Substance/Medication-Induced Mood Disorders

Substance/Medication-Induced Mood Disorders

Substance/Medication-Induced Mood Disorders

Substance use is an especially common cause of mood disorder. Intoxication with cocaine or amphetamines can precipitate manic symptoms, and depression can result from withdrawal from cocaine, amphetamines, alcohol, or barbiturates. Note that for the diagnosis to be tenable, it must develop in close proximity to an episode of intoxication or withdrawal from the substance, which must in turn be capable of causing the symptoms.

Obviously, depression can occur with the misuse of alcohol and street drugs. (As DSM-5 notes, 40% or so of individuals with alcohol use disorder have depressive episodes, of which perhaps half are alcohol-induced, non-independent events.) However, even health care professionals can fail to recognize mood disorders caused by medications. That’s why the case of Erin Finn below is a cautionary tale, probably encountered every working day in clinicians’ offices around the world.

ORDER COMPREHENSIVE SOLUTION PAPERS ON Substance/Medication-Induced Mood Disorders

Essential Features of Substance/Medication-Induced Depressive Disorder

The use of some substance appears to have caused a patient to experience marked, persistent depressed mood or loss of interest in usual activities.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (physical disorders, other depressive disorders, “ordinary” substance intoxication or withdrawal, delirium)

Coding Notes

Specify if:

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers. See sidebar.

Code depending on whether there is evidence that supports a mild or moderate/severe substance use disorder (see Tables 15.2 and 15.3 in Chapter 15).

Essential Features of Substance/Medication-Induced Bipolar and Related Disorder

The use of some substance appears to have caused a mood that is euphoric or irritable.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (physical disorders, other bipolar disorders, schizoaffective disorder, “ordinary” substance intoxication or withdrawal, delirium)

Coding Notes

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers. See sidebar.

Code depending on whether there is evidence that supports a mild or moderate/severe substance use disorder (see Tables 15.2 and 15.3 in Chapter 15).

Erin Finn

Erin Finn came to the clinic straight from her job as media specialist at a political campaign. She’d taken part in her state’s screening program for hepatitis C, which targeted people in her age group—reared before routine testing of the blood supply had reduced the incidence of the disease. Her test had come back positive. When the RNA polymerase test revealed a viral load, she’d agreed to a trial of interferon. “I sometimes feel tired, but I’ve had no other symptoms,” she’d told her doctor.

Though solidly middle-class and conservatively dressed, Erin had actually had a number of possible exposures to hepatitis C. The most likely was a years-ago blood transfusion, but she’d also “had a wild-ish youth, experimented with injectable drugs a few times, even got a tattoo. It’s more or less discreet—the tattoo, I mean.”

Within a few days of starting the medication, she’d begun to complain of feeling depressed, first mildly, then increasing day by day. “It felt worse than that day last year when we thought we’d lost in the primary election,” she told the interviewer. “It’s been a horrible combination of sleeping poorly at night and never completely waking up during the day. And feeling draggy, and tired, and . . . ” She groped for words while fiddling with the two campaign buttons pinned to her coat.

Originally hired to do data entry, Erin had been promoted to write campaign materials for brochures and television. But because she was depressed most of the day, her inability to concentrate had resulted in mistakes. “I’m a crap worker,” she said, “always making simple mistakes in grammar and spelling. It’ll be my fault if we lose in November.”

After a moment, she added, “But I’m not suicidal, I’m not that dumb. Or desperate. But some days, I just wish I was dead.” She thought for a moment. “Were dead!” she corrected herself. “And my boyfriend tells me I’m useless in bed. Along with everything else, I just don’t seem to care about that any more, either.”

Erin subsequently stopped the interferon, and her mood and other symptoms gradually returned to normal. “So the doctor thought I ought to try the interferon again, as a sort of challenge. At first, I said that was a total nonstarter! But then I got to worrying some more about cirrhosis, and thought I’d give it another shot. So to speak.”

She shrugged as she rolled up her sleeve. “I guess hepatitis treatment has a lot in common with politics—neither of them’s bean-bag.”

Evaluation of Erin Finn

Erin’s symptoms would rate her a diagnosis of (relatively mild) major depressive episode, even leaving out the fatigue (which we won’t count because it antedated her use of interferon). Even without all those depressive symptoms, the mere fact of having such a pronounced low mood would fulfill the requirement for medication-induced depressive disorder criterion A. The timing was right (B1), and interferon is well known to produce depressive symptoms in a sizeable number of patients (though more often in those who have had previous mood episodes—B2). And, although it was hardly a controlled experiment, her depressive symptoms did clear up right away, once she stopped the interferon. DSM-5 doesn’t specify a challenge test (sometimes such a test is inadvisable), but a return of Erin’s depressive symptoms after she resumed the medication would forge the final cause-and-effect link.

OK, so we should consider other possible causes of her depression (criteria C and D). I’ll leave that as an exercise for the reader. As for criterion E (distress and disability), res ipsa loquitur. When we turn to Table 15.2 in Chapter 15 for ICD-10 coding, her substance was “Other” (F19), and she had obviously used it only as prescribed, so there was no use disorder. Cross-indexing with the mood disorder column yields F19.94. The ICD-9 code comes from Table 15.3. I would give her GAF score as 55 on admission, 90 at discharge.

Substance/Medication-Induced Mood Disorders