Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And today, we're highlighting Complexity of Psych Case: 4+ co-occurring conditions, which really can present a complex puzzle. Joining me is Dr. Edgar Woznica. He's an instructor of Addiction Psychiatry in the Department of Psychiatry and Behavioral Sciences at Northwestern Medicine

Doctor, thank you so much for joining us. As we get into this topic, can you please just give us a brief overview of the complexity of psych case: 4+ co-occurring conditions. What does that really mean?

Dr. Edgar Woznica: Well, thank you for having me, and I'm happy to clarify. So, one thing that I want to point out is the key use of that word co-occurring rather than comorbid. So often in mental health, when we say comorbid, we're talking about having multiple mental health conditions, but co-occurring suggests the presence of any mental health condition, a mood disorder, anxiety disorder, and psychotic disorder, plus a substance use disorder.

So previously, these patients were called dual diagnosis, but that suggested that somehow a substance use disorder is outside the scope of a psychiatrist or outside of mental health care. And so, using the phrase co-occurring is inclusive, saying this is something that psychiatrists can manage substance use disorders. And it acknowledges that there's a special kind of complexity when someone has a substance use disorder, and then separately a mood, anxiety, or psychotic disorder.

And as you were saying, sometimes it's co-occurring and the patient just has alcohol use disorder and major depressive disorder. But often ,my patients have four or more conditions and that can be multiple substance use disorders, and it can be a mood disorder and several anxiety disorders like PTSD and generalized anxiety disorder. And so, that's where we get to the 4+ co-occurring disorders.

Melanie Cole, MS: At Northwestern Memorial Hospital, you see some of the most severe highest acuity cases when your team is evaluating patients with multiple co-occurring psychiatric conditions, which sometimes up to four or five of these. What do you see as the best approach and most common pitfalls in that diagnostic process, and how do you begin to untangle? And we're going to talk about symptoms in a little bit, but how do you begin to untangle which symptoms belong to which diagnoses?

Dr. Edgar Woznica: It is common for my patients to have four or five mental health conditions, and it can be complicated to figure out what they all are. And it requires a careful history, because taking a cross-sectional approach and looking at what's happening now does not tell you what has been happening across time and which are primary, and which are substance-induced. That's an important point that many of my colleagues have learned previously, but substance intoxication and chronic use can mimic other conditions. So, it's very common for people to have substance-induced depressive or anxiety disorders or substance-induced psychosis and mania.

And so, the core thing that I do is a comprehensive history where I look carefully at the timing of conditions. So, the first part is what began first? Did someone develop a mood disorder, an anxiety disorder, or a psychotic condition before any substance use? Because if that's the case, then it's likely that mood, anxiety and psychosis are primary, and substance-induced is separate. Often though, it's a little bit more challenging because many of the mood and psychotic conditions start in the teenage years, and that's exactly when patients are starting to use substances. And so, usually, you can't rely on the other conditions starting before the substance use.

So if it's a jumble or if the mood or anxiety or psychotic disorders started after the substance use disorders, then you want to look at periods of abstinence. So, was a patient able to maintain abstinence for six months? And if so, what was their mood, anxiety, or psychosis like during that time? If it resolved, then it's probably substance-induced. And if it continued, then it might be primary. I also want to add that even if you're looking at what started first and what happened during periods of abstinence, it's often that you don't get either of those, and the patient hasn't had a sustained period of abstinence and started using substances very early. In that case, it's okay to make an unspecified diagnosis. And I encourage that rather than making an inaccurate primary diagnosis. And if you make an unspecified diagnosis, I talk with the patients about how recovery is difficult. I'm not quite sure what's happening. They may or may not have a separate primary condition, but I'm going to suggest that they can try accessing more resources like an antidepressant or mood stabilizer or antipsychotic. And then, once they're stable and abstinent, we can consider removing some of those medications and obtaining diagnostic clarity. So, if it's not clear, I say let's consider treating it as if it is primary to give you the best chance at recovery. And then, once we have recovery, we clarify from there.

That's how I approach it in terms of a comprehensive history. What I see as common mistakes are taking a substance-induced condition and labeling it as primary. I see this all the time. So, a drug-induced psychosis is labeled as schizophrenia, and that follows the patient in the chart when in fact it's largely due to substance use. And the same thing very commonly happens for drug-induced manias, where the patient is then diagnosed with bipolar disorder and placed on mood stabilizers, which can have some pretty serious toxicities associated with them. And no one is reevaluating to see is this truly a bipolar disorder.

Now, one thing I want to make sure is that I say is that it's not inappropriate to treat a drug-induced psychosis or drug-induced mania as if it is primary. But one should only do it for six months to see does the condition get better and then reevaluate it.

Melanie Cole, MS: Wow, Dr. Woznica, this is an absolutely fascinating topic we're discussing today and certainly complex. As many of these conditions and co-occurring conditions share these symptoms and these overlapping symptoms, how do you distinguish those symptom domains when you've mentioned primary driver and you're determining that versus whatever else might be going on? How do you sort that out? And when you're working with residents, how do you teach them what you're telling us here today?

Dr. Edgar Woznica: It's interesting that you use the phrase primary driver, because what that's getting at is what is either the most significant concern that the patient is coming to you for and what is the primary issue that they face. So, the most significant concern can be the substance use or it can be the other condition, mood or anxiety. And it's important to address that, but also to look at treating both. And I want to be clear about that. So regardless of what the patient is identifying as the primary issue, substance use or the other, it's important to treat both because it's going to be very difficult for a patient to get better without treating both.

And even if someone is following what is called the self-medication hypothesis, where they might be using substances in order to decrease the suffering in their mind, associated with having a major depressive disorder or significant anxiety disorder, the patient won't be able to get better without stopping the substances. So first and foremost, one has to stop the substance in order to get better from the other condition. So when you're talking about primary drivers, it's important to get diagnostic clarity. At the same time, it's also important to treat both regardless of which came first.

Now, the other question you asked is, how do I teach this to residents? And it's a really interesting and fascinating experience to see them mature and get better at making clear diagnoses and formulations. And often in the beginning, it's more jumbled and the resident doesn't have a clear idea how to create a comprehensive treatment plan. Instead, they're acting more based on what they see in the moment. But across time with this gentle guidance of, well, which came first, is it a primary mood disorder or substance-induced? Then they can learn more information and create more comprehensive treatment plans.

Melanie Cole, MS: Dr. Woznica, speak about the role of collaborative care across Psychiatry, Psychology, Primary Care, Social Services when managing these highly complex psychiatric patients.

Dr. Edgar Woznica: So, one thing that many patients are unfamiliar with is what's the difference between a psychiatrist and a therapist? And one of the big differences is that we can make comprehensive assessments and diagnoses. And the other is that we tend to develop more comprehensive treatment plans.

So, one thing that's important that I do is, "Okay, you've got X or Y condition. These are the steps that you can take to get better." And I will not implement all of those steps. So, I may not do acceptance and commitment therapy or dialectical behavioral therapy. And I may not be able to get you into a treatment program, but I can direct you to members of my team, therapists, social workers, et cetera, case managers, who will help you to execute all parts of the treatment plan. So, that's one way in which I interact with colleagues and work with them.

Melanie Cole, MS: It's so important. And as we think about you teaching this complex situation, what advice would you offer early career clinicians who may feel a little overwhelmed by what you do and by the complexity of these types of cases?

Dr. Edgar Woznica: I would recommend that they grow in their discomfort with uncertainty and in recognizing it's okay to consult with colleagues. So, let's start off with the uncertainty. I try to model that there are times, as I said, where despite a comprehensive history, one can't obtain diagnostic clarity in the moment, and it's okay and not a failure to say that I'm not exactly sure what's happening and to write out your thought process. So, the patient may have a primary bipolar disorder. It's difficult to determine because they've been using stimulants repeatedly without a sustained period of abstinence. I'm going to give them mood stabilizers until they obtain abstinence. And then, after six months, we'll reevaluate the continued need for that. And so, you might write an unspecified mood disorder, rule out bipolar disorder.

And the key thing is to write out a plan for how you're going to obtain clarity. So, repeated mental status exams across time, and then reassessment once the patient is abstinent, writing out that thought process allows you to create a plan for how you will obtain diagnostic clarity. And then, the second part that's important is actually doing the work once the patient has reached that abstinence, because we often, or sometimes it's hard to encourage oneself or give oneself the motivation to do the mental work of reformulating a diagnosis, because there's more work involved and it takes more time. So, that's the first part, being comfortable with uncertainty.

And the second part is conferring with colleagues. The field is constantly growing. You may become an expert in one area. But as you do so, then other areas expand and you're not privy to all the latest developments. And it's important to check in with colleagues. So, one thing that I think is important that my colleagues in other parts may not know is that it's fairly solidified that cannabis causes schizophrenia-like syndrome that is very difficult to disentangle from schizophrenia and seems chronic in nature. And that's a development that was provisional and is now more clarified. And so, that sharing that development, if you ask me about it, then I can share how we came to that conclusion and now you have more information as you go forward.

Melanie Cole, MS: That's so interesting, Dr. Woznica. And along those lines then, how do you measure treatment success or progress in patients with multiple co-occurring psychiatric conditions where full remission may not be realistic? How do you measure treatment success for your residents and your colleagues?

Dr. Edgar Woznica: I do think that global impressions matter. So, is the person able to improve their functionality, such that they are getting greater meaning and purpose and enjoyment from relationships, potentially a job, and more stable housing? Those global improvements in functioning are what I'm primarily looking at. And that's honestly often what people are coming to us for. They're struggling with finding those, and they connect accurately their conditions with impairment in reaching that functionality.

Melanie Cole, MS: Dr. Woznica, you have so much information to share and this is a really interesting topic. As we get ready to wrap up here, how has working with these patients shaped your clinical philosophy? And looking ahead, how do you see the Northwestern Medicine program growing, the new process strategies that could better prepare future psychiatrists for the reality of diagnosing and treating patients with multiple co-occurring psychiatric conditions?

Dr. Edgar Woznica: I think one of the biggest changes that has happened in my philosophy or my approach is increasing comfort with doing what I can to help patients, but also drawing a boundary and recognizing that it's not up to me to do much of the work. It's often up to the patients. So, that's a motivational interviewing approach that I encourage providers that are interested in, especially if they're experiencing burnout, because they feel like they're failing in their identity or profession because they're not getting their patients better.

Often with substance use disorders, it's not up to us to develop the perfect plan. It's up to us to help resolve and manage ambivalence to help patients to create their own internal motivations for change. And then, once they have those motivations, they're the ones that come up with the plan for how to get better. So, I think that's been the biggest shift that's happened is I became an addiction psychiatrist.

And then, in terms of how am I helping the next generation? Well, one thing that I'm very excited about and one of the main reasons why I'm here at Northwestern is the opportunity to teach medical students and residents. So, I've vastly expanded the didactic curriculum to improve the background knowledge that providers will have. And I am also increasing the opportunities for preceptoring so residents will be able to take these patients on as their own and then receive guidance from me about how to manage them.

And another aspect I've noticed is that I'm having colleagues ask me questions, whether that's over lunch or in the hallway, that I hope is helping them to develop their own abilities to take care of these patients.

Melanie Cole, MS: Thank you so much, Doctor, for joining us and really sharing your incredible expertise on this topic. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.