Bipolar and Substance Use Disorder Comorbidity: Diagnostic and Treatment Considerations

Both bipolar I and bipolar II disorders are highly comorbid with substance use disorders, and this comorbidity is associated with more severe illness course and early mortality. There is overdiagnosis of bipolar disorder in substance-misusing populations, but careful, structured diagnostic evaluation using family and other third-party confirmation can decrease this likelihood. Limited data for the use of pharmacological interventions to decrease drug and alcohol use in patients with bipolar disorder are available; nevertheless, the Food and Drug Administration-approved treatments for addictions, especially for nicotine and opiate dependence, may still be effective in patients with bipolar disorder. There is limited clinical trial evidence for treating mood episodes in patients with comorbid conditions; current substance use diagnoses do not lead to worse mood outcomes prospectively, suggesting that treatment should not be withheld from this group. Because the health consequences of substance misuse can be so grave, clinicians must be prepared to engage patients in treatment aimed to change behavior.