Bipolar Illness and Substance Use Disorders
By Arline Kaplan © 2000 (All Rights Reserved)
Clinicians who regularly treat patients with bipolar disorder often "view
substance abuse as a part of the illness," said Susan McElroy, M.D., at
a symposium held during the annual American Psychiatric Association meeting
in Chicago.
McElroy, a professor of psychiatry and psychopharmacology at the University
of Cincinnati College of Medicine, explained that about 60% of people with bipolar
I disorder, and 50% of those with bipolar II disorder have a comorbid substance
use disorder (Sonne and Brady, 1999).
In a journal article, McElroy and colleagues (2001) discussed Axis I psychiatric
comorbidity in a cohort of patients with bipolar disorder, as determined in
Stanley Foundation Bipolar Network (SFBN) study. SFBN is a nonprofit group headed
by Robert "Bob" Post, M.D., chief of the Biological Psychiatry Branch
at the National Institute of Mental Health. The multicenter research effort
in bipolar illness involves four centers in the United States and several in
Europe that seek to answer some of the unanswered questions in bipolar illness
regarding illness causes, comorbidities and strategies for long-term treatment.
At the "Bipolar Illness and Alcohol Abuse: Course and Treatment" symposium,
McElroy, professor of psychiatry and psychopharmacology at the University of
Cincinnati College of Medicine, discussed some SFBN study findings along with
other studies.
Epidemiological data from community populations, McElroy said, indicate that
bipolar disorder co-occurs with alcoholism at rates significantly higher than
those in the general population (Brady and Lydiard, 1992; Helzer and Pryzbeck
as cited in Winokur et al., 1995; Regier et al., 1990; Tohen et al., 1998).
"What the Epidemiologic Catchment Area study found was that bipolar disorder
was the Axis I disorder most commonly associated with a substance use disorder,"
McElroy said. "Among those with bipolar disorder, "56% had alcohol
or drug abuse or dependence, compared to people with unipolar depression where
only 27% had a substance use disorder."
Clinical Studies
A number of clinical studies suggest that when bipolar disorder occurs with
comorbid alcohol abuse, the clinician may dealing with either a more severe
form of bipolar disorder or the outcome of the bipolar disorder may be less
favorable, McElroy added. For example, when bipolar disorder is comorbid with
alcohol or drug abuse, the clinician may see an earlier age of onset of the
bipolar disorder (Sonne et al, 1994).
"Several studies also have suggested that comorbid alcohol abuse is associated
with mixed, dysphoric or unpleasant forms of mania as opposed to elated or pure
types of mania [Brady and Sonne, 1995; Keller et al., 1986; Sonne and Brady,
1994]," McElroy said. "There is at least one study suggesting that
alcohol abuse …with bipolar disorder is associated with higher rates of
suicidality [Simpson and Jamison, 1999].
"And then there are several studies suggesting comorbid alcohol abuse in
bipolar disorder is associated with poor outcome of bipolar disorder, whether
that be taking a longer time to recover from an episode of mania, taking a shorter
time to relapse to an episode of mania after recovery, or the finding that alcohol
abuse is associated with higher rates of nonadherence to treatment [Goldberg
et al., 1999; Tohen et al., 1990]. Finally, there are some data to suggest that
comorbid alcohol abuse is associated with a less favorable response to treatment
with lithium [O’Connell et al., 1991; Tohen et al., 1990]. However, I do
think it is important that I note to you that some of these findings aren’t
consistent."
Network Study
McElroy went on to share some data from the Stanley Foundation Network of patients.
The network has developed some common methodological approaches to study the
illness. Nearly 600 patients are currently enrolled in the network. The patients
are carefully evaluated with structured interviews for possible inclusion in
clinical trials.
"We do evaluate their comorbidity very carefully," McElroy said.
She shared the results of the first 288 patients enrolled in the network, focusing
on their substance abuse comorbidity. Of the first 288 patients in the network,
78 (42%) did have a substance use disorder. As diagnosed by Diagnostic and
Statistical Manual for Mental Disorders, 4th Edition (DSM-IV)
criteria, 239 of the patients were bipolar I and 49 were bipolar II.
"Bipolar I patients displayed a slightly greater rate of substance use
disorders than bipolar II (45% versus 31%), but this difference is not statistically
significant," McElroy said.
"As expected when looking at the individual substance use disorders, alcohol
is the most commonly abused substance, followed by marijuana, with cocaine and
stimulants a close third," she said.
McElroy and colleagues then compared patients with and without alcohol abuse
histories according to a variety of clinical and demographic features to see
if any differences emerged.
"We compared 101 patients with alcohol abuse histories with 166 patients
without alcohol abuse histories, regarding ages of onset of first manic and
depressive symptoms, as well as their first treatment for manic and depressive
symptoms, bipolar I versus II diagnosis," she said. "We also looked
at histories of rapid cycling, dysphoric mania, suicide attempts, drug abuse
and family histories.…We found no differences with respect to age of onset
of symptoms or first treatment of symptoms. We found no difference in terms
of histories of rapid cycling, dysphoric mania or suicide attempts. We did find,
as you would probably expect, that the patients who had comorbid alcohol abuse
also had histories of drug abuse. We also found family history differences.
Patients with a history of alcohol abuse, also had family histories of alcoholism
and drug abuse."
The research team did find significant gender differences in the bipolar patients
according to their alcohol abuse comorbidity. Although more men with bipolar
disorder had alcohol abuse histories in the sample, the relative risk for alcohol
abuse was much greater for women than men.
"What we found was that the relative risk for alcohol abuse was greater
for women than men in our patient sample compared to the general population.
In women, 29% of our female patients versus 4.6% of women in the general population
had alcohol abuse histories compared to 49% [of our male patients] versus 25%
[of men in the general population], so that the relative risk for alcohol abuse
in our patients was much greater than in the general population for women than
it was for men," she said.
One question related to how a comorbid substance use disorder might influence
lithium response is being analyzed by Gabriele Leverich, M.S.W., who is affiliated
with NIMH’s Biological Psychiatry Branch, and others, McElroy said.
"We are in the process of comparing lithium nonresponders versus responders.
These are the various factors found that differentiate lithium nonresponders
from responders," McElroy said.
Among those factors associated with lithium nonresponse are early onset of illness,
a history of chronic anxiety or panic attacks and a history of substance abuse.
Interestingly, substance abuse but not alcohol abuse was associated with nonresponse,
McElroy said.
References
Brady KT, Lydiard RB (1992), Bipolar affective disorder and substance abuse.
J Clin Psychopharmacol 12(1 suppl):17S-22S.
Brady KT, Sonne SC (1995), The relationship between substance abuse and bipolar
disorder. J Clin Psychiatry 56(suppl 3):19-24.
Goldberg JF, Garno JL, Leon AC et al. (1999), A history of substance abuse complicates
remission from acute mania in bipolar disorder. J Clin Psychiatry 60(11):733-740.
McElroy SL, Altshuler L, Suppes T et al. (2001), Axis I psychiatric comorbidity
and its relationship to historical variables in 288 patients with bipolar disorder.
Am J Psychiatry 158(3):420-426.
O’Connell RA, Mayo JA, Flatow L et al. (1991), Outcome of bipolar disorder
on long-term treatment with lithium. Br J Psychiatry 159:123-129.
Regier DA, Farmer ME, Rae DS et al. (1990), Comorbidity of mental disorders
with alcohol and other drug abuse. Results from the Epidemiologic Catchment
Area (ECA) study. JAMA 264(19):2511-2518.
Simpson SG, Jamison KR (1999), The risk of suicide in patients with bipolar
disorders. J Clin Psychiatry 60(suppl 2):53-56; discussion 75-76, 113-116.
Sonne SC, Brady KT (1999), Substance abuse and bipolar comorbidity. Psychiatr
Clin North Am 22(3):609-627.
Sonne SC, Brady KT, Morton WA (1994), Substance abuse and bipolar affective
disorder. J Nerv Ment Dis 182(6):349-352.
Tohen M, Greenfield SF, Weiss RD et al. (1998), The effect of comorbid substance
use disorders on the course of bipolar disorder: a review. Harv Rev Psychiatry
6(3):133-141.
Tohen M, Waternaux CM, Tsuang MT, Hunt AT (1990), Four-year follow-up of twenty-four
first-episode manic patients. J Affect Disord. 19(2):76-86.
Winokur G, Coryell W, Akiskal HS et al. (1995), Alcoholism in manic-depressive
(bipolar) illness: familial illness, course of illness, and the primary-secondary
distinction. Am J Psychiatry 152(3):365-372.
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