Treating bipolar and substance abuse – a holistic approach

Bipolar disorder is a very common psychiatric condition, with up to 2.5% of Australians suffering from it at some stage in their life. People with bipolar disorder experience problems with their mood, swinging between depression and extreme happiness. Unfortunately, bipolar disorder is also associated with a high degree of social and occupational problems, but there are now some very effective treatments.

Both medication and psychological therapies are usually required to control the symptoms of bipolar disorder. There are many medications available for lowering symptoms of bipolar, including lithium, olanzapine (Zyprexa), valproic acid and risperidone (Risperdal).

While these treatments can be very effective, they can often be hindered by substance abuse, a problem that is particularly prevalent in those suffering from bipolar disorder. That is why it is really important for doctors to work hard at lowering substance abuse problems in people who suffer 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, 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 disorder can lead to more severe symptoms, more suicide attempts, longer episodes, and a generally lower quality of life.

Some doctors like to treat substance abuse and bipolar as completely separate issues, but there is increasing evidence that treating them both together can lead to better outcomes.

Some people advocate a zero-tolerance approach to substance use, saying that people should just cut themselves off from substances cold turkey. The problem with this is that some people may be unready or unwilling to make such a change, and forcing this approach can lead to the patient feeling alienated and not changing their ways at all.

In these people, a process called ‘harm minimisation’ is often a better approach. Patients are encouraged not to stop outright, but just to put themselves at lower risk. The aim of this is to give them time to decide for themselves that it is better to either cut down or give up entirely.

As a first step, though, it is important to know if a patient actually has a substance abuse problem or not. To do this, doctors sometimes use what is known as a CAGE questionnaire, which is composed of four parts:

1. Have you ever felt you ought to Cut down on the use of [drug]?
2. Have people Annoyed you by criticising your drinking or use of [drug]?
3. Have you ever felt Guilty about your drinking or use of [drug]?
4. 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 the doctor should try to assess how willing the patient is to change.

If a patient is uninterested in changing, gentle education regarding substance misuse may allow them to reconsider their position.

If they are considering change, then knowing the pros and cons of change may prepare them for what they are about to do.

Once someone has decided to make a specific change, it is important to educate them on how to do it well. Having goals to aim for is really important, and some people like to use what are called ‘SMART’ goals, meaning they are Specific, Measurable, Attainable, and Realistic and have a Timeline. Since these allow people to achieve their goals and know when they are met, they can feel proud when they meet them.

Once a patient has started making genuine attempts and acting 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, then assisting the patient towards change should begin again.

It is hoped that this approach will help patients suffering from bipolar disorder to overcome their substance addiction. If these steps can be made, there will be very positive outcomes for the patient, with improved quality of life, greater treatment effectiveness, and better symptom control.