Alcohol and Substance Use Disorders

Substance and alcohol abuse present a clinical challenge in the treatment of any psychiatric illness. For bipolar patients, a comorbid alcohol use disorder (AUD) or substance use disorder (SUD) not only may complicate treatment and illness course (Feinman and Dunner 1996) but also may place the patient at greater risk for suicidality. Suicide risk in alcohol or substance abusing bipolar patients has been found to be up to twice that of bipolar patients without an AUD (Morrison 1974; Tondo et al. 1999).

More recent studies of comorbid SUDs or AUDs in bipolar patients have also demonstrated an increase in suicide risk associated with substance and alcohol abuse (Dalton et al. 2003; Hoyer et al. 2004). SUD and AUD comorbidity may be particularly damaging in bipolar disorder and may reveal a unique factor of the disorder. The added suicide risk observed in bipolar patients with comorbid SUDs or AUDs may not be present in unipolar patients (Hoyer et al. 2004). Comparisons of suicide risk associated with comorbid AUDs versus that associated with co-morbid SUDs have not yielded a clear difference. Dalton et al. (2003) demonstrated that drug use may present greater risk than alcohol use, with a twofold increase in suicide risk for bipolar patients with comor-bid substance abuse. However, Tondo et al. (1999) did not find a similar difference. Additionally, they suggested that not all substances are associated with greater suicidality; they specify polysubstance abuse, heroin, cocaine, and tobacco abuse as additional risk factors, but note that marijuana and hallucinogens may not be as dangerous.

Because early age at illness onset has also been identified as a risk factor for suicidality in bipolar disorder, young bipolar patients with co-morbid alcohol or substance use disorders may form a group that is in particular need of vigilant observation and aggressive clinical intervention. In a longitudinal, case-controlled study of 96 bipolar adolescents, Kelly, Cornelius, and Lynch (2002) demonstrate that those with comor-bid SUDs are at greater risk for suicidality. A comorbid diagnosis of conduct disorder (which diagnostically shares several characteristics with both a SUD and a bipolar diagnosis) is an additional predictor.

Nicotine use and dependence is increasingly recognized as being associated with suicide in bipolar disorder. In a cohort of subjects with unipolar and bipolar disorders followed prospectively after an episode of major depression, smoking was amongst the three most powerful predictors of a future suicide attempt, and was additive with the other two: a history of a suicide attempt and severity of depressive symptoms (Oquendo et al. 2004). This association between nicotine use and suicide is present across several major mental illnesses, and may be related to lower brain serotonin function (Malone et al. 2003). The direction of the relationship between smoking and suicide and whether it is causal is unknown. It would be important to understand whether nicotine use predisposes patients to more dire outcomes, because early intervention to targeted at-risk youth may improve the course of mood disorders.

It is clear that AUDs and SUDs complicate treatment; however, they may also be an indication of a more complex illness course, illness severity, and underlying risk factors for suicidality. Potentially, these underlying difficulties may lead the patient to abuse alcohol or substances and to contemplate suicide. In this manner, comorbid SUDs and AUDs may be perceived as markers of severity in the same vein as age at onset. Although the direction of causality cannot possibly be demonstrated, SUDs and AUDs are clearly associated with increased suicide risk and require added vigilance in clinical care.

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