Clinical Characteristics Associated With Comorbid Bipolar Disorder and Substance Use Disorder in Adolescents

Early interventions targeting comorbid disorders associated with substance use disorders may improve the illness course of bipolar disorder.

Comorbid substance use disorder is prevalent among adolescents with bipolar disorder and is associated with specific dimensional characteristics such as trait impulsivity, behavioral disorders, and anxiety, according to a study published in the Journal of the Canadian Academy of Child and Adolescent Psychiatry.

This cross-sectional study analyzed 100 adolescents from Canada (aged 13 to 19) diagnosed with bipolar disorder I, II, or not otherwise specified based on criteria established by the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime version and at least 1 parent or guardian for each participant. Substance use disorder was defined for participants who met the DSM-IV criteria for drug or alcohol abuse or dependence. 

Assessments of participants’ physical and sexual abuse history, lifetime aggression, and suicidality outside a depressive episode were obtained through interviews. Participants also completed a self-report or parent-report to identify dimensional impulsivity, emotional dysregulation, identity confusion, and interpersonal problems, as well as occurrences of various stressful life events.

Study results showed that 33% of the participants had a lifetime prevalence of substance use disorder: 19% reported alcohol use disorder (11% abuse, 8% dependence) and 25% reported a drug use disorder (4% abuse, 21% dependence), the latter primarily involving cannabis. Onset of substance use disorder preceded bipolar disorder onset in 61% of the participants; bipolar disorder preceded substance use disorder in 18% of the sample; and 21% of the sample reported concurrent onset of substance use and bipolar disorders.

In univariate analyses, adolescents with substance use disorder were significantly associated with a greater prevalence of conduct disorder (P =.02) and oppositional defiant disorder (P =.01) compared with adolescents without substance use disorder. Participants with substance use disorder also reported a greater number of stressful life events (P =.01) and assault of others (P =.03); this behavior was associated with greater self-reported impulsivity and parent-reported anger and depression. In multivariate analyses, substance use disorder was associated with specific variables, including panic disorder (odds ratio [OR] 8.45; 95% CI, 1.64-43.43; P =.01) and oppositional defiant disorder (OR 4.97; 95% CI, 1.22-20.27; P =.02).

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Limitations of the study included the cross-sectional methodology, precluding inferences of causation and a small sample drawn from patients seeking treatment in a tertiary clinical setting and which may not be representative of the larger population. Urine toxicology was not used to optimize diagnostic accuracy, and most of the reported cases of substance use disorder were related to alcohol and cannabis use, which the authors indicate may limit the study, as the results cannot be correlated to other substances, such as cocaine.

Substance use disorder is prevalent among a third of adolescents with bipolar disorder and is associated with high rates of multiple comorbidities, including behavioral disorders, anxiety, violence, impulsivity, and stressful life events. Investigators suggest that targeting specific clinical characteristics and treating associated comorbidities could help guide successful intervention strategies for adolescents with bipolar disorder.


Scavone A, Timmins V, Collins J, et al. Dimensional and categorical correlates of substance use disorders among Canadian adolescents with bipolar disorderJ Can Acad Child Adolesc Psychiatry. 2018; 27(3):159-166.