Dr. Pary is a psychiatrist at Louisville VAMC in Kentucky. Dr. Patel is a psychiatry resident, Dr. Lippmann is a professor, and Dr. Pary is an associate professor, all at the University of Louisville, Kentucky.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations— including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Substance use disorders are associated with increased suicidal behavior in people with a bipolar disorder. The risk of attempted suicide is about double for these patients relative to bipolar patients who do not abuse alcohol. 22 Of those who abuse drugs, 14% to 16% complete suicide. 23
Psychotherapy
Reportedly, integrated cognitive behavioral therapy (CBT) provided better substance abuse outcomes compared with 12-step programs. 24 There also was less substance abuse within the year after CBT. Integrated psychosocial treatment for patients with a mood disorder and substance abuse should involve simultaneous treatment of the 2 conditions. A sequential approach addresses the primary concern and subsequently treats the comorbid disorder, whereas a parallel approach manages both at the same time but in different surroundings. In both approaches, conflicting therapeutic ideologies are a potential difficulty. Given the multiple treatment locations and separate appointments, scheduling problems are an additional difficulty. Coexisting illnesses also are important to consider in the clinical treatment for bipolar patients. As with individual treatments, group therapies take either a sequential approach (more acute disorder treated first) or a parallel approach (disorders treated simultaneously but in separate settings).
Integrated group therapy (IGT) considers patients as having a single diagnosis, focuses on commonalities between relapse and recovery, and reviews the relationship between both conditions. One study compared IGT and treatment as usual in subjects with comorbid bipolar and AUD. 25 The IGT group evidenced fewer days of alcohol use. Other research compared IGT with group drug treatment and found that IGT subjects were more likely to remain abstinent. 26 This type of psychotherapy showed promise in a meta-analysis of integrated treatment in patients with depression and SUDs. 26
Compared with placebo, sertraline/CBT combined treatment reduced alcohol consumption on drinking days. 27 This combination was effective in reducing depression, especially in females.
Acceptance and commitment therapy (ACT) combines mindfulness and behavioral change to increase psychological flexibility. The goal in ACT is for patients to become more accepting of their unpleasant feelings. In a study of alcohol abusers with affective disorders, those treated with ACT, compared with controls, had higher abstinence rates and lower depression scores. 28
Phamacotherapy and Bipolar Disorder
Even when bipolar symptoms were resolved with use of mood-stabilizing medications, usually some alcohol use continued, though no association was found between bipolar disorder and AUDs. 29 With patients’ illness severity and ethanol consumption rated weekly over 7 years, no temporal correlation was found between drinking alcohol and bipolar symptoms.
Similarly, in a study, relief of depressive bipolar symptoms did not result in less frequent alcohol relapse. 30 One hundred fifteen outpatients with bipolar disorder and AUD were randomly assigned to either 12 weeks of quetiapine therapy or placebo. Patients in the quetiapine group experienced significant improvement in mood, but sobriety was not enhanced.
Two studies indicated trends of reduced drinking with use of prescribed alcohol-deterrent drugs. An investigation that compared naltrexone with placebo did not reach statistical significance, but naltrexone was reasonably effective in reducing alcohol consumption and craving. 31 A report on patients with bipolar disorder treated with acamprosate also did not identify any significant differences in alcohol drinking prognosis. 32 Nevertheless, acamprosate was well tolerated and seemed to confer some clinical benefit.
