Substance induced vs. Real Bipolar/Schizophrenia spectrum

[ara96]

Hi,
I'm a third year about to finish adult. I'm very frustrated with some of the patients I've inherited who are coming to my clinic with diagnoses of Schizophrenia, Unspecified Psychosis, Bipolar etc. when I do a more detailed history it is due to meth, spice, Alcohol use or marijuana.

This would mean changing their diagnosis to substance induced and I think they would not meet criteria to stay in our clinic. However, substance induced disorders can persist for a variety of years from what I've seen. Particularly spice.

I am tempted to change their diagnoses but then I worry if insurance will cover their medications down the line? I'm also worried what will happen with regards to their eligbility for services at my clinic.

Any tips for dealing with this?

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[lyla]

I feel your pain. This really depends on the institution you work at.

At the county clinic where I rotate at, we can't bill for substance-related disorders, hence the reason the primary dx is usually unspecified schizophrenia spectrum and other psychotic disorder. And yes, if their primary dx isn't a severe mental illness (schizophrenia spectrum, bipolar, psychotic depression), I believe it is more difficult to get certain services at our clinic.

On the other hand, at the VA, we could have substance-related disorders as the primary diagnosis.

 

[splik]

I feel your pain. This really depends on the institution you work at.

At the county clinic where I rotate at, we can't bill for substance-related disorders, hence the reason the primary dx is usually unspecified schizophrenia spectrum and other psychotic disorder. And yes, if their primary dx isn't a severe mental illness (schizophrenia spectrum, bipolar, psychotic depression), I believe it is more difficult to get certain services at our clinic.

you cannot bill for a substance use disorder as the primary diagnosis if you are not an accredited substance use treatment facility, but you almost certainly can bill for substance-induced disorders, e.g. substance-induced psychotic disorder. this is a very common misunderstanding, i'm not sure where it arises from. similarly, substance-induced mood and psychotic disorders are perfectly billable for inpatient admission, but a primary substance use disorder is not. one snag is that substance-induced disorders aren't considered 'parity diagnoses' so private insurance companies don't have to cover it, but a county clinic is primarily/exclusively medicaid so it should be covered.

that said, from the perspective of DSM-5, if you are psychotic for months (or years) after using substances then it is not a substance-induced psychotic disorder, it is schizophrenia or whatever other diagnosis. substance-induced psychotic disorder/mood disorder etc should wane with clearing of the offending substance. now we can argue about this nosologically, but the DSM-5 (for all its limitations) is quite clear that if you have symptoms more than a month after drug use, then it's not a substance-induced disorder.

 

[Ceke2002]

that said, from the perspective of DSM-5, if you are psychotic for months (or years) after using substances then it is not a substance-induced psychotic disorder, it is schizophrenia or whatever other diagnosis. substance-induced psychotic disorder/mood disorder etc should wane with clearing of the offending substance. now we can argue about this nosologically, but the DSM-5 (for all its limitations) is quite clear that if you have symptoms more than a month after drug use, then it's not a substance-induced disorder.

Definitely this, particularly from my own observations.

Person A - First episode psychosis following a brief (6-12 month) period of experimentation with cannabis and amphetamine based substances. Person is hospitalised under the mental health act, 12 months later person is still requiring of medication despite a complete cessation of all illicit substances. Person A is eventually diagnosed with Schizophrenia.

Person B - Chronic, daily use of crystal meth eventually leading to symptoms of substance abuse induced psychosis. Person B ceases their use of illicit substances, 4-6 weeks later they are showing zero signs of psychosis and their psychotic symptoms do not return outside of further substance abuse. Person B, to my mind at least, does not have an underlying psychotic illness; their symptoms were solely the result of substance intoxication/abuse.

 

[michaelrack]

have you been seeing less formal though disorder in drug-induced (especially stimulant-induced) psychosis. besides time course, any clues for diagnosis a substance-induced psychosis

 

[Dharma]

To follow up on some other comments, it was my understanding that there is a high conversion rate to a primary disorder: Rates and Predictors of Conversion to Schizophrenia or Bipolar Disorder Following Substance-Induced Psychosis. - PubMed - NCBI. (I have the full article but struggling to upload it here).

 

[OldPsychDoc]

This is all a matter of people not fitting neatly into the artificial pigeonholes of DSM, and real life being complicated for these folks.
As @splik says, you can generally bill for (and get paid for) a substance-induced mood disorder or psychotic disorder, but as implied by the OP, in many jurisdictions they may not meet criteria to receive certain publicly-funded services, e.g. county case management, disability, etc., without a primary "Big 4" diagnosis*.

*where I practice, MDD, BPAD, Schizophrenia/Schizoaffective, and Borderline PD.

 

[Ceke2002]

This is all a matter of people not fitting neatly into the artificial pigeonholes of DSM, and real life being complicated for these folks.
As @splik says, you can generally bill for (and get paid for) a substance-induced mood disorder or psychotic disorder, but as implied by the OP, in many jurisdictions they may not meet criteria to receive certain publicly-funded services, e.g. county case management, disability, etc., without a primary "Big 4" diagnosis*.

*where I practice, MDD, BPAD, Schizophrenia/Schizoaffective, and Borderline PD.

We have the same problem here, or at least in South Australia where I was living. A lot of patients fall through the gaps because they don't fit into the 'necessary boxes' to receive treatment at a community mental health level. It's not that unusual for a physician to make a diagnosis of a psychotic type disorder, as opposed to putting down 'substance induced psychosis' in order to ensure a patient can access a certain level of care/treatment.

 

[smalltownpsych]

In my experience, psychotic symptoms from meth use could last a bit longer than a month, but they tend to be much milder if the person does not have an underlying psychotic disorder. The lack of emotional responsiveness, depressed mood, or excitability (bouncing off the walls) can go on for six months or more. Sleep problems can persist for quite some time too. The challenge is that the limbic system is craving something to regulate it and make it feel better for a really long time and this can lead to some exaggeration of symptoms and desire for medications. Sometimes this is a very conscious process and sometimes it's not. If they are not obviously psychotic and impaired, why not wait a bit longer for the brain to continue healing? I see too much medication of the long-term after effects of substance use and it can get really troublesome when the message eventually becomes "I need my medication constantly adjusted so that I can cope with life."

 

[Ceke2002]

In my experience, psychotic symptoms from meth use could last a bit longer than a month, but they tend to be much milder if the person does not have an underlying psychotic disorder. The lack of emotional responsiveness, depressed mood, or excitability (bouncing off the walls) can go on for six months or more. Sleep problems can persist for quite some time too. The challenge is that the limbic system is craving something to regulate it and make it feel better for a really long time and this can lead to some exaggeration of symptoms and desire for medications. Sometimes this is a very conscious process and sometimes it's not. If they are not obviously psychotic and impaired, why not wait a bit longer for the brain to continue healing? I see too much medication of the long-term after effects of substance use and it can get really troublesome when the message eventually becomes "I need my medication constantly adjusted so that I can cope with life."

*nods* Yep, definitely my personal experience with friends battling meth addiction as well. The more noticeable, 'positive' type psychotic symptoms seemed to subside within a 4-8 week window period, but the other stuff you described did last a lot longer. And if they had withdrawn without a proper support/rehabilitative system in place, then chances they would end up swapping one addiction for another in terms of consciously or subsconsiously feeling as if they needed to 'self medicate' was exceedingly high. I may be wrong, but I believe this was one of the main reasons the only person from back then that I did know who ended up with a diagnosis of a primary type psychotic disorder after substance use/intoxication, wasn't given an official diagnosis until a year or more afterwards.

This discussion has been very interesting to follow. I'm still looking at peer support worker roles, and I currently have someone making potential enquiries with their contacts in Melbourne regarding outreach drug counselling type services. Nothing definite, but I imagine if something does eventuate these are the sorts of issues/problems I'm going to need to be aware of in order to effectively work with those higher up in the team, so to speak.