From the January 2019 issue of Massachusetts General Hospital's Mind, Mood, & Memory (MMM)
When Psychiatric Disorders Overlap
Individuals with more than one mental health disorder often need creative solutions to overcome their challenges.
A diagnosis of depression, anxiety or other psychiatric disorder can be overwhelming on its own. But it’s important to understand that having one mental disorder raises your odds of having additional such conditions.
It’s not uncommon, for example, for someone with depression also to have an anxiety disorder, or for a person with attention-deficit hyperactivity disorder (ADHD) also to have a sleep disorder, explains Gregory Fricchione, MD, associate chief of psychiatry and director of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital.
“Anxiety can often make one vulnerable to depression,” he says. “ADHD can lead to a sleep disorder but also be a harbinger for other conditions. Children with ADHD are more likely than peers to develop substance use disorders. ADHD and mood disorders sometimes run together. Many psychiatric disorders are complicated by substance use disorders as patients try to manage their distress with recreational drugs and alcohol.”
Other examples include schizophrenia made complicated by obsessive-compulsive disorder (OCD) symptomatology. Catatonia, a rare condition in which a person may be very still and unresponsive or displays strange movements or other unusual behavior, can occur in patients with bipolar illness, depression, and schizophrenia, among other conditions. The list of common overlapping mental disorders (also known as comorbid psychiatric conditions) is a long one, Dr. Fricchione says.
Coping with Comorbidities
WHAT YOU CAN DO
If you have been diagnosed with a mental disorder:
- Tell your doctor about all the medications and supplements you take, to help reduce the risk of negative drug interactions.
- Be alert for changes in your use of medications, alcohol, or illicit drugs, and take steps to avoid problems such as abuse or addiction. Talk with your doctor if you have concerns, or see a substance abuse specialist. Turning to these substances when coping with depression or other conditions is common, but it can be dangerous.
- Take note of any new symptoms, such as changes in sleep, appetite, mood, energy level, and health-related concerns such as headaches, upset stomach, or breathing difficulties. Discuss these symptoms with your doctor.
- Learn what other psychiatric conditions you may be at risk for, and learn how to identify their symptoms.
When psychiatric disorders overlap, it not only makes daily living that much more difficult for the individual, it can make treatment a big challenge,Êtoo.
Treating more than one disorder at a time can lead to polypharmacy, the simultaneous use of multiple medications. This, of course, can increase the risk of medication side effects, Dr. Fricchione warns.
“The use of a psychostimulant and antipsychotic in an ADHD patient with bipolar illness could lead to worsening mania or psychosis,” he says. “Patients with anxiety and psychosis can become restless and even develop akathesia on antipsychotic medications.” Akathesia is a movement disorder in which an abnormal sense of inner restlessness can be reduced only by physical activity.
Another common, but risky example of polypharmacy is the use of methadone, which is prescribed for maintenance treatment of opiate addiction, and atypical antipsychotics, which are used for bipolar illness, major depressive disorder, and schizophrenia. Atypical antipsychotics include olanzapine (Zyprexa), aripiprazole (Abilify), and many others.
The use of these powerful medications can increase the QTc interval, an important measure of electrical activity in the heart. A prolonged QTc interval can put you at risk for ventricular cardiac arrhythmias, abnormal heart rhythms that can have severe health complications.
“Dose adjustments or switching to mood-stabilizing medications, like anticonvulsants, might be tried,” Dr. Fricchione says, suggesting how doctors try to minimize the risks of polypharmacy in psychiatric patients.
Fortunately, certain non-pharmacological therapies can be quite helpful in treating multiple conditions. Dr. Fricchione notes, for example, that there are specialized cognitive behaviorial therapy (CBT) approaches for anxiety, depression, sleep problems, schizophrenia, and others.
CBT is a form of psychotherapy that focuses on solutions and strategies for coping. It operates from the premise that if you can identify unhelpful thoughts and learn to think differently about a situation, that positive changes in your feelings and behaviors should follow.
Recognizing Overlapping Conditions
While treating multiple psychiatric disorders can be a challenge, simply diagnosing them first can be just as tricky. This is because some very distinct disorders share some common symptoms. For example, signs of ADHD and bipolar illness can include racing thoughts and difficulty focusing, as well as feeling particularly energetic and hyperactive.
Dr. Fricchione adds, though, that some disorders are easily discernible. Alcoholism and schizophrenia can often accompany each other, but the symptoms are much different.
“Patients with symptoms suggestive of schizophrenia as well as symptoms suggestive of bipolar illness are sometimes called schizoaffective, and are treated with atypical anti-psychotics, sometimes in combination with mood stabilizers,” Dr. Fricchione says.
Whenever you start a new drug, tell your doctor immediately if you have any side effects.
Be on Alert
Knowing that you have a heightened risk of a second psychiatric disorder, it’s important to pay close attention to all your symptoms, especially new symptoms that emerge. Dr. Fricchione notes that generalized anxiety disorder, especially in young women, is a major risk factor for developing major depression later in life.
“CBT and/or mindfulness meditation can be tried to prevent depression emergence,” he says. “Young people at risk for psychotic illness should avoid marijuana use, which can increase the onset of psychosis.”
While there aren’t always guaranteed means of preventing a second comorbid condition from developing, Dr. Fricchione says taking your current treatment seriously and learning as much as you can about your risks may help you be better prepared if another challenge appears.
