with these situations.
Cluster B symptoms include excessive emotionality (e.g., when a person is very easily led to tears) and behavioural disruption, in the sense that a person may behave in an overly erratic or overly dramatic manner.
Cluster C symptoms include excessive or inappropriate fear or anxiety. In my practice, I have found that these symptoms occur in people who have been mishandled in their formative years – suffering from the effects of neglect, emotional and physical negativity or abuse, and sexual abuse.
Concurrent Substance Abuse
When a person is experiencing one or more of the constellations or groupings of symptoms described above, alcohol and drug abuse can commonly play a part in the history. For instance, Zarate and Tohen quote a prevalence of comorbid substance use disorder in Bipolar Type I at 60.7% and 48.1% for Bipolar Type II.2 They also state that the likelihood of an individual with bipolar disorder having a substance use disorder is six times greater than that of the general population and twice as common as an individual with unipolar depression.
In my experience dealing with concurrent depression-related symptoms and Cluster symptoms, substance abuse primarily involves alcohol, marijuana, cocaine and heroin. Later in the article, I’ll return to the difficult topic of how these issues can be addressed, focusing specifically on heroin dependence.
Developing a Treatment Plan
Once these patterns of symptoms have been identified, a treatment plan can be formulated and a therapeutic trial of medications established. If the medications seem to satisfy the patient’s symptoms, then that medication should be continued. If the medication does not seem to satisfy the situation, then it can be discontinued in favour of another medication. One situation can be guaranteed here: if abstinence from alcohol and drugs of abuse cannot be maintained, the therapeutic trial will fail.
The treatment of depressive symptoms without indication of the presence of a bipolar facet can be managed with conventional antidepressants. Tailoring the medication in a thoughtful way to the patient’s needs is helpful. For instance, I choose amitriptyline (Elavil) if the patient has significant insomnia or body pain (acautionary note: tricyclic antidepressants have potential danger in that they can be lethal in overdose situations). Fluoxetine (Prozac) is helpful if fatigue is significant. Doxepin (Adepin or Sinequan) is helpful if a person requires an antihistaminic effect (for the presence of allergies or itchy skin). An SSRI medication or clomipramine (Anafranil) is indicated for obsessive-compulsive tendencies. Imipramine (Tofranil) is helpful if there are urinary symptoms, especially nocturia (frequent night-time urination). Bupropion (Wellbutrin) is an ideal antidepressant to select for smokers (smoking is very common among patients who abuse substances and have these three symptom patterns). I preferentially prescribe Bupropion over SSRI medication to avoid sexual dysfunction.
If a person satisfies the criteria for having a bipolar pattern, it’s appropriate to select a mood stabilizer. The most commonly used stabilizing medicines include divalproex (Depakene), lithium carbonate and olanzapine (Zyprexa). Forty per cent of patients with bipolar disorder will establish emotional stability with the use of one mood stabilizing agent, but 60% of patients will require two stabilizing agents.
Each of these medicines has their own advantages and side effects. Divalproex is protective against the elevated mood component and with rapid mood cycling. Divalproex can be used in conjunction with an antidepressant to manage the depressive component, if necessary. The best antidepressant for the depressive component of a bipolar pattern is bupropion as this medicine is less likely to stimulate to a high while it effectively manages the depressive aspect. Divalproex can also facilitate withdrawal from alcohol and benzodiazepines and can be used to reduce incidence of relapse to these drugs. In this case, the divalproex can be continued for six months to one year.
Lithium carbonate is protective against highs and lows in the mood cycle. It is inexpensive and can be effective, but approximately 30-50% of patients with bipolar disorder are considered refractory to lithium treatment (that is, lithium stops working for the person after an initial period of effectiveness).
Olanzapine (also used as an antipsychotic) has a mood stabilizing effect protecting against highs and lows. It is also helpful in the treatment of Cluster B and C symptoms. Gabapentin has significant anxiolytic (anti-anxiety) effects. Lomotrigine also has its place in acute bipolar depression, rapid cycling, refractory bipolar patients and bipolar disorder with OCD.
Conventional wisdom suggests that a person with a bipolar pattern should not be given an antidepressant unless they are on a moodstabilizing agent. Prescribing an antidepressant to a patient with a bipolar pattern without a mood-stabilizing agent, in practice, can precipitate a manic or hypomanic phase and put the patient in danger. Patients with a diagnosis of bipolar disorder will often tell you that they have tried antidepressants and their experience of these antidepressants should serve to inform the doctor that a bipolar pattern is a possibility. The patient will often report that they have been given many different antidepressants and they were of no help at all, or that the antidepressants precipitated a ‘weird feeling’ or a ‘high.’ They will often report the same experience with coffee consumption.
Cluster B and C symptoms can be managed with a low dose of psychotropic medicine. These medicines include respiridone (Respirdal), quetiapine (Seroquel) and olanzapine (Zyprexa). If the patient has Cluster symptoms and insomnia, then quetiapine or olanzapine would be a good choice. If insomnia is not a problem, a morning dose of respiridone could be helpful. Doses of these medications can be increased until the symptoms are resolved. Benzodiazapines are almost always contra-indicated and should only be prescribed with considerable discretion, although they are very helpful in facilitating withdrawal from alcohol and opiates. Trazadone is helpful as a sedative.
Further resolution of these Cluster symptoms can be aided by encouraging the patient to write in letter or dialogue form on a daily basis over a period of time.
Dealing with Substance Abuse, including Heroin
The drug abuse and dependency facet of this problem is a daunting issue for the patient who needs to face it, but the problem is also, one way or another, very manageable. A variety of programs can be of immense help for patients trying to establish recovery form substance abuse. ‘Daytox’ and detox programs as well as residential treatment programs, and one-on-one counselling at alcohol and drug programs are all very helpful. A 12-step program with the help of a sponsor is also helpful. These programs serve to establish structure that protects against relapse; they all facilitate the necessary psychological work.
In my practice, I have a large number of patients dealing with heroin, and when it comes to heroin dependence, the above-mentioned measures may or may not be enough. If a patient has a history of relapsing to narcotics, it may be appropriate to consider the option of a methadone maintenance program. People often have mixed feelings about the use of methadone. However, after considering the advantages of methadone over heroin and the fact that the opiatedependent person can become free of an opiate dependency perhaps only 20% of the time, with hard work and good medical management, one can see that the options are limited.
The continued use of heroin requires procuring the money for the drug and this is at great cost to society. Heroin is used four times a day and the administration of the heroin is associated with a high risk of contracting HIV and Hepatitis C. The heroin user also gets a powerful high. In contrast, the methadone patient requires the medicine once per day and does not get the characteristic high. Methadone is relatively inexpensive and greatly reduces the cost of heroin addiction to society. A person who has been stabilized on methadone and who is also emotionally stable (with or without medications described above) can in time perhaps consider withdrawal of the methadone, and if they are careful and determined enough, they may establish freedom from all opiates. Relapse remains the critical problem here, and as a result, methadone maintenance on an ongoing basis may be the best approach.
Burns, D. (1999), The feeling good handbook. Plume Books.
Horricks, CH. (1985). The psychological profile: A history taking aid. Canadian Family Physician, 31, 864-868
It is challenging for busy family doctors to find twenty minutes for a patient assessment, but taking time can be timesaving. Time must be spent or the patient will never be understood and a complete assessment is worth the effort. In conclusion, identifying three important symptom groupings can lead to pharmacological treatment of depression, bipolar disorder, and Cluster B and C symptoms, in a general practice setting. With abstinence from drugs of abuse, use of community resources such as NA and AA, and psychological work such as counselling and writing exercises, a happier, healthier, more manageable life is achievable.
About the Author
Colin has a family practice in Vancouver and works sessionally with governmental alcohol and drug programs. He is also a Clincial Assistant Professor in the Department of Family Medicine at the University of British Columbia
The author would like to thank Dr. Shimi Kang, and also thank Sherry Small and Grace Lutz for their support during the writing of this article
Hirscheild et al. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionaire. Americial Journal of Psychiatry, 157(II), 1873-1875.
Zarate, Jr., CA & Tohen, MF. (1990). Bipolar disorder and comorbid Axis I disorders: Diagnosis and management. In LN Yatham, V Kusamker & S Kutcher (Eds.) Bipolar disorder: A clincian's guide to biological treatments (pp. 115-138). New York: Brummer Routledge.