Just before Christmas I went to a mass said for my neighbor’s son. He died of an opioid overdose. He left a fiancé, who soon after died of an overdose herself, and a young daughter, now adopted and living across the country. The girl’s grandmother, my neighbor, sees her granddaughter only once a year.
Since then I’ve been thinking a lot about how substance abuse impacts families, and how many people with bipolar disorder have substance abuse problems.
Is it all self-medication, or is there more to it?
The rates of substance use disorder (SUD) in people with bipolar disorder (BP) are astounding. SUD is a disease that affects a person’s brain and behavior and leads to the inability to control the use of a legal or illegal drug.
In the general population, the lifetime prevalence of SUD for alcohol is 8%. It’s 2-3% for other drugs.
In people with BP1, the rates are 58% for alcohol and 38% for other drugs. In BP2, the rates are 39% and 21%.
People with BP have higher rates of SUD than those with any other mental illness except anti-social personality disorder. The most abused substances are alcohol, cannabis, cocaine and opioids.
Veterans with BP in the VA hospital system had the highest occurrence, with 62% reporting SUD.
A first manic episode study found that nearly half of those hospitalized for a first manic episode were abusing substances. The most abused was cannabis, at 46%.
Co-morbid SUD, especially alcohol, also results in more episodes of depression in people with BP.
People with co-morbid SUD also had a higher number of suicide attempts, and were less likely to be categorized as recovered from BP.
The rates of SUD for alcohol and cannabis are so high in people with BP that researchers have begun to investigate whether or not there is a causal link between SUD and BP. We have long been told that people with BP often self-medicate, and this can result in SUD. Evidence is also strong that pre-existing SUD may actually cause BP.
Three studies contrasted the impact of bipolar-first co-morbidity with SUD-first co-morbidity. These studies point to SUD as causal in the development of a subset of BP. SUD-first BP is milder than BP-first BP, but results in more, albeit shorter, episodes of depression. BP-first BP is more likely to result in suicide.
I was abusing meth long before my diagnosis with BP1. My mother protests that this caused my mental illness. But co-morbidity is much more complicated than that. There were symptoms of BP before I ever started using drugs, but full-blown psychotic mania didn’t come until after.
The impact of one disorder on the other is profound, if not clear, and identifying causation is elusive.
It’s obvious that people with BP should avoid drugs other than their prescribed medicine, but in cases of co-morbid SUD that is so much easier said than done.
In research on medications for BP, researchers advocate for selecting out people with co-morbid BP and SUD from the sample of patients in drug trials, as SUD has such a profound impact on the course of BP.
As it stands today, while a significant impact of one condition on the other is certain and reciprocal, the two conditions must be treated independent of one another. Further research is necessary before unified treatment for both disorders can be developed.
Photo by Linas V