Co-occurring+Substance+Use+Disorders

There is abundant evidence and research that displays a relationship between bipolar disorder and substance abuse. In fact, of the psychiatric disorders found on Axis I, bipolar disorder is most associated with co-occurring Substance Use Disorder (Weiss, 2004). The combination of bipolar disorder (BPD) and Substance Use Disorder (SUD) has been shown to be characterized by denial and/or illness minimization leading to the majority of patients with combination BPD and SUD to often not seek treatment for both disorders which often results in frequent relapses by patients with these co-occurring disorders (Weiss, 2004).
 * Bipolar Disorder and Substance Use **

There is a general consensus that the relationship between mania and substance use is a significant one, and research suggests that a lot of medical non-compliance by patients with bipolar disorder results for a reluctance to control their mania; on the opposite side of the spectrum then is the well researched concept that medical compliance on behalf of the bipolar patient is due to a fear of depression, rather than and fear of mania (Weiss, 2004). It is known that depressive episodes occur more often than mania; so why is medical non-compliance more common than medical compliance if there is a positive correlation between a fear of depressive episodes and medical compliance? This has been attributed to the idea that, other than reluctance to control their mania, medical non-compliance can also be the result of a fear of taking their medication with the other substances they are using (Weiss, 2004).
 * Medical Compliance: Predominance of Depression **

Alcohol, cocaine and marijuana are commonly abused by BPD patients, although, once again, the prevalence of abuse of these substances varies greatly, ranging from 18-75% (Maremmani, Perugi, Pacini,& Aksikal, 2006). A study by the ECA reports a higher prevalence rate of any type of substance abuse of addiction in the BPD community than the general population (60.7 versus 27.7%) (Maremmani et al., 2006). Furthermore, though prevalence rates for SUD in correlation with BPD is higher overalls than in the general population, bipolar disorder I has a high rate of co-occurring SUD, but the rate is even higher with bipolar disorder II (Maremmani et al., 2006). Additionally, research has begun to look at the concept of BPD and co-occurring SUD's in regards to onset. The research to date suggests a correlation between the age of onset of BPD and risk of developing a co-occurring SUD with the results yielding that adolescent onset BPD has the highest risk of SUD development (Wilens, Biederman, Milberger, Hahesy, Goldman, Wozniak & Spencer, (2000). Additional research has shown that even though there is a correlation between age of BPD onset and risk of development of SUD there is also a positive connection of the most common order of development of BPD and SUD's with BPD mood symptoms predations Alcohol and PSUD development on average by several years (Salloum & Thase, 2000).
 * Rates of BPD and Co-Occurring SUD's **

1 of 4 patients with BPD have alcohol abuse issues and about half of patients with BPD that have a alcohol abuse problem also use at minimum one other substance with Psychoactive Substances being the most common category (Salloum & Thase, 2000). Alcohol abuse on average is present in 25% of depressed and 20% of manic bipolar patients and the prevalence of alcohol abuse and alcohol dependence is 3 times more likely for those with BPD than the general population (14.7 versus 5% and 31.5 versus 11.6% respectively) (Maremmani et al., 2006).Alcohol and psychoactive substances have both been shown to affect a number of aspects of BPD including hastening recurring episodes, exacerbating inter-episode symptoms and plays a large role in resistance to treatment (Salloum, & Thase, 2000). In the case of alcohol, it has been demonstrated that alcohol use and abuse for those with BPD can alter the presentation of their BPD; this includes that onset and duration of manic and depressive episodes and can also include the partial or complete masking of symptoms of mania which is a key factor in diagnostic confusion with BPD (Salloum, & Thase, 2000).
 * Alcohol Abuse: **

The rate of patients with BPD having a co-occurring Psychoactive Substance Use Disorder (PSUD) rages greatly with research showing the minimum at 18% and the high at 75%; in fact mania is the psychiatric disorder most likely to be associated with alcohol abuse and PSUD's (Salloum, & Thase, 2000). However, regardless of the range of the rate of PSUD's in BPD patients there is the proven general consensus that higher rates of PSUD's are found in patients with BPD than the general population, with the average statistics displaying that those with BPD are approximately 6 times more likely than the general population to have a PSUD (Salloum, & Thase, 2000). A study by Salloum, and Thase (2000) involving 20,000 patients with BPD over half of these patients also had a PSUD (Salloum & Thase, 2000). However, there more information on the impact of BPD on PSUD than on the impact of PSUD on BPD and more information and research on this would be beneficial (Salloum, & Thase, 2000).
 * Psychoactive Substance Use Disorder: **

Although alcohol and PSUD's seem to be the most common co-occurring SUD's they are not the only substances abused by those with BPD. Maremmani and colleagues (2006) have shown the following abused substances statistics: Cocaine dependent patients’ 18-30% Sedative Hypnotic dependent patients: 6.8% Opiate dependent patients: 5.4% Alcohol/PSUD dependent patients: 60% Heroin dependent patients: 55.6% In regards to heroin, mood disorders such as BPD are the most frequent and common form of psychiatric co morbidity for heroin addicts with research showing that 12-54% of heroin addicts are depressed. Additionally, in the lifetime perspective of recurrent depressive disorders, such as BPD, co-occurrence of heroin abuse is found in 60-90% of patients with depressive disorders (Maremmani et al., 2006). Cocaine, being a stimulant, has been shown to worsen manic symptoms of BPD and in the case of opiates research shows that 87% of opiate addicts meet the criteria for at least on psychiatric disorder – including bipolar (Milby, Sims, Khuder, Schumacher, & Huggins, 1996).
 * Other SUD's: **

Treatments such as psychotherapy and CBT have been shown to be effective in the treatment of BPD and SUD’s. Weiss (2004) notes that ambivalence is a key factor the continuation of self medicating and SUD in those with BPD; they suggest that those that fall into the category of having both BPD and a SUD may not necessarily experience consequences of substance use that are easily identifiable and that emphasis by a therapist on the impact of substance use on the course of BPD can assist in eliminating ambivalence and having the patients enter therapy. In conjunction with this idea, Yatham and colleagues (2005) suggest that multidisciplinary management following the chronic disease model may work the best for assisting in the recovery of co-occurring BPD and SUD; this model suggests the following three steps: Stabilize the current BPD episode before addressing long-term strategies Patients should be provided their treatment by a health care team that includes not only a physician but also a nurse or someone that can adequately provide psychoeducation (see step 3), as well as outreach programs and follow up. Psychoeducation: this step involves providing the patient with pertinent information regarding the effects of co-occurring BPD and SUD’s.
 * Recovery **

Their evidence also shows that psychoeduacation, when coupled with psychopharmarcology increase the time between manic and depressive episodes and reduces the rate of relapse.