Author: John Carter

Comorbid Bipolar and Alcohol Use Disorder A Therapeutic Challenge PMC

Likewise, if you are only treated for addiction, the symptoms of bipolar disorder will likely trigger you to relapse and drink again, even after a successful period of sobriety. Bipolar disorder is a condition that causes cycling between manic and depressive moods, and it has a strong correlation with addiction. Over 60 percent of people with bipolar disorder will also be diagnosed with a substance use disorder at some point in their lives. It causes manic moods and depression, both of which can be debilitating and dangerous. Alcohol use disorder commonly co-occurs with bipolar disorder, and it increases the risk for complications, worsens symptoms, and makes treatment more difficult. It is important to understand the risks, to know the facts, and to be cautious about drinking when living with bipolar disorder.

Pediatric onset BD rarely occurs in the absence of comorbid conditions, and the co-occurrence of additional disorders complicates both the accurate diagnosis of BD and its treatment. Manifestation of BD in children and adolescents is not as infrequent as previously assumed, with rates of bipolar spectrum disorder reaching an estimated 4%, especially in US samples (10). If you’ve lost control over your drinking or you misuse drugs, get help before your problems get worse and are harder to treat. Seeing a mental health professional right away is very important if you also have symptoms of bipolar disorder or another mental health condition. If you’re concerned about a loved one and believe they may need residential care, we can help. BrightQuest offers long-term treatment for people struggling with schizoaffective disorders, schizophrenia, and severe bipolar disorder as well as other co-occurring conditions.

Learning to deal with bipolar disorder the right way can influence smarter choices such as the choice to remain abstinent from alcohol. Alcohol Use Disorder (AUD) and Bipolar Disorder are often treated separately. However, it is almost always better to treat the dual diagnosis at the same time rather than have the untreated illness bring back symptoms of the one that received treatment. Call now to connect with a treatment provider and start your recovery journey.

Medications and alcohol

For example, a representative household survey in Iran found a 12-month prevalence of alcohol use disorders of 1% according to DSM-IV criteria and 1.3% according to DSM-5, with higher prevalence rates in urban vs. rural areas (8). For comparison, a recent US household survey reports a 12-month prevalence of DSM-5 AUD of 13.9% (9). Both bipolar disorder and alcohol consumption cause changes in a person’s brain.

The German S3 Guidelines for AUD recommend that both disorders, BD and AUD, should be treated in one setting and by the same therapeutic team (49, 81). If not feasible, a close coordination of therapies, e.g., by means of a case manager, should be established. As mentioned, there is a wide variation of prevalence rates for BD-SUD comorbidity across countries (2) with higher rates in the US than in other industrialized countries. Analyzing the SFBN sample of the two German centers revealed a life-time prevalence of 17.8% for AUD only—compared to 33% in the whole SFBN which included four US and three European centers (two in Germany, one in the Netherlands).

Treatment for Bipolar Disorder and Alcohol Use Disorder Can Be Effective.

The evidence for Assertive community treatment (AST) that has been examined in two RCTs is inconclusive, with one study showing a reduction of alcohol use, the other not when compared to standard clinical case management. Both studies included also patients with other major mental health disorders, such as MDD and schizophrenia; thus, both do not supply information exclusively about changes in the course of BD (96, 97). Citalopram was studied in patients randomly assigned to receive citalopram or placebo for alcohol abuse or dependence. 40 Patients in the citalopram group had more days of drinking and showed little change in frequency of alcohol consumption. There was no improvement in depression severity in the citalopram group relative to the placebo group. Citalopram also has been studied in combination with naltrexone.41 Patients with depression and alcohol dependence were randomly assigned to receive either citalopram or placebo, as well as naltrexone.

1. Both studies included also patients with other major mental health disorders, such as MDD and schizophrenia; thus, both do not supply information exclusively about changes in the course of BD (96, 97).
2. Also, having both conditions makes mood swings, depression, violence and suicide more likely.
3. Positive effects of lithium on SUD apart from indirect effects via mood stabilization could not be substantiated so far (109).
4. Coexisting illnesses also are important to consider in the clinical treatment for bipolar patients.

A controlled study suggested a reduction of alcohol consumption with ondansetron (126). Besides psychotherapy an individually tailored pharmacotherapy is essential in almost all BD patients with comorbid AUD. For BD, pharmacotherapy is an essential component to stabilize mood and prevent recurrences, whereas its role for treating AUD beyond controlling acute withdrawal symptoms is less clear. Randomized controlled studies in BD traditionally exclude patient with concurrent SUD. Thus, the evidence for choosing a mood stabilizer in BD with comorbid AUD is rather weak; strictly speaking, high levels evidence consists of altogether three placebo-controlled studies in this patient group (104–106). To make any suggestion (not even recommendations) about best available treatments we therefore rely on additional low-level evidence from open or retrospective studies and expert opinion.

It can be difficult to get the medication right with bipolar disorder because each person is different and may respond differently to medications. People with bipolar disorder often use medications to stabilize their symptoms. The effects of bipolar disorder vary between individuals and also according to the phase of the disorder that the person is experiencing. Regardless of the blurred nights and the draining hangovers leading to mixed intensified feelings once the alcohol leaves the body, many bipolar individuals still choose to drink. For some, the relaxed feelings and the heightened mania far outweigh the negative effect alcohol has on the mood. Drinking on bipolar medication can turn one drink into several, especially drinking on an empty stomach.

Alcohol and symptoms of bipolar disorder

If you have bipolar disorder, you are at a much greater risk of developing alcohol use disorder. Other theories suggest that people with bipolar disorder use alcohol in an attempt to manage their symptoms, especially when they experience manic episodes. The combination of bipolar disorder and AUD can have severe consequences if left untreated. People with both conditions are likely to have more severe symptoms of bipolar disorder. Among people with bipolar disorder, the impact of drinking is noticeable. About 45 percent of people with bipolar disorder also have alcohol use disorder (AUD), according to a 2013 review.

This recommendation is, by large, based on the CBT studies conducted by Farren et al. In a prospective cohort study, 232 comorbid patients with alcohol dependence and an affective disorder (among whom 102 were individuals with BDs), received inpatient treatment with cognitive behavioral therapy for 4 weeks (90). At 6-month follow-up both groups (depressive and bipolar patients) showed a significant reduction of alcohol consumption, but no difference was found between patients with unipolar and bipolar disorder. At 5-year follow-up, there was still a significant long-term benefit, particularly in those who engaged in post-discharge supportive therapy.

The already cited WHO census across 11 countries showed a mean SUD life time comorbidity with BD of 36.6% with a large variation between countries (2). A meta-analysis including nine national surveys conducted between 1990 and 2015 revealed a mean prevalence of 24% for AUD and of 33% for any SUD except nicotine (28). Analyzing SUD and bipolar comorbidity in clinical settings, the same group reports the highest prevalence for AUD (42%) followed by cannabis use (20%) and any other illicit drug use (17%) (21). Cannabis ranking second after AUD has also been confirmed in other studies (7, 27, 29). Similar rates of SUD were also reported in the Systematic Treatment Enhancement Program Bipolar Disorders (STEP BD) study including 3,750 Bipolar I or II patients (30).

How does alcohol affect bipolar disorder?

For intermediate and long-term treatment, the dogma persisted for a long time that AUD needs to be treated first and sufficiently before attention should be paid to the mental health disorder. Today, strategies that promote concomitant therapy of dual disorders are the established treatment of choice (80) and recommended in major guidelines (81). However, treatment adherence and compliance remain a challenge in this special group, since medications are often not taken as prescribed (61) and psychotherapy appointments are often missed. Studies support that the most important predictor of non-adherence in BD is comorbid alcohol and/or drug abuse (82, 83). Thus, effective psychosocial (84), psychoeducational (85, 86) or psychotherapeutic (87, 88) intervention for AUD and BD can also positively impact on medication adherence and, by this, ameliorate the course especially of BD (84).

A recent catchment area study in Northeast England found a 40% lifetime comorbidity between BD II and AUD, surprisingly with little difference between female (38%) and male (43%) subjects (36). Both bipolar affective disorder (BD) and substance use disorder (SUD) are wide-spread in the general population. Most epidemiological and treatment studies were conducted according to DSM-IV or ICD-10 criteria that distinguishes between substance abuse and dependence as diagnostic entities on its own.

Even when researchers study bipolar disorder or AUD, they tend to look at just one condition at a time. There’s been a recent trend to consider treating both conditions simultaneously, using medications and other therapies that treat each condition. It is thought that the genes that increase the risk of bipolar disorder may be the same genes that influence alcohol addiction. Genetic differences may affect the brain reward system making people with bipolar disorder more vulnerable to alcohol and drug addiction. Atypical antipsychotics (aAP) have increasingly become a treatment of choice in BD.