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Alcoholism and Mood Disorders
Several studies have reported an association between alcoholism and mood disorders.
To date, there have been two large epidemiological studies of psychiatric disorders:
the National Institute of Mental Health's Epidemiologic Catchment Area (ECA)
study (Regier et al. 1990) and the National Comorbidity Survey (NCS) (Kessler
et al. 1996). The ECA study (Regier et al. 1990) revealed that 60.7 percent
of people with bipolar I disorder had a lifetime diagnosis of a substance use
disorder (i.e., an alcohol or other drug use disorder); 46.2 percent of those
with bipolar I disorder had an alcohol use disorder; and 40.7 percent had a
drug abuse or dependence diagnosis (the percentages of people with alcohol
use disorders and drug abuse disorders do not add to 100 due to overlap). Forty–eight
percent of people with bipolar II disorder had a substance use disorder, 39.2
percent had an alcohol use disorder, and 21 percent had a drug abuse or dependence
diagnosis (these figures reflect overlap, as above.) As shown in the table,
alcohol dependence was twice as likely to co–occur in people with bipolar
spectrum disorders than in those with unipolar depression (i.e., depression
without mania). It is also noteworthy that bipolar disorder was more likely
to occur with alcohol dependence than with alcohol abuse (see table). As part
of the ECA study, Helzer and Przybeck (1988) found that mania (i.e., bipolar
I disorder) and alcohol use disorders are far more likely to occur together
(i.e., 6.2 times more likely) than would be expected by chance. Of all other
psychiatric diagnoses investigated in this study, only antisocial personality
disorder was more likely to be related to alcoholism than mania. The findings
of the NCS with regard to the comorbidity of mood disorders and alcoholism
were very similar.
Possible Explanations For Comorbidity
Although researchers have proposed explanations for the strong association
between alcoholism and bipolar disorder, the exact relationship between these
disorders is not well understood. One proposed explanation is that certain
psychiatric disorders (such as bipolar disorder) may be risk factors for
substance use. Alternatively, symptoms of bipolar disorder may emerge during
the course of chronic alcohol intoxication or withdrawal. For example, alcohol
withdrawal may trigger bipolar symptoms. Still other studies have suggested
that people with bipolar disorder may use alcohol during manic episodes in
an attempt at self–medication, either to prolong their pleasurable
state or to sedate the agitation of mania. Finally, other researchers have
suggested that alcohol use and withdrawal may affect the same brain chemicals
(i.e., neurotransmitters) involved in bipolar illness, thereby allowing one
disorder to change the clinical course of the other. In other words, alcohol
use or withdrawal may "prompt" bipolar disorder symptoms (Tohen
et al. 1998). It remains unclear which if any of these potential mechanisms
is responsible for the strong association between alcoholism and bipolar
disorder. It is very likely that this relationship is not simply a reflection
of cause and effect but rather that it is complex and bidirectional. Genetic
factors may also play a role, as described below.
Familial Risk of Bipolar Disorder and Alcoholism
The role of genetic factors in psychiatric disorders has received much attention
recently. Some evidence is available to support the possibility of familial
transmission of both bipolar disorder and alcoholism (Merikangas and Gelernter
1990; Berrettini et al. 1997). Common genetic factors may play a role in
the development of this comorbidity, but this relationship is complex (Tohen
et al. 1998). Preisig and colleagues (2001) conducted a family study of mood
disorders and alcoholism by evaluating 226 people with alcoholism with and
without a mood disorder as well as family members of those people. The researchers
found that there was a greater familial association between alcoholism and
bipolar disorder (odds ratio of 14.5) than between alcoholism and unipolar
depression (odds ratio of 1.7). These findings have implications for prevention
and treatment. A positive family history of bipolar disorder or alcoholism
is an important risk factor for offspring.
Alcoholism's Effect on Comorbid Bipolar Disorder. A growing
number of studies have shown that substance abuse, including alcoholism, may
worsen the clinical course of bipolar disorder. Sonne and colleagues (1994)
evaluated the course and features of bipolar disorder in patients with and
without a lifetime substance use disorder. They found that compared to non–substance
abusers, substance–abusing bipolar patients were more likely to have
frequent hospitalizations for affective symptoms, earlier onset of bipolar
disorder, more rapid cycling, and more mixed mania (the latter two considered
to be the most severe, treatment–resistant forms of bipolar disorder).
Keller and colleagues (1986) compared patients who had pure depression or pure
mania with patients who had mixed or rapid cycling bipolar disorder and found
that a higher percentage of patients with mixed or rapid cycling bipolar disorder
had concurrent alcoholism (13 percent) and that these patients had a slower
recovery from the bipolar disorder. Although this association does not necessarily
indicate that alcoholism worsens bipolar symptoms, it does point out the relationship
between them. A comparison of patients with bipolar disorder and a coexisting
substance use disorder with others who had bipolar disorder alone found that
those with comorbid substance use disorders had an earlier age of onset for
their mood disorder, were more likely to be male, had more comorbid psychiatric
disorders in addition to bipolar disorder, and were significantly more likely
to have mixed mania at the time of interview (Sonne and Brady 1999b).
Although research suggests that alcohol and other drug abuse may worsen the
course of bipolar disorder, some data indicate that patients with bipolar disorder
and alcoholism do better in substance abuse treatment than alcoholic patients
with other mood disorders. O'Sullivan and colleagues (1988) found that alcoholics
with bipolar disorder functioned better during a 2–year followup period
than did primary alcoholics (i.e., those without comorbid mood disorders) or
alcoholics with unipolar depression. This suggests that bipolar patients may
use alcohol primarily as a means to medicate their affective symptoms, and
if their bipolar symptoms are adequately treated, they are able to stop abusing
alcohol. Hasin and colleagues (1989) found that patients with bipolar II disorder
were likely to have an earlier remission from alcoholism compared with patients
with schizoaffective disorder or bipolar I disorder. Researchers have also
proposed that the presence of mania may precipitate or exacerbate alcoholism
(Hasin et al. 1985).
In conclusion, it appears that alcoholism may adversely affect
the course and prognosis of bipolar disorder, leading to more frequent hospitalizations.
In addition, patients with more treatment–resistant symptoms (i.e., rapid
cycling, mixed mania) are more likely to have comorbid alcoholism than patients
with less severe bipolar symptoms. If left untreated, alcohol dependence and
withdrawal are likely to worsen mood symptoms, thereby forming a vicious cycle
of alcohol use and mood instability. However, some data indicate that with
effective treatment of mood symptoms, patients with bipolar disorder can have
remission of their alcoholism.
Order of Onset
An important factor in studying the influence of one comorbid disorder on another
is the order of onset of the two disorders. A mood disorder that occurs prior
to the onset of another psychiatric disorder is called a primary affective
disorder. Secondary affective disorders occur after the onset of other psychiatric
disorders. Feinman and Dunner (1996) conducted a retrospective chart review
of three groups of patients: Those with primary bipolar disorder with
no history of substance abuse (primary group), with 103 patients Those with
primary bipolar disorder complicated by substance abuse, which began after
the onset of bipolar disorder (complicated group), with 35 patients Those
with bipolar disorder that came after the onset of substance abuse (secondary
group), with 50 patients. The researchers found that patients in the complicated
group had a significantly earlier age of onset of bipolar disorder than the
other groups. They also found that the complicated and secondary groups had
higher rates of suicide attempts than did the primary group. Preisig and
colleagues (2001) also reported that the onset of bipolar disorder tended
to precede that of alcoholism. They concluded that this finding is in accordance
with results of clinical studies that suggest alcoholism is often a complication
of bipolar disorder rather than a risk factor for it. In a 5–year
follow-up study, Winokur and colleagues (1995) evaluated a group of bipolar
patients with and without alcoholism. In the alcoholic patients, bipolar
illness and alcoholism were categorized as being either primary or secondary.
The patients with primary alcoholism had significantly fewer episodes of
mood disorder at followup, which may suggest that these patients had a less
severe form of bipolar illness. Thus, there is growing evidence that the
presence of a concomitant alcohol use disorder may adversely affect the course
of bipolar disorder, and the order of onset of the two disorders has prognostic
implications. Specifically, bipolar patients with secondary alcoholism may
be better able to stop drinking if their bipolar illness is adequately treated;
and, conversely, bipolar patients with primary alcoholism (alcoholism occurs
first) may be better able to control their mood symptoms if they are able
to stop drinking.
Comorbidity and Diagnostic Issues
Almost every alcoholic will report having mood swings. It is very important
to distinguish these alcohol–induced symptoms from actual bipolar disorder.
However, diagnosing bipolar disorder in the face of alcohol abuse can be
difficult because alcohol use and withdrawal, particularly with chronic use,
can mimic nearly any psychiatric disorder. Alcohol intoxication can produce
a syndrome indistinguishable from mania or hypomania, characterized by euphoria,
increased energy, decreased appetite, grandiosity, and sometimes paranoia.
However, these alcohol–induced manic symptoms generally occur only
during active alcohol intoxication, which makes them fairly easy to differentiate
from mania associated with bipolar I disorder. Still, alcoholic patients
going through alcohol withdrawal may appear to have depression. Depression
is a key symptom of withdrawal from several substances of abuse, and studies
have demonstrated that symptoms of withdrawal–related depression may
persist for 2 to 4 weeks (Brown and Schuckit 1988). Because of this phenomenon,
it is likely that observation during lengthier periods of abstinence (i.e.,
continued observation following the withdrawal stage) is important for the
diagnosis of depression as compared with mania.
Bipolar II disorder and cyclothymia are even more difficult to reliably diagnose
because of the more subtle nature of the psychiatric symptoms. Because of the
diagnostic difficulties, it may be that this diagnostic group is often overlooked.
Although these less severe forms of bipolar disorder may not be as disruptive
as bipolar I disorder, it is still important to recognize and treat them in
order to break the potential cycle of mood problems leading to substance use,
which leads to a worsening of mood symptoms, which in turn may worsen the substance
abuse, leading to even worse mood symptoms.
As a general rule, it seems appropriate to diagnose bipolar disorder if the
symptoms clearly occur before the onset of the alcoholism or if they persist
during periods of sustained abstinence. The adequate amount of abstinence for
diagnostic purposes has not been clearly defined. Family history and severity
of symptoms should also factor into diagnostic considerations. Given that bipolar
disorder and substance abuse co–occur so frequently, it also makes sense
to screen for substance abuse in people seeking treatment for bipolar disorder.
Treatment Of Comorbid Bipolar Disorder And Alcoholism
Psychosocial interventions have often been considered the mainstays of treatment
for alcoholism and other substance use disorders. Several studies have demonstrated
success with cognitive behavioral therapy in treating alcoholism (Project
MATCH Research Group 1998). Many of the principles of cognitive behavioral
therapy are commonly applied in the treatment of both mood disorders and
alcoholism. Weiss and colleagues (1999) have developed a relapse prevention
group therapy using cognitive behavioral therapy techniques for treating
patients with comorbid bipolar disorder and substance use disorder. This
therapy uses an integrated approach; participants discuss topics that are
relevant to both disorders, such as insomnia, emphasizing common aspects
of recovery and relapse.
Interestingly, the same investigators (Weiss et al. 2000) evaluated the progress
of a group of substance abusers with comorbid bipolar spectrum disorders who
were pursuing psychosocial treatment independently, rather than as a result
of being assigned to it by the researchers. Potential study participants were
told that the investigators were interested in better understanding the relationship
between bipolar disorder and substance abuse and therefore wished to see them
monthly for 6 months. The investigators found that psychotherapy and Alcoholics
Anonymous (AA) attendance decreased over time and that substance use tended
to increase from month 1 to month 6. The focus of the study participants' psychotherapy
also changed, with less emphasis on their specific disorders and more emphasis
on family, school, work, and other personal issues. Although differences in
mood or substance use between months 1 and 6 were not statistically significant,
there was a trend for increased substance use. If the study participants had
continued with AA and if psychotherapy had continued to focus on bipolar disorder
and alcoholism, the patients' substance use might have improved. Given the
generally poor prognosis associated with bipolar disorder and alcoholism, it
is important to educate patients concerning the relationship between these
two disorders. The authors concluded that the development of dually focused
psychosocial treatments for this population may help improve substance use
and affective outcomes.
Sonne, S., & Brady, K. (2002). Bipolar Disorder and Alcoholism. Alcohol Research & Health, 26(2), 103.
Reflection Exercise #7
The preceding section contained information
about the comorbidity of alcoholism and bipolar disorder. Write
three case study examples regarding how you might use the content of this section
in your practice.
Peer-Reviewed Journal Article References:
Hogarth, L., Hardy, L., Mathew, A. R., & Hitsman, B. (2018). Negative mood-induced alcohol-seeking is greater in young adults who report depression symptoms, drinking to cope, and subjective reactivity. Experimental and Clinical Psychopharmacology, 26(2), 138–146.
Meredith, L. R., Green, R., Grodin, E. N., Chorpita, M., Miotto, K., & Ray, L. A. (2021). Ibudilast moderates the effect of mood on alcohol craving during stress exposure. Experimental and Clinical Psychopharmacology. Advance online publication.
Stevenson, B. L., Dvorak, R. D., Kramer, M. P., Peterson, R. S., Dunn, M. E., Leary, A. V., & Pinto, D. (2019). Within- and between-person associations from mood to alcohol consequences: The mediating role of enhancement and coping drinking motives. Journal of Abnormal Psychology, 128(8), 813–822.
According to Sonne, what differences in symptoms do bipolar clients with comorbid substance-abuse disorders experience? To select and enter your answer go to .