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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
Familial Risk of Bipolar Disorder and Alcoholism
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
Comorbidity and Diagnostic Issues
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.
Treatment Of Comorbid Bipolar Disorder And Alcoholism
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.
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