I had a chance to listen to a Medscape podcast that featured an interview with Michael Ostacher MD, a psychiatrist with a special interest in patients who suffer from both bipolar disorder and an SUD.
Some of his more interesting observations:
The physician’s perspective will depend largely on the setting in which they encounter the patient with co-occurring bipolar and substance disorders. In a typical Emergency Room, it’s when the SUD is active and acute, demanding immediate intervention. In a specialty outpatient practice, however, the substance disorder is likely to be inactive, a key part of the patient’s history.
As for the substances involved in such cases, he claims that conforms to patterns of common usage: Since alcohol and cannabis are far and away the most prevalent drugs of abuse in society, those SUDs are also the most likely to be found. Doesn’t mean there aren’t others involved, of course.
The discussion cites prevailing estimates that “somewhere between 45% and 70%…who have a diagnosis of bipolar disorder will have at some point in their lifetime met the criteria for a substance use disorder.” That’s a very high percentage. Again, likely to be active if the patient is younger, and by history if they are of more advanced age.
Ostacher notes that “perhaps as few as 10% or 12% of those who are seeking treatment for bipolar disorder will present with an active SUD that requires attention.” I admit that sounded low to me, but he’s probably correct. My impression stems from the population I’m most familiar with — patients in either an intensive outpatient or residential rehab setting.
Ostacher’s attitude towards treatment of co-occurring bipolar & SUD is refreshingly optimistic. “It’s probably not the case that people who have substance use disorders actually do worse once they’re in treatment with you,” he maintains ( ‘you’ being a physician). He seems to recommend an integrated model, where both disorders are treated at the same time, by the same clinicians, using a unitary treatment plan.
That’s as opposed to older models such as the serial approach, where the idea was treat the SUD separately, and then to use a second treatment plan (and possibly a second treatment program) to address the bipolar disorder. I’ve seen that in action, and found it impractical and unsuccessful.
The experts do acknowledge that many physicians, on first learning that a patient is both bipolar and SUD, groan silently in anticipation of a difficult treatment course and a poor outcome. As a result, they may dismiss the possibility of lasting recovery — often, at a loss to both patient and family.
I’m familiar with that aspect of the problem. Still haven’t forgotten the utter certainty with which one family’s physician predicted the fate of a young male patient with bipolar disorder.
“We’ll wind up sending him through another rehab, probably more expensive than the last one, and he’ll do well for a while, and then he’ll start drinking and get crazy all over again. And when that’s over, he’ll go into a funk and probably try to kill himself.” He shook his head in disgust. “Maybe this time, he’ll finish the job.”
I don’t know how that case turned out. But somehow, that physician had allowed himself to become part of the family’s problem, rather than its solution.
