Ask the Expert: Treatment Strategy for Co-occurring Bipolar Disorder and Alcohol Abuse

Detoxification. The first step involves evaluation of the need for detoxification, and, if this need is present, a determination of whether the appropriate strategy involves inpatient versus outpatient detoxification. Outpatient detoxification may be appropriate for individuals without serious medical problems, without a past history of complicated detoxifications or withdrawal seizures, and for whom adequate support mechanisms are in place. However, affective instability, a suicidal tendency, more severe alcohol use, or a risk of inappropriate benzodiazepine use would strongly suggest the need for inpatient detoxification.

If detoxification is indicated, use of both antiepileptic agents and benzodiazepines is recommended. Emerging data suggest that valproate and carbamazepine, in addition to being appropriate mood stabilizers in bipolar disorder, are efficacious in treating withdrawal and may be associated with improved outcomes (2). Thus, treatment with valproate or carbamazepine, using benzodiazepines as needed for breakthrough withdrawal symptoms, is a reasonable approach. Close monitoring of hepatic function is imperative during treatment, and benzodiazepine use should be closely monitored and limited to the acute withdrawal period.

Diagnosis. Once the patient has been stabilized with detoxification (if necessary), the next step is to clarify the affective disorder diagnosis. Does the individual have true bipolar disorder, or is the symptom complex more consistent with substance-induced mood disorder? Evaluation of affective symptoms with an extended period of abstinence is ideal but typically not practical. At a minimum, a thorough assessment of the timing and duration of affective episodes should be conducted, with a focus on any relationship to periods of heavy substance use or abstinence. Involving individuals close to the patient can be a tremendous help in developing a timeline of illness history. If affective episodes only occurred in the context of substance use, a careful watch-and-wait approach is advised, following the patient's affective state during a period of abstinence.

If an individual with symptoms suggestive of bipolar disorder cannot provide a clear-cut history of an independent mood disorder or cannot maintain an adequate period of abstinence, aggressive treatment of the alcohol use disorder is indicated (see 4 and 5 below). The decision to include mood stabilization while addressing alcohol use depends on clinical judgment. If affective symptoms lead to clinically significant distress or impairment (e.g., dangerous impulsivity), a trial of mood stabilizers, which can be tapered after abstinence is achieved, with close monitoring for reemergence of symptoms, is a reasonable approach. In the case of less severe affective symptoms that may or may not be related to substance use, close monitoring in the absence of mood stabilizer therapy may be reasonable while the individual's alcohol use is addressed.

Mood stabilization. The overall guiding principle in choosing appropriate pharmacotherapy involves addressing the prevailing presentation of bipolar disorder with co-occurring substance abuse: rapid cycling and mixed mania. First, discontinue any antidepressant agents, which can lead to rapid cycling. The mood stabilizer of choice in this population is valproate, as the largest body of evidence supports efficacy for both affective and alcohol use outcomes (3). If there is no response after the serum level is maximized, switch to a second-line agent as described below. If there is insufficient improvement, consider combination therapy with another mood stabilizer or an atypical antipsychotic agent.

Second-line agents include lamotrigine and carbamazepine. Lamotrigine has been reported to be particularly effective for rapid cycling (4), and limited evidence supports its utility in substance-using individuals with bipolar disorder. There is less direct evidence to support the use of carbamazepine in this population, but given its efficacy in bipolar disorder plus usefulness in detoxification, I would consider it a fair second-line agent. Lithium should be avoided, given its poor efficacy in mixed and rapid cycling presentations and problems with compliance (5).

Emerging evidence supports the use of atypical antipsychotic agents in bipolar disorder. However, no controlled studies have rigorously investigated atypical antipsychotic drugs in bipolar substance users. Open-label and retrospective studies, as well as case series, provide limited support for use of quetiapine, aripiprazole, and olanzapine (5).

Alcohol pharmacotherapy. Once relative stability of affective symptoms is achieved, consideration should be given to pharmacotherapy addressing alcohol dependence, in particular naltrexone, acamprosate, and disulfiram. The literature on the use of these agents is, unfortunately, very sparse, but at least one trial has suggested an advantage of naltrexone or disulfiram over placebo (6). When naltrexone is used, monitor for emerging dysphoria and transaminasemia. With disulfiram, ensure that the individual can comprehend the risks involved with alcohol coingestion, limit prescription of disulfiram to those individuals for whom impulsivity is being adequately controlled, and monitor for emerging psychiatric symptoms. Although topiramate is not approved by the U.S. Food and Drug Administration for alcohol dependence, there is also some indication that it can improve alcohol outcomes. Given the lack of data to support its use as monotherapy in bipolar disorder, consideration should be given to adjunctive treatment with topiramate (2).

Psychosocial therapies. A crucial component in effective, comprehensive treatment of co-occurring bipolar and alcohol use disorders involves psychosocial therapy. Referral to Twelve-Step programs, such as Alcoholics Anonymous (AA), can be quite beneficial, and adjunctive psychotherapy with a trained addiction counselor addressing Twelve-Step facilitation, cognitive behavioral skills, and motivational enhancement therapy can provide important skills for achieving and maintaining sobriety. Individuals should try several different AA meetings to find those that suit their personality and style and should be aware of the occasional AA member who discourages use of any psychotropic medications. However, this stance is not supported by AA, and individuals can generally find an AA meeting that appropriately supports their recovery from both alcohol abuse and bipolar disorder.

Although treatment of the individual with comorbid problems is perhaps more complicated than treating bipolar disorder or alcohol dependence alone, following a systematic approach can provide guidance and direction. Recovery is possible for those with bipolar and alcohol use disorders, and the journey to recovery can provide a sense of self-efficacy and satisfaction for those who embark on it.