The phenomenological and treatment course of bipolar illness is significantly affected by comorbid SUD.31 As with other comorbidities, substance use may start before presentation of actual bipolar symptoms, and may obscure the mood diagnosis.32 The temporal onset of substance abuse and bipolar disorder may also reflect different clinical courses.33
In general, higher rates of mood lability, rapid cycling, mixed episodes, suicidality, and other medical conditions complicate BPD and affect recovery times as well as rates of remission during hospitalization.34,35 There is also the risk of violent behavior with comorbid substance abuse.19 Impulsivity is an overlapping and overarching feature of bipolar and substance use disorders, and it further complicates the course of the illness.36 Comorbid substance abuse is also a significant contributor to treatment nonadherence in patients with bipolar disorder. Its presence confounds attempts at symptomatic and functional recovery.31
Treatment approaches. Unfortunately, there are few controlled data on the pharmacotherapeutic management of comorbid SUD and BPD. Response to lithium is generally poor in patients with BPD comorbid with alcohol abuse, although it is not clear whether this relates to nonadherence or the association with mixed states.29,34
Anticonvulsants (eg, valproate, topiramate, carbamazepine, and lamotrigine) have shown a favorable effect in decreasing use of alcohol and cocaine.37-40 In another study, treatment with valproate or carbamazepine was more likely to induce remission in hospitalized bipolar patients with histories of substance abuse other than lithium.34 A major concern with these agents, however, is balancing the treatment effects with the potential for hepatic, hematological, and other adverse effects, especially in this susceptible patient population.
Second-generation antipsychotic agents, including quetiapine and aripiprazole, reduced drug use and craving in small open-label studies.41,42
Treatment of comorbid BPD and SUD invariably requires an integrated approach that focuses on both disorders simultaneously, and incorporates both psychotherapy and pharmacotherapy. This dual-disorder approach incorporates case management, vocational rehabilitation, individual and family counselling, housing, and medications.43-44
Kraepelin’s insight into the onset and atypical phenomenology of BPD in childhood/adolescence was not fully acknowledged until recently.15 Despite the lack of a formal nosology in this age group, a 2001 NIMH consensus conference affirmed the existence and potential diagnosis of BPD in prepubertal children.45 This atypical mixed-state phenotype seems to overlap with symptoms of attention-deficit/hyperactivity disorder (ADHD), which include irritability, impulsivity, distractibility, overactivity, rapid speech, and emotional lability. The overlap generates the need for diagnostic precision or the determination of a separate comorbid condition. The lack of diagnostic tools and the overlap of these disorders with conduct disorder and oppositional defiant disorder adds to the diagnostic confusion. Irritability, for example, cuts across all diagnostic categories and is a poor differentiator.46
Drugs Mentioned in This Article
Carbamazepine (Carbatrol, Tegretol, others)
Lithium (Eskalith, Lithane, Lithobid)
Valproate/valproic acid (Depakote, others)
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Perlis RH, Miyahara S, Marangell LB, et al. Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol Psychiatry. 2004;55:875-881.