Ihsan Salloum, MD, MPH

B. Inclusion of the Global Assessment of Functioning scale

C. The diagnostic model for personality disorders

D. The terms that have been a mainstay of mental health vocabulary for nearly a quarter century

 The diagnostic model for personality disorders

• Despite multiple proposed categorical or dimensional changes, only a few were adopted in the final version of DSM-5
• One of the major proposals rejected was the revision of 

the hybrid categorical-dimensional model for personality disorders


• Implementation of this proposed new model by October 2014 would probably have imposed significant burden on clinical practice and the research community and would have required a revision of academic curricula for residency programs and clinical practice guidelines
• Instead, this model was included in Section III for further research.

Diagnosing Psychiatric Disorders: The Synchronization of DSM-5 and ICD-10-CM

,” by Ihsan Salloum, MD, MPH, and Ingrid Vasiliu-Feltes, MD, MBA, on which this quiz was based.

Poll

DSM-5 stands out for the introduction of several new specifiers, which will allow for more accurate coding. Which of the items mentioned in this quiz did not change in DSM-5?

Mini Quiz: DSM-5 Basics

CME credit for this article is now expired. It appears here for informational purposes only. Some of the material may have changed.

This article provides an overview of the changes in DSM-5 and a review of how DSM-5 relates to ICD-10-CM.

At the end of this article, readers should be able to:

1. Describe the relationship of DSM-5 and ICD-10-CM.

2. Recognize how DSM-5 can translate into changes in clinical practice.

3. Analyze how changes occurring in mental health might impact mental health records, regulatory policies, and reimbursement models.

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The publication of DSM-5 is the culmination of more than a decade-long revision of earlier versions of DSM. The importance of DSM is highlighted by its impact on the practice of psychiatry in the US and on psychiatric research throughout the world. The implications of a diagnostic and classification system are extensive. The role of a classification system has evolved from its early origin as a system to record causes of mortality to the current complex versions of taxonomies with a broad range of roles and functions used by multiple stakeholders.

International diagnostic classifications and guides

The two most widely used classification systems in psychiatry are the World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD) and DSM.

 The ICD is one of the WHO’s Family of International Classifications (WHO-FIC).

 The ICD is usually updated every 10 years to reflect scientific advances in medicine and health sciences, enhance clinical and health system utility, and optimize public health usefulness.

The ICD has its historical roots in the International Classification of Causes of Death, which was produced by the International Statistical Institute in 1893.

 The WHO produced the Sixth Revision of the ICD (then called International Classification of Diseases, Injuries and Causes of Death) in 1948. A separate section on mental disorders was included for the first time in ICD-6; Chapter V of the current ICD focuses on mental and behavioral disorders.

Since its publication more than 60 years ago, DSM has become a standard reference for clinical psychiatric practice in the US. DSM-I was produced in 1952 as a national classification system for the American Psychiatric Association in conjunction with ICD-6. DSM-II was published in conjunction with ICD-8 in 1968. The lack of reliability of psychiatric diagnosis was a major concern for existing diagnostic systems. The Feighner criteria proposed criterion-based diagnosis in 1972 to enhance diagnostic reliability.

 These criteria were expanded in the Research Diagnostic Criteria, and this approach was adopted in DSM-III.

The introduction of the notion of standardized nosology along with diagnostic criteria in 1980 with the publication of DSM-III constituted a major paradigm shift within DSM and psychiatric classification in general. The emphasis was placed on descriptive psychopathology and the use of specific diagnostic criteria for each mental disorder. The new standard significantly improved reliability of psychiatric diagnosis and enhanced communication among clinicians and other stakeholders.

Although the adoption of specific diagnostic criteria for mental disorders contributed to the extraordinary expansion in psychiatric research, it did not lead to similar advances in the validity of current nosological entities, and empirical work on the classification system itself has been relatively limited. Since 1980, DSM-III has been revised 4 times, DSM-III-R in 1987, DSM-IV in 1994, DSM-IV-TR in 2000, and most recently DSM-5 in May 2013.

Attempts to synchronize ICD-10 (1992) and DSM-IV compromised the inclusion of a comprehensive diagnostic format by using a multiaxial system. ICD-10 included a research version with specified diagnostic criteria as well as a clinical guide version.

The process of updating the mental disorders chapter of ICD-11 is currently under way. It is expected that DSM-5 and the upcoming ICD-11 Chapter V will be synchronized as much as possible. Benefits of an optimized harmonization include easier clinical communication between the two systems and enhanced comparability of research findings and their applicability across national boundaries. An international treaty that mandates using the ICD coding system in the US also drives harmonization between the two systems. The currently used ICD-9-CM (US adaptation) will be replaced by ICD-10-CM in October 2014.

Section I (DSM-5 Basics) consists of an introduction and guide to the use of the manual; Section II describes diagnostic criteria and codes with diagnostic and associated features; Section III includes emerging measures and models. The Appendix highlights changes from DSM-IV to DSM-5 and contains glossaries of technical terms and cultural concepts as well as alphabetical and numerical listings of DSM-5 diagnoses and codes (according to ICD-9-CM and ICD-10-CM).

A total of 22 broad diagnostic categories are described in “Diagnostic Criteria and Codes” (Section II). Detailed diagnostic criteria with coding and recording procedures as well as a list of specifiers are included for each specific disorder listed within a broad category. This is followed by a description of the essential elements and associated features that support the diagnosis, including prevalence, development, and course, as well as risk and prognostic factors. The latter are categorized as environmental, genetic, psychological, and course modifiers. Section II also includes culture- and gender-related diagnostic issues, suicide risk, and functional consequences. Differential diagnosis is briefly discussed, and the main disorder-related comorbidities are highlighted.

Section III (“Emerging Measures and Models”) includes tools and techniques helpful in clinical decision making and in understanding the cultural context of mental disorders as well as in identifying diagnostic conditions that merit further research. Level 1 is a cross-cutting symptom measure that serves as a review of systems across mental disorders, while the Level 2 severity measures (available online at www.psychiatry.org/dsm5) are intended to be used following Level 1 measures “to explore significant responses to the Level 1 screen.”

A severity scale for schizophrenia and the WHO Disability Assessment Schedule, Version 2 (WHODAS 2.0) are included. Used internationally, WHODAS 2.0 assesses functional capacity in 6 domains: understanding and communication, getting around, self-care, getting along with people, activities (household and school/work), and participation in society. Although it is time-intensive, WHODAS 2.0 allows for a standardized tracking method for disability progression or remission.

DSM-5 retains the brief culture-related diagnostic issues within the “Associated Features Supporting Diagnosis” section included in DSM-IV-TR; however, cultural formulation is expanded in Section III, which also includes the cultural formulation interview (CFI). The CFI presents a detailed guide for a culturally informed interview. The “Glossary of Cultural Concepts of Distress” is an additional entry in the Appendix.

Section III also contains proposed disorders for future studies, including an alternative model to diagnose personality disorders. Proposed categories that caused controversy during the development phase were Internet gaming disorder, caffeine use disorder, and suicidal behavior disorder. Other conditions for future studies, such as attenuated psychosis syndrome, depressive episodes with short-duration hypomania, persistent complex bereavement disorder, neurobehavioral disorder associated with prenatal alcohol exposure, and nonsuicidal self-injury, were seen as less problematic.

Key changes in DSM-5 include deletion of the multiaxial format along with various degrees of changes within diagnostic categories. The multiaxial format, a conspicuous concept in both DSM-III and DSM-IV, has been deleted from DSM-5 because of limited use by clinicians. Clinical diagnoses-mental disorders, personality disorders, intellectual disability, and other medical conditions formerly listed on Axis I, II, and III in DSM-IV-are now listed together. A select set of the ICD-9-CM V codes and the new ICD-10-CM Z codes are used as a separate notation for psychosocial and contextual factors.

The Global Assessment of Functioning (GAF) scale (Axis V in DSM-IV) was eliminated from DSM-5 because it was deemed an inadequate measure of mental health disability. It was also seen as an insufficient method for assessing determinations of medical necessity for treatment required by managed care organizations or workers’ compensation programs. For clinical use, the WHODAS 2.0 is a more valid and useful instrument to assess disability. In addition to assessing specific areas of functioning, the WHODAS 2.0 provides severity rating on a scale of 1 to 5 that can be used to monitor change over time and to report disability data.

The DSM multiaxial system was praised for its clinical utility because it provided a comprehensive and systematic evaluation of the patients’ presenting problems, integrating a bio-psycho-social approach. DSM-5 does not present an alternative conceptualization to the multiaxial approach to diagnosis.

Despite multiple proposed categorical or dimensional changes, only a few were adopted in the final version of DSM-5. One of the major proposals rejected was the revision of the hybrid categorical-dimensional model for personality disorders. Implementation of this proposed new model by October 2014 would probably have imposed significant burden on clinical practice and the research community and would have required a revision of academic curriculums for residency programs and clinical practice guidelines. Instead, this model was included in Section III for further research.

Changes in terminology included deletion of terms that have been a mainstay of mental health vocabulary for nearly a quarter century. Some terms were deleted as an attempt to reduce stigma (eg, mental retardation, developmental disorder, stuttering, reading disorder, and mathematics disorder), others because of lack of validity (eg, autism, Asperger syndrome, schizophrenia subtypes), and still others as an attempt to simplify the nomenclature and make a smoother transition toward the style used in ICD-10 coding (eg, hair pulling disorder, skin picking disorder).

There were few changes in diagnostic groupings. Mood disorders are streamlined into separate broad categories of bipolar and related disorders and depressive disorders. Obsessive-compulsive and related disorders are separated from anxiety disorders as a separate broad category. Similarly, PTSD is regrouped with trauma- and stress-related disorders and separated from anxiety disorders. Substance use disorders are restructured by combining both abuse and dependence diagnoses. For the first time, DSM includes a behavioral addiction disorder-gambling disorder-within the substance-related and addictive disorders group.

DSM-5 also introduced completely new categories based on the exten-sive research published over the past decade. Major and mild neurocognitive disorders have attracted much attention. Concerns were expressed about the potential for over-diagnosing mental illness. On the other hand, the inclusion of these categories was considered to be in alignment with current neurobiological models and also would allow for early intervention. Other noteworthy categories are agoraphobia-which can now be diagnosed without the presence of panic attacks-and disruptive mood dysregulation disorder. The latter raised criticism in the media, and opinions will likely continue to diverge. Advocates emphasized that this new category will reduce the overuse or misdiagnosis of bipolar disorder in children and adolescents, whereas its opponents fear that more children will gain a mental health diagnosis given the rather minimal and vague criteria required.

Several new disorders added in DSM-5 also caused controversy because of their potential impact on the prevalence of mental disorders: premenstrual dysphoric disorder, hoarding disorder, skin picking disorder, pain disorder, and binge eating disorder. It was agreed that identification of binge eating disorder would provide the possibility of early treatment and intervention to prevent further morbidity and progression to bulimia or anorexia.

Concerns were expressed about potential over-diagnosis and for increasing the rate of psychiatric diagnoses in the US. Similar concerns were voiced over making the age criterion less restrictive for certain disorders, thus allowing the expansion of the diagnosis to more patients (eg, autism spectrum disorder, ADHD, feeding and eating disorders).

Clinical practice and research criteria will be influenced by the revisions that occurred in the specific diagnostic criteria for schizophrenia, bipolar disorder, and PTSD. The removal of bereavement as an exclusion criterion for MDD when the duration of symptoms is less than 2 months after the death of a loved one will also impact clinical practice and research. Bipolar disorders now are in a category of their own, and mixed episode is eliminated. All major subtypes for schizophrenia are deleted: 2 symptoms are now required instead of 1 from the quad of delusions, hallucinations, and disturbed speech and behaviors. DSM-5 also eliminates the special attribution of bizarre delusions and first-rank auditory hallucinations in diagnosing schizophrenia. Similarly, the requirement of non-bizarre delusions is eliminated for delusional disorder, and shared delusional disorder is no longer a separate entity. For PTSD, the subjective experience criterion is removed and now there are 4 instead of 3 distinct clusters (re-experiencing, avoidance, negative cognition, and arousal).

DSM-5 stands out for the introduction of several new specifiers, which will allow for more accurate coding and assist practitioners during the transition to ICD-10-CM. They are all significant, because they trigger a shift in clinical reasoning. Mixed criteria can now be applied for all types of mood episodes (depression, hypomania, mania), anxious distress can be listed for all depressive and bipolar disorders, and catatonia can be coded with any other specified disorder. Panic attacks are categorized as expected or unexpected and can be listed as specifiers with any other DSM-5 diagnosis. To simplify the nomenclature, DSM-5 introduced similar specifiers for all mental health conditions (panic attacks, catatonia) and deleted criteria that were causing ambiguity. (See the 

From a broader international health care harmonization perspective, there seems to be a clear advantage to aligning DSM-5 with the ICD system used in more than 110 countries. Ideally, this should contribute to higher statistical data validity across nations regarding morbidity and mortality; enhanced ability to conduct public health surveys; and implementation of data-driven, large-scale preventive models. Practically, however, there will be an immediate effect on mental health services and significant additional financial burdens on the health care system.

For successful implementation, adaptation will be required from all major stakeholders. On a macro level, these include managed care organizations, insurance providers, and health care technology companies; the micro level includes mental health practitioners and researchers. All the operational changes require a complex array of policy and contracting revisions, significant capital investments, and updated electronic systems capable of handling the ICD-10-CM 7-digit requirements.

 For clinicians, this may translate into improved clinical documentation to support higher granularity of coding, revised staffing models to assist with more complex billing and coding processes, and updated mechanisms to obtain authorization of mental health services. Perhaps one of the most challenging facets will be the revision and implementation of innovative payment models related to ICD-10-CM coding practices.

The trend to simplify nomenclature was criticized by many mental health professionals. However, it will likely be welcomed by multidisciplinary teams and physician extenders who have no mental health training but will now be required to have a greater degree of involvement in behavioral health documentation given the stipulations of the Affordable Care Act. In addition, managed care organizations are in the process of revising their medical necessity criteria based on the new DSM-5 single-axis model and the new ICD Z codes that are derived from information contained in the previous axis IV (psycho-social and environmental factors) that will likely generate new algorithms for authorizing mental health services.

For behavioral health services, the widespread national health care changes are especially complex, because of the major HIPAA 5010 revisions in January 2012 and Current Procedural Terminology (CPT) coding changes in January 2013. Many providers and organizations are still adjusting to these and now face implementation of DSM-5 and ICD-10-CM. As with all previous operational changes in health care, a drop in productivity is to be expected, which can be especially challenging for behavioral health organizations that already struggle with lower rates of reimbursement. Another important element specific for mental health services is maintaining patient privacy in light of increased documentation requirements and emphasis on multidisciplinary interventions as integrated, patient-centered models of care are becoming increasingly timely with the upcoming changes in the delivery of health care beginning January 2014.

The two most widely used classification systems are ICD-10 and DSM. These systems are mutually influential. For example, ICD-10 included 2 major features-the multiaxial format and the diagnostic criteria-that were adopted by DSM-III. Recent diagnostic guides highlight the importance of an integrated approach to presenting problems in a patient-centered framework. Compared with other classification systems and guides, DSM-5 is the only one that does not offer a comprehensive integrated formulation of presenting problems.

The overall structure and content of DSM-5 does not differ in vast ways from its predecessors, which may help in its implementation. The availability of Level 1 and Level 2 measures should improve diagnostic precision in busy clinical practices. New categories and changes in certain diagnostic criteria may also affect research and estimated rates of psychiatric disorders in the community. In addition, the emphasis on symptoms, metrics, and criteria should enhance precision in diagnosing psychopathology; however, it may need to be complemented with assessment models attuned to better respond to the complexities and needs of the patient. The availability of the cultural formulation and of the CFI provides an opportunity for enhanced care by emphasizing the patient’s uniqueness. The assessment of disability using the WHODAS 2.0 represents an improvement compared with GAF as an assessment of disability.

The practicality of applying all the suggested instruments and measures in busy clinical practices remains to be evaluated. Simplifying the added specifiers and course modifiers and using ICD-10-CM coding may facilitate the implementation of DSM-5 despite the challenging and complex web of coding requirements.

Dr Salloum is Chief of the Division of Substance and Alcohol Abuse in the Department of Psychiatry and Behavioral Sciences at the University of Miami, Miller School of Medicine, Miami. Dr Vasiliu-Feltes is Chief of Clinical Compliance and Quality Assurance and Director of the Clinical Trials Program in the Department of Psychiatry and Behavioral Sciences at the University of Miami, Miller School of Medicine.

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Articles

The two most widely used classification systems are ICD-10 and DSM. These systems are mutually influential. Recent diagnostic guides highlight the importance of an integrated approach to presenting problems in a patient-centered framework. Specifics here.

Bipolar disorder (BD) is among the top causes of disability worldwide and is the fourth leading mental illness as a source of disease burden in established market economies.

 BD complicated by alcoholism and substance use disorder (SUD) represents a serious public health problem and a major challenge to treatment providers. Several large epidemiologic surveys during the past 20 years have confirmed a high association between BD and SUD.

 The Epidemiological Catchment Area Study, completed in the 1980s, found that BD I and BD II had the highest association with SUD, compared with any other major psychiatric disorder.

 The study reported that the prevalence of lifetime alcohol abuse or dependence in persons with BD I and BD II was 46% and 39.2%, respectively. Similarly, the National Comorbidity Survey found that respondents with mania were 8 to 9 times more likely than the general population to have an additional lifetime disorder of drug or alcohol dependence.

The largest and most recent epidemiologic study to date, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), surveyed a representative sample of over 42,000 respondents in the United States. The researchers found that mania and hypomania were associated with very high rates of SUD.

 Respondents with mania were 6 times more likely to have alcohol dependence and, strikingly, 14 times more likely to have drug dependence during the previous 12 months.

The lifetime prevalence of mania in respondents with drug use disorders in the NESARC study ranged from 8.9% to 33.4%, while that of hypomania ranged from 3.7% to 13.4%. These rates are much higher than those reported for the general population in that sample, which was 3.31% for mania and 2.33% for hypomania.

Furthermore, more than 68% of persons with BD are current cigarette smokers and more than 82% are lifetime smokers, making tobacco dependence the most frequent, and perhaps the least addressed, SUD in this population.

Comorbidity of BD and SUD is characterized by a complicated course with multiple recurrences of bipolar episodes and increased hospitalizations. Patients also have a high frequency of other comorbid disorders, including physical conditions and additional psychiatric comorbidities, such as anxiety and polysubstance dependence disorders. Medical comorbidities are heightened in this group of patients by vulnerabilities to metabolic disorders8 and added risk of morbidities associated with alcoholism and SUD, such as chronic viral hepatitis B and C, HIV/AIDS, and the risk of injury and violence.

Furthermore, the suicide attempt rate for patients with BD is more than 50%,

 and the risk of suicide attempt is significantly higher when associated with SUD.

 In addition, BD is associated with pervasive social, family, and employment dysfunction.

Another complicating factor is the variegated and changing clinical picture characteristic of the course of BD.

 The variability in the clinical symptoms during a treatment episode is often exacerbated and confounded by the use of psychoactive substances and may lead to polypharmacy.

Poor treatment adherence in this population is also a serious clinical challenge that significantly impacts treatment response and outcome. Thus, the reported increased mortality in patients with comorbid psychiatric SUD is not surprising.

The association between BD and alcoholism and/or SUD negatively affects the manifestations and course of each disorder. Substance abuse appears to increase the symptom burden in BD.

 Patients presenting in an acute manic episode with alcoholism had significantly increased mood lability, impulsiveness, violent behavior, other drug use, and overall symptom severity as compared with those presenting with mania but without alcoholism.

 Compared with men, women with BD appeared to have a significantly higher risk for alcoholism16 and had more symptoms of sad mood, lowself-esteem, increased anxiety, and increased libido than women who had BD without alcoholism or men with BD and alcoholism.

 Furthermore, SUD reportedly led to an earlier age of BD onset and contributed to late recovery and more frequent bipolar episodes.

BD, on the other hand, was found to predate the onset of SUD. Adolescent-onset BD has been shown to be a risk factor for SUD. For example, Wilens and colleagues

 found that adolescents with an onset of BD at age 13 or older were 5 times more likely to develop SUD. A striking finding of their study was that most of these adolescents also had multiple comorbid psychiatric disorders in addition to substance use and BD and 21% of them were smokers.

 completed a prospective study of a sample of patients with BD and comorbid alcoholism. They found that patients who had BD onset before substance abuse onset reported longer periods of mood episodes and alcohol use than those patients whose alcohol abuse began before the onset of BD.

Mood states have also been found to correlate with increased alcohol and drug use. One study found that participants who were in the manic phase reported drinking almost 3 times as much alcohol as those in the depressive phase, with those in the mixed state falling in between.

Impulsivity, a common symptom of BD, has also been linked to the risk of developing alcoholism and SUD. Impulsivity appears to be significantly higher in persons with acute mania and alcoholism than in those with either acute mania or alcoholism alone.

Furthermore, unstable bipolar illness severely impairs coping skills, contributing to substance use relapse or impeding efforts at sobriety (

Developing an appropriate and effective treatment approach

An integrated approach is the recommended treatment model for this population. Such an approach should include simultaneous treatment for both BD and SUD in the same setting. However, the concept of treatment integration should be considered in a broader context to fully address the treatment needs for these complex conditions (

). Integration should be considered at the health care delivery system level to ensure appropriate financing and access to treatment and at the provider level to ensure appropriate training and commitment to competently deliver care under these challenging conditions.

An obvious need for integration is at the specific intervention level. There is an urgent need to identify effective pharmacologic agents and psychosocial interventions to optimize treatment response for this population. Another important aspect of the integration model is to enhance the recognition of the deleterious relationship between these dual diagnoses in persons with these disorders.

Misdiagnosis and underdiagnosis of BD have been noted to commonly occur, with an estimated 10-year lag between symptom onset and full recognition of the BD.

 The presence of an SUD can obscure the diagnosis of BD, because intoxication by or withdrawal from a number of substances can mimic manic and depressive symptoms. Most notoriously, stimulant intoxication can mimic manic or manic paranoid states. On the other hand, depressant intoxication and withdrawal can mimic depressive agitated and anxious states.

It is generally suggested that symptoms must persist for a period of 4 weeks in a drug-free state before declaring a primary psychiatric disorder. This is likely an oversimplified statement, because it employs 1 rule-waiting a period of 4 weeks-for a disparate number of psychoactive substances with different pharmacodynamic and pharmacokinetic profiles. This 4-week period is also highly impractical in the current system of care. More research is needed to clarify the validity and duration of psychoactive-induced disorders. Significant mood symptoms persisting beyond the expected intoxicating or withdrawal effects of a specific psychoactive substance would most likely require treatment. For example, several clinical trials in patients with concomitant major depressive disorder and alcohol dependence have noted that depressive symptoms showed modest improvement in the placebo group beyond the 1 to 2 weeks of detoxification and treatment.

 These findings suggest that a shorter period of time may be sufficient to confirm and initiate treatment for the depressive disorder

BD, alcoholism, and SUD are chronic relapsing disorders that require a longterm treatment approach to ensure continuity of treatment between episodes. It is important to emphasize preventive and recovery issues. Self-help activities, including participation in dual-diagnosis self-help groups and consumer advocacy groups, such as the Depression and Bipolar Support Alliance (

What role does psychotherapy play in the treatment process?

Psychotherapy has a crucial role in the overall treatment of patients who present with multiple psychosocial needs and dysfunctions. Psychotherapy also has an essential role in cementing the therapeutic alliance, enhancing treatment and medication adherence, and addressing relapse prevention and recovery issues.

To date, only 1 form of integrated group therapy has been developed specifically for comorbid BD and addictive disorder.

 developed integrated group therapy, a weekly group therapy for patients with BD and SUD that addresses similarities and common themes involved in the recovery process of both disorders. Specific individual counseling for these patients is being developed.

The use of simple education material also has been found to be helpful. For example, we found the use of the Personal Calendar, published by the Depression and Bipolar Support Alliance, to be very helpful in the selfmanagement of bipolar symptoms by allowing for mood charting. Education to recognize early warning signs of mania and depression and to identify effective coping strategies to avoid deterioration into full episodes was found to be effective in preventing hospitalization.

Effective pharmacotherapy for comorbid BD and SUD is still limited. Currently, there are 2 published double-blind placebo-controlled studies, 1 in adult patients with BD I and alcohol dependence and 1 pilot study in adolescents with bipolar spectrum disorder and substance use.

 A number of openlabel trials of various medications also have been published (Table 3).

 conducted a 6-week, double-blind, placebo-controlled trial of lithium in 25 adolescents with BD I, BD II, and SUD. Patients treated with lithium had significantly fewer positive urine drug screens (mostly for marijuana) and showed more improvement on the Clinical Global Impression scale. To date, there has been no replication or confirmation of these promising results by larger and more definitive trials.

The other placebo-controlled trial evaluated the efficacy of valproate maintenance in patients with BD and alcoholism. In that study, 59 patients with BD and alcohol dependence were randomly selected to receive placebo or valproate in addition to treatment as usual, which consisted of lithium and weekly psychosocial counseling.

 The results showed an advantage of valproate over placebo in decreasing heavy drinking, as well as in preventing relapse to heavy drinking. Furthermore, in those patients who were more compliant, there was a significant decrease in the number of drinks per drinking day (ie, those receiving valproate on average drank half as much as those receiving placebo). The medication was well tolerated and there were no serious adverse events.

Another double-blind placebo-controlled study evaluated carbamazepine for cocaine dependence.

Although carbamazepine was not effective in participants with only cocaine dependence, there was a trend toward an advantage over placebo on cocaine-positive urine in a subgroup of patients with a history of affective disorder, including BD.

A recent study found significantly decreased cocaine use among patients receiving valproate compared with placebo in a subgroup of 15 patients with BD, alcoholism, and cocaine abuse.

 Other studies have suggested that anticonvulsants compared with lithium may be better tolerated in patients with comorbid BD and SUD.

Thus, from the current available evidence, it appears that certain anticonvulsants may provide a beneficial effect for comorbid BD and SUD. There is more information available for valproate than carbamazepine.

Some atypical antipsychotic medications, such as clozapine, aripiprazole, and quetiapine, may have a role in treat-ing comorbid BD and SUD. However, there are no published double-blind, placebo-controlled studies to support their efficacy in this population.

Another promising approach is the use of medications found to be effective for addictive disorders in combination with those indicated for BD.

 For example, 3 agents (disulfiram, naltrexone [oral and monthly intramuscular injection], and acamprosate) are approved by the FDA for alcoholism. In awell-conducted clinical trial, topiramate, which is not approved for alcoholism by the FDA, was found to decrease alcohol use.

BD with comorbid substance abuse represents a complex clinical condition with difficult treatment challenges. Treatment for BD requires an integrated approach that includes specific psychotherapy as well as the use of medication that targets comorbid BD and SUD. Such treatment should be done in a long-term continuum-of-care model, with a focus on episode prevention and health recovery.

There is still scant empiric evidence for effective pharmacotherapeutic and psychotherapeutic treatment interventions, although certain anticonvulsants have shown the most promise to date. The vulnerability of adolescent-onset BD in leading to SUD calls for vigorous screening and preventive strategies for this high-risk population.

Dr Salloum is associate professor of psychiatry at the Western Psychiatric Institute and Clinic of UPMC at the University of Pittsburgh School of Medicine. He reports that he has received research support from AstraZeneca, Abbott Laboratories, Ortho-McNeil Pharmaceutical, Drug Abuse Sciences, Inc, Alkermese, Inc, Oy Contral Pharma, and Lipha Pharma. He is a consultant for Abbott Laboratories, Forest Laboratories, Cephalon, and AstraZeneca, and he is on the speakers' bureau for Abbott Laboratories.

Acamprosate (Campral) 
Aripiprazole (Abilify) 
Carbamazepine (Carbatrol, Tegretol, others) 
Clozapine (Clozaril) 
Disulfiram (Antabuse) 
Naltrexone (Depade, ReVia) 
Naltrexone intramuscular injection (Vivitrol) 
Quetiapine (Seroquel) 
Topiramate (Topamax) 
Valproate/Valproic acid (Depakote, others)

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Strakowski SM, DelBello MP, Fleck DE, et al. Effects of co-occurring alcohol abuse on the course of bipolar disorder following a first hospitalization for mania. Arch Gen Psychiatry. 2005;62:851-858. 

Salloum IM, Cornelius JR, Daley DC, et al. Efficacy of valproate maintenance in patients with bipolar disorder and alcoholism: a double-blind placebo-controlled study. Arch Gen Psychiatry. 2005;62:37-45.

Bipolar disorder I and II have the highest association with substance use disorder, compared with any other major psychiatric disorder. Treatment requires an integrated approach that includes specific psychotherapy as well as the use of medication.

Ihsan Salloum, MD, MPH

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