By Joseph F. Goldberg, MD (bio)
Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
Substance use disorders are in many respects among the most challenging of all comorbidities with respect to both the diagnostic clarity and optimal treatment of bipolar disorders.
Let’s start by realizing that persons with a bipolar disorder often also have a substance use disorder at some point in their lives. The same is true the other way around—persons with a substance use disorder are more likely than others to also have a bipolar disorder. This comorbidity between bipolar disorders and substance use disorders is of great importance in the diagnosis and treatment of both the disorders.
How common is this comorbidity?
A large meta-analysis of epidemiological studies among over 200,000 bipolar disorder patients placed the lifetime prevalence of any substance use disorder at 33% and of an alcohol use disorder at 24% (Hunt et al., 2016a).
In other words, at some times in their lives, among patients with bipolar disorders:
– A THIRD also has some substance use disorder (alcohol or other)
– A QUARTER also has an alcohol use disorder.
Another large meta-analysis by the same team but of studies done in clinical populations (Hunt et al., 2016b) found the lifetime prevalence of any substance use disorder to be even higher than that in the meta-analysis of general population studies that was mentioned above.
The substance use disorders that most commonly occur in persons with a bipolar disorder, evaluated in clinical settings where the comorbidity is even higher than in the general population, are (Hunt et al., 2016b):
– Alcohol use disorder — in 42% of patients with a bipolar disorder
– Cannabis use disorder — in 20% of patients with a bipolar disorder
Who is more likely to have this comorbidity?
1. Those who had an onset of the bipolar disorder before the age of 18 years are nearly twice as likely to also have a substance use disorder (Joslyn et al., 2016; Hunt et al., 2016b). The substance use may be both a precipitating factor for and a consequence of the early onset of the bipolar disorder (Hunt et al., 2016b).
2. Men with a bipolar disorder are more likely to also have a substance use disorder compared to women with a bipolar disorder (Messer et al., 2017). For example, the lifetime prevalence of alcohol use disorder was 35% in men with a bipolar disorder versus 17% in women with a bipolar disorder (Hunt et al., 2016b).
Clinicians should make sure to carefully screen all patients with a bipolar disorder for a substance use disorder and vice versa.
Editor: We should take care to avoid the error of assuming that because the person has a substance use disorder, the additional diagnosis of bipolar disorder must be an error. Sometimes it is, and sometimes it is not. Either way, it is important to not make a diagnostic mistake. For some very helpful tips on how to cut through diagnostic confusion and on how to treat patients with this comorbidity, please see the following articles by Dr. Goldberg:
Hunt GE, Malhi GS, Cleary M, Lai HM, Sitharthan T. Comorbidity of bipolar and substance use disorders in national surveys of general populations, 1990-2015: Systematic review and meta-analysis. J Affect Disord. 2016a Dec;206:321-330. doi: 10.1016/j.jad.2016.06.051. Epub 2016 Jun 25. Review. PubMed PMID: 27426694.
Hunt GE, Malhi GS, Cleary M, Lai HM, Sitharthan T. Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis. J Affect Disord. 2016b Dec;206:331-349. doi: 10.1016/j.jad.2016.07.011. Epub 2016 Jul 9. Review. PubMed PMID: 27476137.
Joslyn C, Hawes DJ, Hunt C, Mitchell PB. Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review. Bipolar Disord. 2016 Aug;18(5):389-403. doi: 10.1111/bdi.12419. Epub 2016 Aug 17. Review. PubMed PMID: 27530107.
Messer T, Lammers G, Müller-Siecheneder F, Schmidt RF, Latifi S. Substance abuse in patients with bipolar disorder: A systematic review and meta-analysis. Psychiatry Res. 2017 Jul;253:338-350. doi: 10.1016/j.psychres.2017.02.067. Epub 2017 Apr 8. Review. PubMed PMID: 28419959.
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