Dual Diagnosis of Bipolar & Substance Use Disorder: Summary of New Scientific Article

As an educator, I have access to a database of current scientific research through my school's library, so I regularly check for new studies on bipolar disorder. When I find something good, I'll share it on the blog, translating some of the science lingo into regular-speak layman's terms.

Last month (5/2012) a scientific article appeared in the Psychiatric Annals titled "Implications and Strategies for Clinical Management of Co-occurring Substance Use in Bipolar Disorder." It is not actually a new study, but a new article that examines what is currently known on the topic by looking at data from numerous studies. There is so much info in this study, I plan to write a few blog posts, one to summarize each of the main findings, including the association between bipolar disorder and cigarette smoking.


Bipolar Disorder and Substance Use Disorders
Bipolar patients have an unusually high incidence of Substance Use Disorders (SUD). When bipolar disorder and an SUD occur together, it is considered a dual-diagnosis condition, and described as co-morbidity. Previous studies have shown that 50-60% of bipolar patients will develop at least one SUD in their lifetime. 

SUDs have been found to have a significant negative impact on the quality of life of bipolar patients. They are associated with higher rates of unemployment, violence and incarceration, as well as lower adherence to psychiatric treatment, longer and more frequent episodes, more mixed episodes, poor response to treatment, and double the number of suicide attempts.

It is not entirely clear why this co-morbidity occurs. No genetic or neurological explanation has been identified. The commonly held belief is that bipolar patients are self-medicating. Rates of substance use remain high even during periods of relatively normal mood, and rather than helping, can worsen symptoms of depression (alcohol) or mania (cocaine).


And if the bipolar + SUD association isn't problematic enough itself, nearly half of those diagnosed with bipolar disorder have at least one other co-occurring psychiatric disorder during their lifetime.

Treatment of Co-occurring Bipolar and Substance Use Disorder
Treating the bipolar disorder and SUD separately, as though they are not interrelated, doesn't work well. Researchers are beginning to encourage clinicians to consider bipolar disorder and the co-occurring SUD together, as if they are one disorder--bipolar substance abuse. In this integrated approach, the patient is responsible for his/her participation in treatment, such as taking bipolar meds as directed, abstinence from substance use and integrated group therapy. This approach was found to be twice as effective in reducing substance use as was group drug counseling alone. Still, there are currently no optimal treatment guidelines for co-occurring bipolar disorder and SUD.

Does Bipolar Medication Help Reduce Substance Use?
Yes and no. Atypical antipsychotics, such as Abilify (aripiprazole) and Seroquel (quetiapine), have been reported to help reduce stimulant abuse, such as cocaine and methamphetamine, but not use of alcohol. 

Anti-convulsant medications such as Depakote (valproate), used in combination with lithium, have been shown to reduce alcohol use in bipolar-SUD co-morbid patients. But a similar study of rapid-cycling bipolar patients showed that this drug combo was no better than lithium alone for reducing substance use.  In addition, the anti-convulsant/lithium combo was not found to be more effective than lithium alone in controlling bipolar symptoms in bipolar-SUD patients.

What the Hell Am I Doing?
Personally this paper was so striking because it seems that much of what they were describing pertained to me, and perhaps you as well. I am bipolar, have what I consider to be a moderate drinking problem, and, although currently not smoking, I've smoked intermittently throughout my life since I was a teen. Now I use nicotine gum to help me avoid cigarettes. (Soon I will create another post on what this study revealed about smoking and bipolar disorder.)

The paper even discussed how rates of metabolic syndrome (pre-diabetes) and cardiovascular disease are significantly higher for bipolar patients and even higher for those with co-occuring bipolar disorder and substance use. My family has a history of cardiovascular issues (what both my mother and grandmother died from). 

Considering all of this information together really shook me up and made me realize that in addition to the psychological dangers of bipolar disorder, its presence is associated with other medical problems, such an increased risk of dying prematurely from liver failure (alcoholism) or cardiovascular disease (smoking and family history).

Today one of my students told me that her mother had just died of cancer. Her mother was only was 44 years old. I am 44 years old, and acutely feeling my mortality. I want to live and see my children grow up.