Bipolar Type I Disorder and Co-occurring Substance Use Disorders

Michael A Cerullo, Stephen M Strakowski
US Psychiatry, 2009;2(1):37-40
pdf icon download pdf ejournal view ejournal

Abstract

Epidemiological research indicates that there is a high prevalence rate of co-occurring substance use disorders (SUDs) in patients with bipolar disorder (BPD). A conservative estimate suggests that the lifetime prevalence of SUDs in bipolar disorder is at least 40%. Alcohol and cannabis are the substances most often abused, followed by cocaine and opioids. Co-occurring SUDs are correlated with negative effects on illness outcome, including more frequent and prolonged affective episodes, decreased compliance with treatment, a lower quality of life, and increased suicidal behavior. There is little research examining treatments in this comorbid population. The two placebo-controlled trials support the addition of valproate to lithium in bipolar patients with co-occurring alcohol dependence and lithium treatment in bipolar adolescents with co-occurring SUDs. Data from the few open-label trials have provided limited evidence for divalproex, aripiprazole, and naltrexone in bipolar patients with co-occurring alcohol use disorders and divalproex, quetiapine, and aripiprazole for bipolar patients with co-occurring cocaine use disorders. More research into specific treatments in patients with BPD and co-occurring SUDs is desperately needed. The high rate and negative effect on outcome of co-occurring SUDs in patients with BPD suggest that SUD cannot be ignored. Therefore, treatment of both disorders is necessary and, until more definitive research is available, this means treating both disorders separately using the best treatment for each disorder.
Keywords
Bipolar disorders, substance disorders, co-occuring, epidemiology
Disclosure This work is supported in part by the Stanley Medical Research Institute and National Institutes of Mental Health awards MH066626, MH068801, and MH071931 (to Stephen M Strakowski, MD).
Received: February 06, 2008 Accepted June 04, 2008
Correspondence: Michael A Cerullo, MD, Department of Psychiatry, 231 Albert Sabin Way (ML0559), Cincinnati, OH 45267-0559. E: cerullmc@ucmail.uc.edu

Bipolar I disorder (BPD) is a serious mental illness with a lifetime prevalence of approximately 1–3%.1–3 The treatment of bipolar disorder is often complicated by co-occurring substance use disorders (SUDs). In fact, BPD has the highest prevalence of co-occurring SUDs among all psychiatric conditions except antisocial personality disorder.4 In this article we examine the epidemiology, outcome, etiology, and treatment of patients with BPD and co-occurring SUDs. This review extends two previous reviews of this topic by the authors.5,6

Epidemiology

Evidence for the general prevalence of BPD and co-occurring SUDs comes from several large population-based studies (see Table 1). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)2 examined the prevalence and co-occurrence of the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) substance disorders in a representative sample of 43,093 respondents in the US. Subjects with BPD had a 58% lifetime prevalence of co-occurring alcohol use disorders and a 38% lifetime prevalence of any drug use disorder. The National Institutes of Mental Health Epidemiologic Catchment Area Program4 examined the prevalence and co-occurrence of DSM IV substance and mood disorders in a representative sample of 20,291 persons from community and institutional settings. Subjects with BPD had a 61% lifetime prevalence of any drug or alcohol use disorder.4

Epidemiological data on the co-occurrence of SUDs also come from studies examining the clinical characteristics of large populations of subjects with BPD (see Table 1). Cassidy et al.7 surveyed 392 patients with BPD and found a lifetime prevalence of 48.5% for alcohol abuse, 36% for cannabis abuse, 24.2% for cocaine abuse, and 4.6% for opioid abuse. The point prevalence for each SUD was 28.5% for alcohol abuse, 22.2% for cannabis abuse, 10.2% for cocaine abuse, and 1.0% for opioid abuse. McElroy et al.8 evaluated 239 BPD outpatients and found a lifetime prevalence of 36% for alcohol use disorders, 40% for cannabis use disorders, 10% for cocaine use disorders, and 8% for opioid use disorders.

Two large first-episode mania studies9–14 have also provided useful prevalence data (see Table 1). The University of Cincinnati First-episode Mania Study9–13 followed over 100 patients with BPD after an initial manic or mixed presentation. They found that patients with BPD had a 42% lifetime prevalence of alcohol use disorders and a 46% lifetime prevalence of cannabis use disorders.12,13

References:
  1. Narrow W, Rae D, Robins L, Regier D, Revised Prevalence Estimates of Mental Disorders in the United States: Using a Clinical Significance Criterion to Reconcile 2 Surveys’ Estimates, Arch Gen Psychiat, 2002;59:115–23.
  2. Grant B, Stinson F, Hasin D, et al., Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions, J Clin Psychiatry, 2005;66:1205–15.
  3. Pini S, Queiroz V, Pagnin D, et al., Prevalence and burden of bipolar disorders in European countries, Eur Neuropsychopharm, 2005;15:425–34.
  4. Regier D, Farmer M, Rae D, et al., Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study, JAMA, 1990;264(19):2511–18.
  5. Cerullo M, Strakowski S, Substance Abuse in Bipolar Disorder: An Update, Curr Psychos Ther Rep, 2006;4(4):171–5.
  6. Cerullo M, Strakowski S, The prevalence and significance of substance use disorders in bipolar type I and II disorder, Subst Abuse Treat Prev Policy, 2007;2(29): Epub ahead of print.
  7. Cassidy F, Ahearn E, Carrol B, Substance abuse in bipolar disorder, Bipolar Disord, 2001;3:181–8.
  8. McElroy S, Altshuler L, Suppes T, et al., Axis I Psychiatric Comorbidity and Its Relationship to Historical Illness Variables in 288 Patients With Bipolar Disorder, Am J Psychiatry, 2001;158(3):420–26.
  9. Strakowski S, Keck P, McElroy S, et al., Twelve-month outcome after a first hospitalization for affective psychosis, Arch Gen Psychiat, 1998;55(1):49–55.
  10. Strakowski S, DelBello M, Fleck D, et al., The impact of substance abuse on the course of bipolar disorder, Biol Psychiat, 2000;48:477–85.
  11. Patel N, DelBello M, Keck P, et al., Phenomenology associated with age at onset in patients with bipolar disorder at their first psychiatric hospitalization, Bipolar Disord, 2006;8:91–4.
  12. Strakowski S, DelBello M, Fleck D, et al., Effect of co-occurring alcohol abuse on the course of bipolar disorder following a first hospitalization for mania, Arch Gen Psychiat, 2005;62:851–8.
  13. Strakowski S, DelBello M, Fleck D, et al., The effects of co-occurring cannabis use disorders on the course of bipolar disorder following a first hospitalization for mania, Arch Gen Psychiat, 2007;64(1):57–64.
  14. Tohen M, Zarate Jr C, Hennen J, et al., The McLean- Harvard First-Episode Mania Study: Prediction of recovery and first recurrence, Am J Psychiatry, 2003;160(12): 2099–2107.
  15. Tohen M, Stoll A, Strakowski S, et al., The McLean first-episode psychosis project: six month recovery and recurrence outcome, Schizophr Bull, 1992;18(2):273–82.
  16. Tohen M, Hennen J, Zarate Jr, et al., Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features, Am J Psychiatry, 2000;157:220–28.
  17. Sachs G, Thase M, Otto M, et al., Rationale, design, and methods of the systematic treatment enhancement program for bipolar disorder (STEP-BD), Biol Psychiat, 2003;53:1028–42.
  18. Weiss R, Ostacher M, Otto M, et al., Does recovery from substance use disorder matter in patients with bipolar disorder?, J Clin Psychiat, 2005;66(6):730–35.
  19. Dalton E, Cate-Carter T, Mundo E, et al., Suicide risk in bipolar patients: the role of co-morbid substance use disorders, Bipolar Disord, 2003;5:58–61.
  20. Goldberg J, Garno J, Leon A, et al., A history of substance abuse complicates remission from acute mania in bipolar disorder, J Clin Psychiat, 1999;60(11):733–40.
  21. Swann A, Dougherty D, Pazzaglia P, et al., Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder, Am J Psychiatry, 2005;162(9):1680–87.
  22. Martinez J, Marangell L, Simon N, et al., Baseline predictors of serious adverse events at one year among patients with bipolar disorder in STEP-BD, Psychiatr Serv, 2005;56(12):1541–8.
  23. Salloum I, Cornelius J, Daley D, et al., Efficacy of Valproate maintenance in patients with bipolar disorder and alcoholism, Arch Gen Psychiat, 2005;62(1):37–45.
  24. Geller B, Cooper T, Sun K, et al., Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency, J Am Acad Child Adolesc Psychiatry, 1998;37(2):171–8.
  25. Salloum I, Douaihy A, Cornelius J, et al., Divalproex utility in bipolar disorder with co-occurring cocaine dependence: A pilot study, Addict Behav, 2007;32:410–15.
  26. Brown S, Jeffress J, Liggin J, et al., Switching outpatients with bipolar or schizoaffective disorders and substance abuse from their current antipsychotic to aripiprazole, J Clin Psychiat, 2005;66(6):756–60.
  27. Brown S, Beard L, Dobbs L, et al., Naltrexone in patients with bipolar disorder and alcohol dependence, Depress Anxiety, 2006;23:492–5.
  28. Brown E, Nejtek V, Perantie D, et al., Lamotrigine in patients with bipolar disorder and cocaine dependence, J Clin Psychiat, 2003;64(2):197–201.
  29. Brown S, Nejtek V, Perantie D, et al., Quetiapine in bipolar disorder and cocaine dependence, Bipolar Disord, 2002;4: 406–11. 30. Strakowski S, Tsai S, DelBello M, et al., Outcome following a first manic episode: cross-national US and Taiwan comparison, Bipolar Disord, 2007;820–27.
close

This content is copyright protected

However, if you would like to share the information on this webpage, you may use the headline and link below:

Bipolar Type I Disorder and Co-occurring Substance Use Disorders

Read more: Bipolar Type I Disorder and Co-occurring Substance Use Disorders