Comorbidity of Bipolar and Substance Use Disorders

Bipolar disorder and substance use disorder co-occur at very high rates. The high rate is likely due to a complex interaction of biological, social, and psychological factors, and some research suggests that use of substances may be to mitigate symptoms associated with bipolar disorder. Some studies have shown that men with bipolar disorder may be at a higher risk for a substance use disorder than women. The co-occurrence of these disorders leads to poorer treatment outcomes because of higher rates of suicidality, poor treatment adherence, lower quality of life, and more frequent relapse. This population deserves special treatment consideration.

Psychopharmacological Treatments for Bipolar Disorder

The discovery of lithium in 1946 led to a revolution in the management of bipolar disorder as well as other psychiatric conditions. Since that time and especially in the past 20 years, treatment options for bipolar disorder have progressively advanced such that a modern practitioner has a number of evidence-based options to manage the illness. However, the evidence is strongest in adults for acute mania and weakens in other mood states and in youth. Nonetheless, based on the available evidence, this chapter provides recommendations for first-, second-, and third-line pharmacological treatments for bipolar illness to guide clinicians. Additionally, specific considerations for the various medications are reviewed. Suggestions are provided for both adults and youth.

Genetics of Bipolar Disorder

An individual’s genetic makeup has the power to inform medical practice and shape disease prevention, diagnosis, and treatment to improve lifelong outcomes. Genetics has integrated into some aspects of general medicine; however, there has been less success in incorporating genetics into psychiatry. This chapter discusses the genetics of bipolar disorder. As revealed from family, twin, and adoption studies, bipolar disorder is highly heritable, with estimates suggesting the disorder coincides with the highest heritability compared with other psychiatric disorders. While association studies have identified genes of interest that may contribute to risk for the disorder, these studies have been difficult to replicate, and genes identified have shown small effect sizes on their own. More recent approaches to studying polygenic risk and epigenetics modifications of the genome are starting to be applied to bipolar disorder. Early findings utilizing these approaches are discussed. Additionally, this chapter discusses emerging work suggesting genetic associations that may cross diagnostic boundaries in psychiatry and genetic endophenotypes that may one day be incorporated into clinical practice for improving prediction, diagnosis, and treatment of bipolar disorder. While more work is needed to understand the genetics of bipolar disorder and ways to integrate genetics into clinical practice, there is hope on the horizon, and familial information can already guide clinical practice.

Cognitive Behavioral Models of Emotional Dysregulation in Bipolar Disorder

This chapter provides a characterization of cognitive impairment in bipolar disorder and how emotions affect cognition and lead to cognitive biases. The Behavioral Approach System and Interactive Cognitive Model of bipolar disorder are reviewed, along with the newer Interactive Influence Model of Emotion and Cognition, which holds promise in future applications to mood disorders. These models provide a framework for the development and expansion of neurobiological models and psychotherapeutic interventions for bipolar disorder. The authors conclude by noting that, while models of bipolar disorder still need to be expanded to account for cognitive and behavioral influences beyond simple correlations with symptom outcomes, their importance is clearly demonstrated in the development of cognitive behavioral therapies, cognitive remediation therapies, and mindfulness-based cognitive therapies for bipolar disorder. The ability to test the efficacy of these, and other, cognitive behavioral therapeutics in controlled trials based on the predictions of well-characterized models of bipolar disorder will undoubtedly lead to advances in patient care.

Comorbidity of Bipolar Disorder and Medical Disorders

Much of the excess mortality in bipolar disorder can be attributed to medical comorbidities, particularly cardiometabolic disorders. This observation has been noted for more than a century. The proportion of excess mortality attributable to cardiovascular disease has increased in recent years. In addition to mortality, there are increased cardiovascular risk factors in bipolar disorder across the life span. The prevalence of these comorbidities is thought to be elevated by aberrations in particular biological pathways, including inflammation, oxidative stress, and neurotrophic factors. Medical comorbidities significantly affect the lives of patients with bipolar disorder in the form of decreased treatment response, increased symptom severity, and increased mortality risk. To successfully ameliorate the negative impacts of medical comorbidities on patients with bipolar disorder, an integrated emphasis on cardiometabolic health alongside mental health is warranted, including behavioral, pharmacological, and systems-related approaches.

Course of Bipolar Disorders

Bipolar disorder is a lifelong condition in most individuals, with a complex and dynamic course of illness that consists of recurrent affective episodes complicated by other psychiatric and behavioral symptoms. Before illness onset, at-risk individuals demonstrate nonspecific psychiatric symptoms that evolve into, usually, depressive episodes and ultimately mania or hypomania during adolescence. Recovery after a first manic episode is typical, but recurrences are common, and with more episodes, the risk for recurrences increases. A number of clinical factors are associated with recurrences, including co-occurring psychiatric and medical problems. Suicide is a major concern in the course of illness, so understanding risk factors may help mollify the likelihood of this outcome. Similarly, cardiovascular disease rates are elevated and associated with premature death. This chapter provides a review of the factors affecting and associated with bipolar disorder across the life span.

A Programmatic Approach to Treatment

Bipolar disorder is a complex, dynamic illness that affects mood, cognition, and psychosocial function across a wide range of behaviors. A myriad of symptoms wax and wane, causing distress and confusion. Functional recovery is often slow, and every recurrence creates setbacks that accumulate, potentially creating long-term disability. This complexity requires an integrated treatment approach that incorporates multiple modalities, from psychopharmacological to psychosocial, in order to maximally benefit individuals suffering from bipolar disorder. With a comprehensive care plan, most individuals with bipolar disorder will lead successful lives. An integrated practice unit specialized in treating bipolar disorder in the form of a 6-week cycle is discussed as one example of such an approach.

Assessment Tools

Bipolar disorders are difficult to diagnose and treat, despite their global prevalence and pervasiveness. With the proper tools, however, clinicians and researchers alike are able to detect bipolar disorders in their patients and establish the proper treatment plans. Knowing the prevalence of bipolar disorders and other common diagnoses in a specific setting, gathering predictive information before the first visit, and screening patients with efficient, low-cost assessment options are a few of the ways that clinicians can be better prepared to detect bipolar disorders in their patients. Further, assessment should not halt once a diagnosis is established; brief, recurring measures to collect data about a patient’s current state throughout treatment offer important information about symptoms, progress, and how a treatment plan can be tailored to meet a client’s ongoing needs. This chapter equips clinicians and researchers with the tools to confidently diagnose their patients with bipolar disorders, suggesting tips to establish diagnostic hypotheses as well as specific assessments for both adults and youths for whom the diagnosis seems likely. Technology in particular offers the opportunity to access low-cost assessment options and administer ongoing measures to ensure that clinicians continue to meet their patients’ needs throughout the treatment process.

Integrative Medicine and Lifestyle Management in the Treatment of Bipolar Disorder

The circadian disruption associated with bipolar disorder and the success of social rhythm therapies in ameliorating distress and improving functioning make it clear that “healthy habits”—sufficient sleep, nutritious eating, and plentiful exercise—are important components of successful outcomes for persons with bipolar spectrum disorders. Additionally, evidence for the benefits of nutritional interventions and phototherapy is growing. Finally, mood charting and other self-help strategies are increasingly recognized as important components of recovery. Given that 20 to 50% of adults with bipolar disorder use some form of nonconventional therapy, it is important for mental health providers of all disciplines to be familiar with the literature in this area. This chapter provides an overview of integrative interventions and reviews evidence supporting their use.

Neurobiology of Bipolar Disorder

As frequently occurs in science, progress made on the neurobiology of bipolar disorder has followed a nonlinear course that often revisits deserted concepts. The neurobiological blueprint of bipolar disorder continues to unfold from a neurotransmitter-based hypothesis to include peptides and intracellular signaling pathways, and into a broader neuronal network perspective that involves cortical and subcortical regions in the brain. Moreover, new evidence makes it increasingly clear that the mechanisms of disease in bipolar disorder extend beyond the brain, providing plausible “missing links” between psychopathology and the elevated medical comorbidities. This is illustrated by the expanding role of the circadian system in bipolar disorder and the emerging evidence on the contribution of spinal afferents to the construct of mood, portraying that brain–body communication pathways are relevant to the pathophysiology of bipolar disorder. This chapter provides an overview of the current and emerging neurobiological frameworks for bipolar disorder.