APA Practice Guidelines

4. Substance use disorders in bipolar patients

cont. from

Bipolar disorder with a co-morbid substance use disorder is a very common presentation, with bipolar disorder patients of both sexes showing much higher rates of substance use than the general population. For example, the Epidemiologic Catchment Area study found rates of alcohol abuse or dependence in 46% of patients with bipolar disorder compared with 13% for the general population. Comparable drug abuse and dependence figures are 41% and 6%, respectively. Substance abuse may obscure or exacerbate endogenous mood swings. Conversely, co-morbid substance use disorder may be overlooked in patients with bipolar disorder. Substance abuse may also precipitate mood episodes or be used by patients to ameliorate the symptoms of such episodes. Co-morbid substance use is typically associated with fewer and slower remissions, greater rates of suicide and suicide attempts, and poorer outcome.

Treatment for substance abuse and bipolar disorder should proceed concurrently when possible. It is also helpful to obtain consultation from an addiction expert, such as an addiction psychiatrist, or to arrange for concomitant treatment of the bipolar disorder and the substance use disorder in a dual-diagnosis program.

Alcohol abuse and its effects may affect bipolar disorder pharmacotherapy. For instance, alcohol-related dehydration may raise lithium levels to toxicity. Hepatic dysfunction from chronic alcohol abuse or from hepatitis associated with intravenous substance use may alter plasma levels of valproate and carbamazepine. If the hepatic dysfunction is severe, the use of these hepatically metabolized medications may be problematic. In these cases, coordination with the patient's primary care physician or gastroenterologist is recommended.

5. Co-morbid psychiatric conditions

Patients with co-morbid personality disorders pose complicated diagnostic pictures. They are clearly at greater risk for experiencing intrapsychic and psychosocial stress that can precipitate or exacerbate mood episodes. Patients with co-morbid personality disorders generally have greater symptom burden, lower recovery rates from episodes, and greater functional impairment. In addition, these patients may have particular difficulty adhering to long-term treatment regimens.

Relative to the general population, individuals with bipolar disorder are at greater risk for co-morbid anxiety disorders, especially panic disorder and obsessive-compulsive disorder. Co-morbid anxiety disorders may predict a longer time to recovery of mood episodes. Treatment for the bipolar disorder and the co-morbid anxiety disorder should proceed concurrently.

The presence of co-morbid attention deficit hyperactivity disorder (ADHD) in adults and chiraldren with bipolar disorder may make it difficult to monitor changes in mood states. Of note, adults with bipolar disorder and co-morbid ADHD are likely to have experienced a much earlier age at onset of their mood disorder relative to those without co-morbid ADHD.

B. Demographic and Psychosocial Factors

1. Gender

A number of issues related to gender must be considered when treating patients with bipolar disorder. Hypothyroidism is more common in women, and women may be more susceptible to the antithyroid effects of lithium. Additionally, rapid cycling is more common in women. Treatment with antipsychotics and, to a lesser extent, SSRIs may elevate serum levels of prolactin and result in galactorrhea, sexual dysfunction, menstrual disorders, and impaired fertility.

continue: Continuing/Discontinuing Medications in Pregnancy

top . pages 1 2 3 4 5 6 . send to friend . bipolar site map

Written 4/02. Reviewed: 03/2006