Substance misuse is often present in individuals with other psychiatric problems. People with bipolar have very high rates of substance misuse that make diagnosing and treating either issue challenging for clinicians. Research has shown that approximately half of individuals who have bipolar will experience alcohol misuse, and many will develop alcohol dependence. Nicotine use is also overrepresented among individuals with bipolar, with dependence on nicotine being three times higher among bipolar clients than among individuals with no history of mental health problems.
The comorbidity of these issues creates an increased risk for financial insecurity, unemployment, aggression, physical health problems, and decreased quality of life. The presence of substance misuse also doubles the risk for suicide in people with bipolar. Additionally, people who have both bipolar and substance use problems are more likely to experience other psychological problems, including panic, anxiety, and posttraumatic stress. Together, these issues place individuals with bipolar at a much higher risk for increased health care needs and early mortality. The onset of substance misuse is critical to diagnosis. Some people use alcohol and drugs to cope with the high and low moods of bipolar. Understanding the history of substance misuse is a key factor to determining the severity and ultimate course of bipolar in people who have a history of both.
Bryan K. Tolliver of the Department of Psychiatry & Behavioral Sciences at the Medical University of South Carolina believes that all of these elements must be addressed individually and collectively to ensure proper treatment. In a recent report, Tolliver underscores the difficulties that these relapsing and remitting conditions present for clinicians. Clients currently using alcohol or drugs may be masking the severity of bipolar symptoms when they present for treatment. This could result in improper diagnosis and over- or undertreatment of symptoms. Clients with comorbidity also have low treatment adherence, further exacerbating their symptoms. Because of the nature of both substance use and bipolar, clients themselves may be perpetuating their own stigma. Tolliver says, “As a result, individuals may be least likely to recognize that they are ill during periods when symptoms are most severe.” He believes that an integrated approach, identifying substance use history, bipolar history, and co-occurring mental health problems, is the most effective way to accurately diagnose, treat and manage all of the challenges these individuals face.
Tolliver, B. K., Hartwell, K. J. (2012). Implications and strategies for clinical management of co-occurring substance use in bipolar disorder. Psychiatric Annals, 42.5, 190-197.
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