Bipolar Youth at Risk for Substance Abuse?

Psychiatric history and family factors found to be possible predictors of substance abuse in bipolar youth

(RxWiki News) Bipolar disorder has been previously linked with substance abuse in adolescents. It's possible that certain symptoms or behaviors can help target youth before they develop a substance use disorder.

A recent study looked at the predictors of substance use disorders (SUD) in adolescents with bipolar disorder.

The researchers found that a history of substance use, behavioral disorders, family history of SUD, not feeling close to family and not taking antidepressants were the biggest predictors of first onset of SUD. The findings also showed that the risk of developing a substance use disorder increased as the number of predictors increased in the study participants.

The researchers found that the identification of these predictors could potentially help target cases of SUD before onset, and lead to preventative strategies for bipolar youth.

"Talk to a psychiatrist about substance abuse if your child is bipolar."

This study was conducted through the Western Psychiatric Institute and Clinic of the University of Pittsburgh School of Medicine, the Centre for Youth Bipolar Disorder in the Sunnybrook Health Sciences Centre at the University of Toronto, and the David Geffen School of Medicine at the University of California at Los Angeles. The lead author was Benjamin I. Goldstein, MD, PhD, from the University of Pittsburgh School of Medicine.

Participant data came from a previous study called the Course and Outcome of Bipolar Youth (COBY). The current researchers analyzed the COBY study to look at possible predictors of first onset of substance abuse disorders in bipolar adolescents.

The researchers selected 167 adolescents between the ages of 12 and 17 years, 11 months who had previously been diagnosed with any type of bipolar disorder, had not experienced first onset of SUD at intake and weren't simultaneously diagnosed with schizophrenia, mental retardation, autism or mood disorders. 

At intake, adolescents and their parents were separated and individually interviewed about the adolescents' psychiatric history, including family psychiatric history and history of medication, over the adolescents' lifetime.

The researchers measured any instance of:

  • depression
  • hypomania (continual extreme happiness usually followed by irritability)
  • mania (abnormally elevated or irritable mood, arousal or energy levels)
  • psychosis (generic term for "loss of contact with reality")
  • attention deficit/hyperactivity disorder 
  • conduct disorder 
  • oppositional defiant disorder 
  • anxiety
  • panic disorder 

In addition, the researchers asked about any family conflict, level of familial functioning, and the presence of any significantly negative (i.e., death of a family member) or positive (i.e., academic or athletic success) life events.

The researchers found that 54 of the participants (32 percent) experienced first onset of SUD during the course of the study. The average age of onset was 18 and it happened 2.7 years after intake.

The findings showed that cannabis disorders were the most common, with 17 percent of the participants with SUD reporting cannabis abuse, and 5 percent reporting dependence. Alcohol use disorders were the second most common, with 16 percent reporting abuse, and 5 percent reporting dependence.

Other drug abuse/dependence was not reported in more than 1.2 percent of the participants. However, the researchers found that 76 percent of the participants who experience first onset of SUD reported abuse or dependence on at least two substances.

The researchers discovered that the participants who developed SUD were more likely than those who did not develop SUD to have a lifetime history of smoking cigarettes, cannabis use and alcohol use; a history of lifetime oppositional defiant disorder; and/or a family history of mania/hypomania, anxiety or SUD.

Those in the SUD group were also more likely to not use medication for treatment, to not function better overall, feel less close to their families, and report more negative life events.

The researchers determined that the participants with an increased risk of SUD were:

  • 4.33 times as likely to have used alcohol
  • 2.74 times as likely to have a history of lifetime panic disorder
  • 2.33 times as likely to have a history of oppositional defiant disorder
  • 2.54 times as likely to have a family history of SUD
  • 2.04 times as likely to report not feeling close to their families
  • 2.23 times as likely to not be using medication

The researchers also found that as the number of predictors increased, the risk of SUD increased. There was a 14 percent increased risk of SUD with zero to two predictors, a 46 percent increased risk with three predictors, and a 75 percent increased risk with four to five predictors.

Based on the findings, the researchers suggest that as much as 50 percent of bipolar youth will develop SUD by early adulthood. And the researchers estimated that an additional 10 to 20 percent of the study population is likely to develop SUD in the years right after adolescence.

Ultimately, the researchers believe that the identification of these predictors can help target and prevent possible cases of SUD in bipolar youth. However, the researchers maintain that these findings need to be researched in more detail before the results of this study can be generalized to all bipolar youth.

The authors noted a few limitations.

First, the COBY study was a naturalistic observational study, meaning that the current researchers analyzed the participants without interfering with their behavior. Therefore, cause and effect could not be determined, nor could the actual effectiveness of potential treatments.

Second, SUD was completely self-reported by the adolescents and their parents. Third, the COBY study did not include a comparison group of youth who were not bipolar.

"These findings confirm conventional wisdom: teens and adults with bipolar disorder tend to present with additional co-morbidity, especially substance abuse disorders. Anecdotally, this is because patients who either in the manic or depressed phase of the illness seek to 'treat themselves' (ie, the self medicating hypothesis of substance abuse) or their judgment is impaired enough from their mood symptoms that their willingness to engage in risky behaviors increases," Aaron Krasner, MD, a board certified Child/Adolescent and Adult Psychiatrist at Silver Hill Hospital in New Canaan, CT, told dailyRx News.

"I have found in particular a correlation between cannabis use and depressive/anxiety symptoms in bipolar patients who have often reported transient symptomatic improvements with exposure to drugs and alcohol – but a long term deterioration in the course of their illness given that patients who are using drugs and alcohol principally forget to take their medications," Dr. Krasner explained.
"All in all, it is crucial for patients with bipolar illness and their treaters to continually assess their substance use or misuse and consider initiating treatments for the condition when indicated. Ignoring substance abuse in the bipolar patient could be big mistake and this paper encourages us to take on the problems non-judgmentally and directly," said Dr. Krasner.

This study was published in the October edition of the Journal of the American Academy of Child & Adolescent Psychiatry.

The National Institute of Mental Health and the Sunnybrook Foundation provided funding.

Review Date: 
October 4, 2013