Bipolar and substance abuse – recommendations for concurrent treatment
Bipolar disorder is a very common psychiatric condition, with a lifetime prevalence of up to 2.5% in Australia, and is associated with a high level of social disablement. Both pharmacological and psychological therapies are usually required to attain adequate control. There are many medications available for treatment, including lithium, olanzapine (Zyprexa), valproic acid and risperidone (Risperdal), all of which are effective in lowering symptoms. However, these treatments can often be hindered by concurrent substance abuse, a problem that is particularly prevalent in those suffering from bipolar disorder.
Substance abuse is a very common occurrence in patients with bipolar disorder, especially in men. Research has shown that of men with bipolar/mania, up to 61% smoke tobacco, between 32% and 39% have had a history of alcohol abuse or dependence, and 30.5% have a history of illicit drug use or dependence. While these figures are lower for women, especially for illicit drug and alcohol use, levels still remain far above what is seen in the general population. This is an unfortunate finding, as concurrent substance abuse with bipolar can lead to more severe symptoms, more suicide attempts, longer episodes and a generally lower quality of life. In many cases, these two issues are dealt with separately, however, there is evidence that it is more effective to treat both simultaneously.
Substance abuse can also sometimes lead to interactions with prescription medications used to treat the disorder, and so it is important that physicians have an array of techniques useful for addressing substance abuse, which also leads to better outcomes.
While often it may be tempting to adopt a zero-tolerance approach advocating abstinence, some people may be unready or unwilling to make such a change. Forcing this approach can lead to the patient feeling alienated. In these people, harm minimisation can be a highly useful initial approach, which can reduce tensions between doctor and patient, and hopefully progress eventually to a more prolonged attempt at reducing intake.
To have the best outcomes, it is important to intervene at the appropriate level for where the patient sees themselves. Firstly, it is important to screen for a substance or alcohol abuse problem, which can be done using the CAGE questionnaire. This is composed of four parts:
- Have you ever felt you ought to Cut down on the use of [drug]?
- Have people Annoyed you by criticising your drinking or use of [drug]?
- Have you ever felt Guilty about your drinking or use of [drug]?
- Have you ever used a drink in the morning as an Eye-opener? Have you found that your take [drug] some days after waking to feel okay?
If a patient answers yes to two or more of these, then substance use is a problem and it is important to assess the patient’s attitude towards changing this situation.
If a patient is uninterested in change, then gentle education regarding substance misuse may allow them to reconsider their position. Motivational interview techniques can be used, including asking key questions with empathy and reflective listening.
If they are considering change, then knowing the pros and cons of change may prepare them for what they are about to do. This is a critical factor in engagement, as it allows patients to express concerns. Once they have decided to make a specific change, it is important to educate patients about the best way to go about instigating that change.
Goal planning could focus on ‘SMART’ goals, making the change quantifiable by setting specific targets. ‘SMART’ goals are Specific, Measurable, Attainable, and Realistic and have a Timeline. Once a patient has started making genuine attempts and taken action to change, they should be provided with guidance and help reaching their goals.
It is important to minimise the chances of a relapse by providing encouragement and developing relapse prevention strategies. Unfortunately, these do not always work, and if a relapse does occur, assisting the patient towards change should begin again.
It is hoped that, if doctors adopt these approaches in combination with adequate pharmacological treatment when dealing with patients suffering from bipolar disorder, the outcomes will be better and there will be less antagonism between the patient and treating physician.
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