ADOLESCENTS WITH BIPOLAR DISORDER ARE AT A HUGELY INCREASED RISK OF SUBSTANCE ABUSE COMPARED TO THE GENERAL POPULATION.

Most substance abuse follows the onset of bipolar disorder, not vice versa.  A good interview is abetter way of assessing substance use than urine toxicology screens.

Ben Goldstein found that on 8 year follow up, 32% of bipolaradolescents developed a substance abuse disorder (SUD).  Those treated with antimanic agents were muchless likely to develop SUD.   Childrenwith persisting emotion dysregulation were: 1) more likely to develop SUD; 2)more likely to start earlier; and 3) have a more severe form of combined(multiple) SUD.

MORAL:  Treat bipolar disorder psychopathology in adolescents well and help them avoid SUD.

Wilen suggested the following Treatment paradigm.

1.       Aggressive psychoeducation for parents and theirchild about SUD, and this should start before age 12.  

2.       Engage in close monitoring of mood and substanceuse.  

3.       Use groups, CBT and DBT, and motivationalenhancement.  That is increased interest and interaction about what is not going well, how can things be helped to go better, do you want to get back to sports or the ability to drive a car again?  How can we help get you there?

     4.  Clinicians should work with the parents even if the child does not come in the beginning.

There also are some pharmacological approaches (beyond thegoal of achieving good mood regulation. Geller et al 1998 found that lithium helped decrease substance use.

DelBello et al 2011 found that quetiapine plus topiramate was more helpful in decreasing marijuana use than quetiapine plus placebo.

The supplement N-acetylcysteine (NAC) is useful for avariety of SUD and addictions include smoking, alcohol, marijuana, cocaine, andheroin. (See our review in Issue #1 of 2010 for a discussion of possible mechanisms of these effects.  Safety in children has been demonstrated in the Fung et at study in those with autism ages 4to 17.  Positive effects on depression have also been reported in adults with bipolar disorder, substantially beating placebo after @ 3 months).

BOTTOM LINE: Bipolar disorder in an adolescent is a medical emergency and multimodal efforts for treating the illness well and heading off the development of a SUD may be lifesaving.   PSYCHOEDUCATION IS A MUST.  Bipolar disorder and SUD in combination is like a metastatic malignancy; all the stops must be pulled out in order to slow it or cure it.

‍