Treating the Highs & Lows of Bipolar Adults

Several studies have reported an association between alcoholism and mood disorders. To date, there have been two large epidemiological studies of psychiatric disorders: the National Institute of Mental Health's Epidemiologic Catchment Area (ECA) study (Regier et al. 1990) and the National Comorbidity Survey (NCS) (Kessler et al. 1996). The ECA study (Regier et al. 1990) revealed that 60.7 percent of people with bipolar I disorder had a lifetime diagnosis of a substance use disorder (i.e., an alcohol or other drug use disorder); 46.2 percent of those with bipolar I disorder had an alcohol use disorder; and 40.7 percent had a drug abuse or dependence diagnosis (the percentages of people with alcohol use disorders and drug abuse disorders do not add to 100 due to overlap). Forty–eight percent of people with bipolar II disorder had a substance use disorder, 39.2 percent had an alcohol use disorder, and 21 percent had a drug abuse or dependence diagnosis (these figures reflect overlap, as above.) As shown in the table, alcohol dependence was twice as likely to co–occur in people with bipolar spectrum disorders than in those with unipolar depression (i.e., depression without mania). It is also noteworthy that bipolar disorder was more likely to occur with alcohol dependence than with alcohol abuse (see table). As part of the ECA study, Helzer and Przybeck (1988) found that mania (i.e., bipolar I disorder) and alcohol use disorders are far more likely to occur together (i.e., 6.2 times more likely) than would be expected by chance. Of all other psychiatric diagnoses investigated in this study, only antisocial personality disorder was more likely to be related to alcoholism than mania. The findings of the NCS with regard to the comorbidity of mood disorders and alcoholism were very similar.

Possible Explanations For Comorbidity
Although researchers have proposed explanations for the strong association between alcoholism and bipolar disorder, the exact relationship between these disorders is not well understood. One proposed explanation is that certain psychiatric disorders (such as bipolar disorder) may be risk factors for substance use. Alternatively, symptoms of bipolar disorder may emerge during the course of chronic alcohol intoxication or withdrawal. For example, alcohol withdrawal may trigger bipolar symptoms. Still other studies have suggested that people with bipolar disorder may use alcohol during manic episodes in an attempt at self–medication, either to prolong their pleasurable state or to sedate the agitation of mania. Finally, other researchers have suggested that alcohol use and withdrawal may affect the same brain chemicals (i.e., neurotransmitters) involved in bipolar illness, thereby allowing one disorder to change the clinical course of the other. In other words, alcohol use or withdrawal may "prompt" bipolar disorder symptoms (Tohen et al. 1998). It remains unclear which if any of these potential mechanisms is responsible for the strong association between alcoholism and bipolar disorder. It is very likely that this relationship is not simply a reflection of cause and effect but rather that it is complex and bidirectional. Genetic factors may also play a role, as described below.

Familial Risk of Bipolar Disorder and Alcoholism
The role of genetic factors in psychiatric disorders has received much attention recently. Some evidence is available to support the possibility of familial transmission of both bipolar disorder and alcoholism (Merikangas and Gelernter 1990; Berrettini et al. 1997). Common genetic factors may play a role in the development of this comorbidity, but this relationship is complex (Tohen et al. 1998). Preisig and colleagues (2001) conducted a family study of mood disorders and alcoholism by evaluating 226 people with alcoholism with and without a mood disorder as well as family members of those people. The researchers found that there was a greater familial association between alcoholism and bipolar disorder (odds ratio of 14.5) than between alcoholism and unipolar depression (odds ratio of 1.7). These findings have implications for prevention and treatment. A positive family history of bipolar disorder or alcoholism is an important risk factor for offspring.

Alcoholism's Effect on Comorbid Bipolar Disorder. A growing number of studies have shown that substance abuse, including alcoholism, may worsen the clinical course of bipolar disorder. Sonne and colleagues (1994) evaluated the course and features of bipolar disorder in patients with and without a lifetime substance use disorder. They found that compared to non–substance abusers, substance–abusing bipolar patients were more likely to have frequent hospitalizations for affective symptoms, earlier onset of bipolar disorder, more rapid cycling, and more mixed mania (the latter two considered to be the most severe, treatment–resistant forms of bipolar disorder). Keller and colleagues (1986) compared patients who had pure depression or pure mania with patients who had mixed or rapid cycling bipolar disorder and found that a higher percentage of patients with mixed or rapid cycling bipolar disorder had concurrent alcoholism (13 percent) and that these patients had a slower recovery from the bipolar disorder. Although this association does not necessarily indicate that alcoholism worsens bipolar symptoms, it does point out the relationship between them. A comparison of patients with bipolar disorder and a coexisting substance use disorder with others who had bipolar disorder alone found that those with comorbid substance use disorders had an earlier age of onset for their mood disorder, were more likely to be male, had more comorbid psychiatric disorders in addition to bipolar disorder, and were significantly more likely to have mixed mania at the time of interview (Sonne and Brady 1999b).

Although research suggests that alcohol and other drug abuse may worsen the course of bipolar disorder, some data indicate that patients with bipolar disorder and alcoholism do better in substance abuse treatment than alcoholic patients with other mood disorders. O'Sullivan and colleagues (1988) found that alcoholics with bipolar disorder functioned better during a 2–year followup period than did primary alcoholics (i.e., those without comorbid mood disorders) or alcoholics with unipolar depression. This suggests that bipolar patients may use alcohol primarily as a means to medicate their affective symptoms, and if their bipolar symptoms are adequately treated, they are able to stop abusing alcohol. Hasin and colleagues (1989) found that patients with bipolar II disorder were likely to have an earlier remission from alcoholism compared with patients with schizoaffective disorder or bipolar I disorder. Researchers have also proposed that the presence of mania may precipitate or exacerbate alcoholism (Hasin et al. 1985).

In conclusion, it appears that alcoholism may adversely affect the course and prognosis of bipolar disorder, leading to more frequent hospitalizations. In addition, patients with more treatment–resistant symptoms (i.e., rapid cycling, mixed mania) are more likely to have comorbid alcoholism than patients with less severe bipolar symptoms. If left untreated, alcohol dependence and withdrawal are likely to worsen mood symptoms, thereby forming a vicious cycle of alcohol use and mood instability. However, some data indicate that with effective treatment of mood symptoms, patients with bipolar disorder can have remission of their alcoholism.

Order of Onset
An important factor in studying the influence of one comorbid disorder on another is the order of onset of the two disorders. A mood disorder that occurs prior to the onset of another psychiatric disorder is called a primary affective disorder. Secondary affective disorders occur after the onset of other psychiatric disorders. Feinman and Dunner (1996) conducted a retrospective chart review of three groups of patients:  Those with primary bipolar disorder with no history of substance abuse (primary group), with 103 patients Those with primary bipolar disorder complicated by substance abuse, which began after the onset of bipolar disorder (complicated group), with 35 patients Those with bipolar disorder that came after the onset of substance abuse (secondary group), with 50 patients. The researchers found that patients in the complicated group had a significantly earlier age of onset of bipolar disorder than the other groups. They also found that the complicated and secondary groups had higher rates of suicide attempts than did the primary group. Preisig and colleagues (2001) also reported that the onset of bipolar disorder tended to precede that of alcoholism. They concluded that this finding is in accordance with results of clinical studies that suggest alcoholism is often a complication of bipolar disorder rather than a risk factor for it.  In a 5–year follow-up study, Winokur and colleagues (1995) evaluated a group of bipolar patients with and without alcoholism. In the alcoholic patients, bipolar illness and alcoholism were categorized as being either primary or secondary. The patients with primary alcoholism had significantly fewer episodes of mood disorder at followup, which may suggest that these patients had a less severe form of bipolar illness. Thus, there is growing evidence that the presence of a concomitant alcohol use disorder may adversely affect the course of bipolar disorder, and the order of onset of the two disorders has prognostic implications. Specifically, bipolar patients with secondary alcoholism may be better able to stop drinking if their bipolar illness is adequately treated; and, conversely, bipolar patients with primary alcoholism (alcoholism occurs first) may be better able to control their mood symptoms if they are able to stop drinking.

Comorbidity and Diagnostic Issues
Almost every alcoholic will report having mood swings. It is very important to distinguish these alcohol–induced symptoms from actual bipolar disorder. However, diagnosing bipolar disorder in the face of alcohol abuse can be difficult because alcohol use and withdrawal, particularly with chronic use, can mimic nearly any psychiatric disorder. Alcohol intoxication can produce a syndrome indistinguishable from mania or hypomania, characterized by euphoria, increased energy, decreased appetite, grandiosity, and sometimes paranoia. However, these alcohol–induced manic symptoms generally occur only during active alcohol intoxication, which makes them fairly easy to differentiate from mania associated with bipolar I disorder. Still, alcoholic patients going through alcohol withdrawal may appear to have depression. Depression is a key symptom of withdrawal from several substances of abuse, and studies have demonstrated that symptoms of withdrawal–related depression may persist for 2 to 4 weeks (Brown and Schuckit 1988). Because of this phenomenon, it is likely that observation during lengthier periods of abstinence (i.e., continued observation following the withdrawal stage) is important for the diagnosis of depression as compared with mania.

Bipolar II disorder and cyclothymia are even more difficult to reliably diagnose because of the more subtle nature of the psychiatric symptoms. Because of the diagnostic difficulties, it may be that this diagnostic group is often overlooked. Although these less severe forms of bipolar disorder may not be as disruptive as bipolar I disorder, it is still important to recognize and treat them in order to break the potential cycle of mood problems leading to substance use, which leads to a worsening of mood symptoms, which in turn may worsen the substance abuse, leading to even worse mood symptoms.
As a general rule, it seems appropriate to diagnose bipolar disorder if the symptoms clearly occur before the onset of the alcoholism or if they persist during periods of sustained abstinence. The adequate amount of abstinence for diagnostic purposes has not been clearly defined. Family history and severity of symptoms should also factor into diagnostic considerations. Given that bipolar disorder and substance abuse co–occur so frequently, it also makes sense to screen for substance abuse in people seeking treatment for bipolar disorder.

Treatment Of Comorbid Bipolar Disorder And Alcoholism
Psychosocial interventions have often been considered the mainstays of treatment for alcoholism and other substance use disorders. Several studies have demonstrated success with cognitive behavioral therapy in treating alcoholism (Project MATCH Research Group 1998). Many of the principles of cognitive behavioral therapy are commonly applied in the treatment of both mood disorders and alcoholism. Weiss and colleagues (1999) have developed a relapse prevention group therapy using cognitive behavioral therapy techniques for treating patients with comorbid bipolar disorder and substance use disorder. This therapy uses an integrated approach; participants discuss topics that are relevant to both disorders, such as insomnia, emphasizing common aspects of recovery and relapse.

Interestingly, the same investigators (Weiss et al. 2000) evaluated the progress of a group of substance abusers with comorbid bipolar spectrum disorders who were pursuing psychosocial treatment independently, rather than as a result of being assigned to it by the researchers. Potential study participants were told that the investigators were interested in better understanding the relationship between bipolar disorder and substance abuse and therefore wished to see them monthly for 6 months. The investigators found that psychotherapy and Alcoholics Anonymous (AA) attendance decreased over time and that substance use tended to increase from month 1 to month 6. The focus of the study participants' psychotherapy also changed, with less emphasis on their specific disorders and more emphasis on family, school, work, and other personal issues. Although differences in mood or substance use between months 1 and 6 were not statistically significant, there was a trend for increased substance use. If the study participants had continued with AA and if psychotherapy had continued to focus on bipolar disorder and alcoholism, the patients' substance use might have improved. Given the generally poor prognosis associated with bipolar disorder and alcoholism, it is important to educate patients concerning the relationship between these two disorders. The authors concluded that the development of dually focused psychosocial treatments for this population may help improve substance use and affective outcomes.
- Sonne, Susan C. and Kathleen T. Brady; Bipolar Disorder and Alcoholism; Alcohol Research & Health; 2002, Vol 26 Issue 2, p103


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Personal Reflection Exercise #7
The preceding section contained information about the comorbidity of alcoholism and bipolar disorder.   Write three case study examples regarding how you might use the content of this section in your practice.

Update
Alcohol use is associated with affective and interoceptive network alterations in bipolar disorder

Martyn, F. M., McPhilemy, G., Nabulsi, L., Quirke, J., Hallahan, B., McDonald, C., & Cannon, D. M. (2023). Alcohol use is associated with affective and interoceptive network alterations in bipolar disorder. Brain and behavior, 13(1), e2832. https://doi.org/10.1002/brb3.2832

Peer-Reviewed Journal Article References:
Hogarth, L., Hardy, L., Mathew, A. R., & Hitsman, B. (2018). Negative mood-induced alcohol-seeking is greater in young adults who report depression symptoms, drinking to cope, and subjective reactivity. Experimental and Clinical Psychopharmacology, 26(2), 138–146.

Meredith, L. R., Green, R., Grodin, E. N., Chorpita, M., Miotto, K., & Ray, L. A. (2021). Ibudilast moderates the effect of mood on alcohol craving during stress exposure. Experimental and Clinical Psychopharmacology. Advance online publication.

Stevenson, B. L., Dvorak, R. D., Kramer, M. P., Peterson, R. S., Dunn, M. E., Leary, A. V., & Pinto, D. (2019). Within- and between-person associations from mood to alcohol consequences: The mediating role of enhancement and coping drinking motives. Journal of Abnormal Psychology, 128(8), 813–822.

Online Continuing Education QUESTION 21
According to Sonne, what differences in symptoms do bipolar clients with comorbid substance-abuse disorders experience? Record the letter of the correct answer the CE Test.