Review articlePrevalence of comorbid bipolar and substance use disorders in clinical settings, 1990–2015: Systematic review and meta-analysis
Introduction
It is well known that substance use disorders (SUDs) are over-represented in individuals with bipolar disorder (BD) as shown by the epidemiological catchment area (ECA) study (Regier et al., 1990). This raises the question, what is the link between SUD and bipolar illness? One line of evidence suggests those predisposed to BD may experiment with illicit substances more than others (Goldberg, 2001). For some, substance use may precede or follow the onset of BD while in others, substances are used as a means of self-medication that can predispose or facilitate early onset of an affective disorder (Goldstein and Bukstein, 2010). Thus, substance use is enmeshed with BD and appears to be both a cause and a consequence of early onset (Bally et al., 2014, Gibbs et al., 2015).
Substance use further complicates the clinical picture by interfering with the trajectory and destabilising the course of bipolar illness - specifically increasing the frequency of episodes and number of hospitalisations, and may also interfere with mood-stabilising effects of drugs by reducing their efficacy or requiring higher doses to achieve their effectiveness (Levin and Hennessy, 2004, Rakofsky and Dunlop, 2013, Salloum and Thase, 2000). Comorbid SUDs may also contribute to more varied and complex clinical presentations in BD, increase relapse rates, worsen depressive features and increase the frequency of self-harm and suicide attempts in BD (Baldassano, 2006, Levin and Hennessy, 2004). Thus, a better understanding of the factors that lead to co-occurrence is needed along with the development of interventions that reduce the likelihood of those with BD developing substance dependence. This will be informed by initially mapping accurately the prevalence of comorbid SUDs and BD.
Therefore, the principal objective of this systematic review is to report prevalence rates of SUDs comorbid with BP. We achieve this by combining the findings of studies conducted between 1990 and 2015 in treatment settings, involving large follow-up cohorts and national case registries. This time period was selected because it includes the seminal ECA study (Regier et al., 1990) and we have used it in two previous systematic reviews (Lai et al., 2015) Hunt et al., 2016 – facilitating direct comparisons. Our endeavour was to collate prevalence rates based on type of substance used, type of SUD (abuse, use, or dependence) where the study was carried out (recruited as inpatient, out-patient/community or mix) based on studies using large cohorts or from studies using consecutive admissions or random samples of outpatients or community-based subjects with BD; e.g., bipolar I (BD-I), bipolar II (BD-II) disorder.
We determined the prevalence rates and odds ratios (ORs) of SUDs between men and women and between BD-I and BD-II disorders for various SUDs using meta-analysis. We also compared studies that reported the effect of SUDs on age of onset and number of hospitalisations for those with or without a lifetime SUD and BD.
Section snippets
Methods
Methods were based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines (Liberati et al., 2009, Moher et al., 2009) and guidelines for Meta-Analysis for Observational Studies in Epidemiology (MOOSE) (Stroup et al., 2000).
Search findings
A total of 1612 titles were found after removal of duplicates from electronic searches (Fig. 1). Among them 1208 articles were judged not relevant on the basis of titles by two independent reviewers leaving 404 articles to be examined in the next round. Of the 404 articles, 253 articles were judged by two independent reviewers not relevant by reviewing the abstract (n=20) or full text (n=233) and the remaining 151 articles were read in detail to assess inclusion/exclusion criteria and if they
Discussion
This systematic review and meta-analysis found strong associations between co-occurring SUDs and bipolar illness in clinical settings and large BD cohorts. The SUDs with the highest prevalence were alcohol use (mean 30%, Fig. 2) followed by cannabis use (mean 20%) or any drug use disorder (mean 17%). The high prevalence of cocaine (11%) and amphetamine reported in some studies is cause for concern given the activating effects of these drugs and the likelihood of precipitating a treatment
Conclusion
This systematic review of studies conducted using clinical samples over the last 25 years shows comorbidity between SUDs and bipolar disorders are highly prevalent in hospital- and community-based samples. The meta-analysis revealed that males had higher risks of having a SUD compared to females that was similar for alcohol as well as cannabis use disorders. The prevalence of SUDs was similar between groups of patients with BD-I and BD-II. Those with a SUD had on average an earlier onset and
Authors disclosures
Authors have nothing to disclose.
Role of funding source
No financial support was received for this study.
Contributors
GH and HL were responsible for the development of the research question, article searching, and interpretation of the data. HL, GH and MC were responsible for screening articles and data extraction. GH and MC conducted the assessment of bias. GH performed the meta-analysis, produced the figures. GH and GM wrote the draft manuscript. GM and TS were responsible for the development of the research question and critical revision of the manuscript. All authors have reviewed and approved the final
Conflict of Interest
No conflict declared.
Acknowledgements
We thank members of the library staff at Concord Hospital for assisting with retrieval of full text articles.
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