Managing Comorbid Bipolar Disorder and Alcohol Use Disorder: Clinical Challenges and Conundrums

Dr Raby recommended the CAGE questionnaire10 as “very valuable” in determining the presence, nature, and degree of AUD. He noted that an especially useful question is, “Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?”

“If a person needs to drink first thing in the morning, he or she is at risk of withdrawal and DTs [delirium tremens] without the drink. This risk has to be managed.”

Other useful rating scales include the Young Mania Rating Scale, the Bech-Rafaelsen Mania Scale, the symptom checklist-90 (SCL-90), the Mood Disorder Questionnaire, and the Alcohol Use Disorders Identification Test.4

Pharmacotherapeutic Approaches

Both experts emphasized that it is essential to treat BD and AUD simultaneously rather than sequentially. A person in an acute state of intoxication needs to be stabilized first and then, “while the person is in a safe setting, such as a detox facility, this is the time to initiate or optimize medication for BD and also start the person on medication to prevent relapse to alcohol use,” Dr Salloum said.

“Unfortunately, the research base supporting pharmacologic interventions in this population is very limited,” Dr Salloum remarked.

Valproate has shown some utility in reducing alcohol consumption.4 Naltrexone and disulfiram have been helpful in reducing alcohol use and relapse in patients with BD.4

According to Dr Raby, investigating the patient’s eating patterns can help inform a medication strategy.

“Patients who drink and do not eat have a much higher risk of medication complications, and the longer the pattern has persisted, the greater the risk of psychiatric and neurological complications.”

A preference for high-calorie, high-carbohydrate foods, heavy drinking, and a family history of alcoholism “all provide important clues to medication response, especially to naltrexone,” he said.

However, in a patient who is restless, anxious, irritable, and insomniac, Dr Raby prefers to use disulfiram and lithium together.

“In my experience, the person begins to feel calmer within a week, the racing thoughts begin to slow down, alertness sets in, and the person is able to concentrate better,” he reported.

However, the approach has the risk of causing serious adverse effects in a patient not fully committed to abstinence. “I warn the patient that there are major risks in using alcohol while taking disulfiram. If I sense a lack of commitment, I would use naltrexone instead.”

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He noted that gabapentin, levetiracetam, and carbamazepine can be helpful with withdrawal.11-13 In particular, gabapentin has been shown to reduce craving, promote longer abstinence, and combine well with naltrexone.11,12

Dr Salloum recounted that his group compared valproate with placebo as an add-on treatment to lithium in 59 patients with diagnoses of BD-1 and AUD. The valproate group had a significantly lower proportion of heavy drinking days than the placebo group, and higher valproate serum concentration significantly correlated with improved alcohol use outcomes.14

Nonpharmacologic Approaches

Pharmacotherapy should be accompanied by psychosocial approaches, according to both experts.

Dr Salloum recommends “integrated care” that ideally includes treating BD and AUD in the same setting. In the absence of this model, a multidisciplinary approach combining pharmacotherapy and effective psychotherapies would be appropriate.

Approaches that have been studied include integrated group therapy (IGT), which combines therapeutic interventions that address BD and drug counseling principles of SUDs.15,16 Early recovery adherence therapy (ERAT) incorporates motivational enhancement therapy, relapse prevention, and educational approaches.17 An intervention incorporating motivational interviewing and cognitive behavioral therapy has been shown helpful in reducing use of drugs or alcohol and improving mood symptoms and impulsivity in this population.18

Dr Raby noted that Alcoholics Anonymous (AA) can be helpful for some patients. Self-Management and Recovery Training (SMART), a support program for people with addictions and behavioral disorders, is an alternative for people who do not find AA to be helpful.

Dr Salloum also recommends the Depression and Bipolar Support Alliance as a helpful self-help organization.

Create a Safe, Nonjudgmental Environment

“Some psychiatrists and other practitioners do not want to treat people until they become sober,” Dr Salloum observed. He attributed the reluctance to stigma, fear, or lack of experience in treating addictive disorders.

 “There is stigma in mental illness and stigma in substance abuse, so people who have both are doubly stigmatized and vulnerable,” he said.

He encouraged practitioners to create a safe environment and a strong therapeutic relationship, and to “treat people with dignity, nonjudgmentalism, and open-mindedness, using shared decision-making as much as possible.”


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