Research reportReasons for substance use in dual diagnosis bipolar disorder and substance use disorders: A qualitative study
Introduction
The lifetime prevalence of alcohol abuse and drug abuse in people with bipolar disorder is known to be three to nine times that of the general population (Regier et al., 1990, Ten Have et al., 2002, Merikangas et al., 2007). Among patients hospitalised for mania or mixed affective episodes, nearly 60% had a lifetime diagnosis of substance use disorder (Cassidy et al., 2001). Negative outcomes have been reported in patients with bipolar disorder and comorbid substance use disorders including suicide (Isometsa, 2005), suicide attempts (Hawton et al., 2005, Simon et al., 2007), poor insight and denial of illness (Salloum and Thase, 2000), and treatment non-adherence (Keck et al., 1998). Therefore patients with dual diagnosis bipolar disorder and substance use disorders form an important group of patients to study from clinical and public health perspectives.
There have been no previous systematic qualitative analyses of substance use in bipolar disorder, and few systematic studies of any design concerning the reasons why patients with bipolar disorder abuse alcohol and illicit drugs. Reasons for substance use in bipolar disorder include the self-medication hypothesis, an attempt by patients to reduce the intensity of their symptoms through alcohol and street drugs (Strakowski and DelBello, 2000, Weiss et al., 2004, Bizzarri et al., 2007a). Strakowski and DelBello (2000) also found some evidence to suggest that substance use may be a symptom or precipitant of bipolar disorder, and that bipolar disorder and substance use disorders may share common risk factors such as impulsivity (Swann et al., 2005), comorbidity with anxiety disorder (Mitchell et al., 2007, Goldstein and Levitt, 2008) or sensation seeking (Bizzarri et al., 2007b). Substance use can be a coping mechanism for managing the early symptoms or prodromes of manic and depressive episodes before the full episode of mania or depression appears (Lam and Wong, 1997, Lam and Wong, 2005).
A clinical approach to tackling the co-occurrence of bipolar disorder and substance use disorders involves motivational interviewing to modify the substance abuse and a formulation of how the reasons for substance use relate to the phase of illness and the person with bipolar disorder (Weiss et al., 2007). An understanding of the patient's perspective is key to therapeutic success because this information can be used both in the formulation of the patient's problems, and to communicate and motivate the patient to change their substance use behaviour. We explored how patients with dual diagnosis bipolar disorder and substance use disorders viewed the relationship between substance use and bipolar disorder in an inductive qualitative study that made no assumptions about the relationship between mood and substance use.
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Study sample
All patients included in the study were adults with a diagnosis of bipolar 1 disorder and current and/or past alcohol or drug abuse or dependence. Inclusion criteria were: 1. a SCID-DSM-IV diagnosis of bipolar disorder (First et al., 1997); 2. a SCID-DSM-IV diagnosis of substance use disorder (First et al., 1997); 3. 18 years of age or older; 4. willing to give written informed consent. Exclusion criteria were: 1. bipolar disorder secondary to an organic cause; 2. a current DSM-IV mood episode
Patterns of substance use in relation to phase of illness
Table 1 shows the clinical and sociodemographic features of the sample. All patients had a history of past DSM-IV alcohol or drug dependence. Six (40%) patients had current DSM-IV alcohol or drug use disorders; only one was abstinent from alcohol and illicit drugs while the remaining eight reported occasional or regular moderate alcohol or drug consumption. Each patient showed a pattern of substance use that varied with their phase of illness (pre-diagnosis, depressive prodrome, manic prodrome,
Discussion
In order to engage patients with dual diagnosis bipolar disorder and substance use disorder into a discussion about the merits and problems of substance use it is important to understand the patient's perspectives, even if they appear misguided to the clinician. The current report explored patients' own reasons for substance use in a sample characterised by the presence of both bipolar disorder and current or past alcohol or other substance use disorder. We employed an inductive approach
Role of funding source
Funding for this study was provided by a grant from Mersey Care NHS Trust. The funding source had no further role in study design, in the collection, analysis and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Mersey Care NHS Trust.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgements
Funding for the study came from the Mersey Care NHS Trust. The work described here forms part of a thesis for a MPhil degree at the University of Liverpool performed by the first author (CH).
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