When dealing with anyone that has a mental health disorder and also a substance use disorder, as counselors we should research the disorders and the treatments properly before going into any session. With Dual Diagnosis or Co-Occurring mental or behavioral health disorders there is double the research and care needing to be took when entering the therapeutic session. “Dual Diagnosis is when an individual is diagnosed with a substance use disorder and also has a co-occurring mental health or behavioral disorder” (Center, 2018). “According to the National Institute on Drug Abuse (NIDA), people who are substance abusers are 2x’s more likely to suffer from mood and anxiety disorders” (Center, 2018). This paper analyzes the bipolar disorder in effect with substance abuse by providing background information on bipolar disorder (BD) and substance use disorder (SUD). This paper will give you definition of what bipolar disorder and substance use disorder is, the percentage of individuals with this diagnosis, and the symptoms of a bipolar individual. Then the paper will discuss a bipolar disorder and substance abuse individual, which is referred to as defined above, Dual Diagnosis along with symptoms of individuals who have this dual diagnosis. The paper will then go on and provide best treatment methods and offer those that are not beneficial to dually diagnosed bipolar clients.
BIPOLAR DISORDER:
Bipolar disorder (aka manic-depressive illness) is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks (Mental Health, 2018). There are 4 different types of bipolar disorder and they are Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, and other specified and unspecified Bipolar and related disorders (Mental Health, 2018). In these different types the individual can experience really “up” or happy moods and excited movements or they can experience really “down” or sad moods or depressive periods (Mental Health, 2018). These periods are labeled as “Mood Episodes”, and are nothing like the typical moods the individual has expressed (Mental Health, 2018). There are times (episodes) when the individual can be feeling both extremely happy and hopeless, at the same time, these mood variances are referred to as an episode with “Mixed Features” (Mental Health, N. O., 2018). Scientists are trying to figure out the causes for bipolar disorder but most agree that there is not solely one cause for it but multiple circumstances that contribute to it (Mental Health, N. O., 2018). They say that some individuals with certain genes are more likely to be diagnosed with bipolar disorder (Mental Health, N. O., 2018). The genes are not always the cause, studies done on identical twins have shown that just because one has the bipolar disorder, the other one does not typically get it and their genes are identical (Mental Health, N. O., 2018). According to the text, “bipolar disorder tends to run in families” (Mental Health, N. O., 2018). Individuals who have a sibling or a parent with the disorder is more likely to have it than those who do not have bipolar disorder in their family tree (Mental Health, N. O., 2018).
When it comes to diagnosing this disorder, it can be very hard for a doctor due to the fact that some of the symptoms expressed in bipolar disorder can be expressed in others as well (Mental Health, N. O., 2018). For example with an individual who may be experiencing psychosis symptoms(hallucinations, delusions, etc.) will have moods that project as an extreme mood may be labeled or diagnosed with schizophrenia instead of the bipolar disorder (Mental Health, 2018). Also with anxiety disorders like ADHD can be actually a person in another extreme mood of the bipolar disorder (Mental Health, N. O., 2018). So needless to say the physician is always supposed to be open with suggestions and the knowledge of each of the different possibilities. It is our job to make sure we diagnose our client correctly and provide them the best treatment plan for them, just because one treatment worked for one person does not mean it will work for them all. So we must keep this in mind throughout our whole career. And again, if they are improperly diagnosed then the proposed treatment plan may cause more harm than good to the patient.
SUBSTANCE ABUSE DISORDER:
According to a study done by NIDA, people with severe mental illness are 4x’s more likely to be heavy alcohol users (Center, 2018). These individuals are also 5x’s more likely to to be daily tobacco users (Center, 2018). “Substance use disorders as defined by the DSM-V, are which are defined as mild, moderate, or severe to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual (Harrington, 2015). “Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home” (Harrington, 2015). There are several different substance use disorders defined in the DSM-V. The most commonly used in the U.S. are Alcohol Use Disorder, Tobacco Use Disorder, Stimulant Use Disorder, Opioid Use Disorder, Cannabis Use Disorder, and Hallucinogen Use Disorder (Harrington, 2015). For the purpose of this paper I will discuss 3 of the 6 most commonly used here in America.
Alcohol Use Disorder is the number one drug being abused across America, and in part because it is legal. “According to the Centers for Disease Control and Prevention (CDC), excessive alcohol use causes 88,000 deaths a year” (Harrington, 2015). A survey that was done in 2014, stated that 52.7% of adolescents aged 12 and older had reported being alcohol consumers (Harrington, 2015). “Many of these alcohol users drink in moderation, but of the 176.6 million alcohol users in America, an estimated 17 million have an Alcohol Use Disorder” (Harrington, 2015). Among these drinkers, there are 3 types of drinking: Moderate, Binge, and Heavy Drinking (Harrington, 2015). Moderate drinking is defined as “drinking up to 1 drink a day for women and up to 2 drinks a day for men” (Harrington, 2015). Binge drinking is defined as “drinking 5 or more drinks on the same occasion for at least one day in the past 30 days” (Harrington, 2015). Heavy Drinking is defined as “drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days” (Harrington, 2015).
The second most common is Tobacco Use Disorder, according to a survey done in 2014, 25.2% of individuals 12 or older, an estimated 66.9 million, use tobacco (Harrington, 2015). The third most commonly used substance in America is Cannabis (Harrington, 2015). “In 2014, approximately 22.2 million people ages 12 and up reported using marijuana” (Harrington, 2015). “Some symptoms of cannabis use disorder include disruptions in functioning due to cannabis use, the development of tolerance, cravings for cannabis, and the development of withdrawal symptoms, such as the inability to sleep, restlessness, nervousness, anger, or depression within a week of ceasing heavy use” (Harrington, 2015). “Using marijuana heavily during youth has been linked to increasing the risk of developing mental illness and poorer cognitive functioning” (Harrington, 2015).
BIPOLAR DISORDER AND SUBSTANCE ABUSE:
According to the National Survey on Drug Use and health in 2012, 8.4 million adults in the United States have both a mental and substance use disorder (Center, 2018).Individuals who are trying to relieve the effects of their bipolar disorder may turn to substance use in a way to numb themselves ( ). Some of the ways that substance abuse affects the behaviors and emotions of a bipolar disorder individual include “Intensification of symptoms (mood swings, poor judgment, impulsivity, hostility, and irritability), longer episodes of emotional instability, Increased number of suicide attempts and diminished quality of life” ( ).
“Treating both of these disorders at the same time can be intricate, and will require intensive attention to the symptoms of the mental illness as well as the behaviors associated with addiction” ( ). “The effectiveness of a treatment plan for individuals with dual diagnoses, are typically higher when both conditions are treated at the same time, and within the same program” ( ). “Treatment should draw from multiple modalities and disciplines to address the client’s neurological, psychological, physical, and psychosocial needs” ( ). Some of the approaches include Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), Solution-Focused Therapy (SFT), and Trauma therapies ( ). MI is when the therapist and client partner in helping the client define sources of motivation and achieve self-defined goals. The text states that it is “especially useful in treating individuals who are working to recover from the effects of addiction” ( ). “CBT addresses the learned thought patterns and destructive behaviors that contribute to addiction, depression, and anxiety” ( ). “Clients learn to identify self-defeating thoughts and actions, and replace them with more positive, self-affirming coping strategies” ( ). “SFT is client-centered modality that helps individuals with mental illness and addiction set and achieve specific goals” ( ). “Rather than delving deeply into the origins of mental health issues or substance abuse, SFT focuses on measurable outcomes of therapy” ( ). “Trauma therapies such as Seeking Safety and Eye Movement Desensitization Reprocessing (EMDR) target the unprocessed memories and internalized fears that can intensify anxiety or depression” ( ). There are “integrated rehabilitation programs that incorporate therapy for bipolar disorder and other forms of mental illness with addiction treatment” ( ). Some of the addiction treatment services offered at these facilities include medical detox, inpatient treatment, residential services, partial hospitalization programs and outpatient programs.
TREATMENT PLANS FOR BIPOLAR DISORDER:
“Treatment helps many bipolar patients, even those with the most severe forms of bipolar disorder to gain better control of their mood swings and other bipolar symptoms” (Mental Health, N. O., 2018). An effective treatment plan usually includes a combination of medication and psychotherapy (also called “talk therapy”)” (Mental Health, N. O., 2018). When treating a bipolar disorder patient, we must remember that the “bipolar disorder is a lifelong illness, and that episodes of mania and depression typically come back over time” (Mental Health, N. O., 2018). With that being said just because the treatment plan they are on now seems effective, later on when a tolerance is built, it may become ineffective and then it is “back to the drawing board”. “Between episodes, many people with bipolar disorder are free of mood changes, but some people may have lingering symptoms” (Mental Health, N. O., 2018). Because Substance Use Disorders usually are chronic and relapsing conditions, periods of drug and/ or alcohol use should be expected and not considered a sign of treatment failure (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). Also integrating treatments for both disorders instead of going at them separately may be what is best in terms of effectiveness (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). With that being said targeting Bipolar Disorder symptoms with mood-stabilizing medications and substance abuse with nonpharmacologic modalities such as drug counseling, likely will bring about the best results” (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). Psychosocial Therapy (AA, NA, etc.) may benefit a Bipolar Disorder patient if their mood is stable (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018).
There were a few different studies ran to test effectiveness of lithium, anticonvulsants, antipsychotics and two substance use disorder medications (Naltrexone, and Disulfiram). In the first study, lithium would seem to be a good option to treat these co-occurring patients, but in the study done its effectiveness was tried and the results were not effective with the treatment of the substance use disorder. Lithium was tolerated and improved psychiatric symptoms but the patients still showed failed drug-tests (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). With the anticonvulsants . In the study done with the Substance use disorder medications (Naltrexone and Disulfiram), there was a moderate decrease in alcohol consumption while being given the two substances. When they were incorporated together, there was not a significant difference in the cessation of alcohol consumption so the conclusion we take from this is that one is not significantly better with the cessation of alcohol consumption, but they both do tend to contribute to more alcohol cessation than the patients who were not given the drugs (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). However, in these studies there is a new manic episode expressed amongst bipolar disorder patients while taking these drugs (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). “In a patient with opioid dependence, and a manic episode triggered by naltrexone in a patient with BD with comorbid alcohol dependence” (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018). “At both low and high doses, disulfiram is associated with induction of psychotic mania in alcoholic patients without a personal or family history of Bipolar Disorder” (Nery, F. G., MD,PHD, & Soares, J. C., MD., 2018).
There are several techniques along with medications that can be a part of the treatment plan. Some of them include but are not limited to psychotherapy or “talk therapy” , electroconvulsive therapy, sleeping medications, supplements, and keeping a life chart with the patient (Mental Health, N. O., 2018).
Medications generally used to treat bipolar disorder include Mood stabilizers, Atypical antipsychotics, and Antidepressants” (Mental Health, N. O., 2018). “In Psychotherapy you can provide support, education, and guidance to people with bipolar disorder and their families” (Mental Health, N. O., 2018).In Psychotherapy there are different subdivisions of techniques including Cognitive Behavioral Therapy (CBT), Family-Focused Therapy, Interpersonal and Social Rhythm Therapy, Psychoeducation, etc (Mental Health, N. O., 2018). “In electroconvulsive therapy you can provide relief for people with severe bipolar disorder who have not been able to recover with other treatments” (Mental Health, N. O., 2018). “ECT may cause some short-term side effects, including confusion, disorientation, and memory loss” (Mental Health, N. O., 2018). With that being stated, individuals who have the bipolar diagnosis should make sure they know the risks associated with this therapy (Mental Health, N. O., 2018). Where sleep medication can be introduced is when an individual with the disorder that are having issues going to sleep (Mental Health, N. O., 2018). There are times when a certain medication does not work well with the sleeping medications or others when the sleeping medication itself does not work, when circumstances arise it is always recommended to talk with your doctor to determine the next and best steps (Mental Health, N. O., 2018). As I mentioned earlier, if effectiveness of the treatment plan is good for a while and then eventually stops being as effective, then it is time for a recant on the treatment plan with the patient. With that being stated, “keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and life events can help clients and doctors track and treat bipolar disorder most effectively” (Mental Health, N. O., 2018).