Elsevier

Journal of Affective Disorders

Volume 206, December 2016, Pages 331-349
Journal of Affective Disorders

Review article
Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990–2015: Systematic review and meta-analysis

https://doi.org/10.1016/j.jad.2016.07.011Get rights and content

Highlights

  • Substance use disorders (SUDs) are highly prevalent in bipolar disorder.

  • Psychostimulant use is cause for concern as misuse may mimic manic symptoms.

  • Males had higher rates of lifetime SUDs compared to females for all substances.

  • Prevalence of SUDs were high in both bipolar I and bipolar II disorders.

  • Those with comorbid SUDs had earlier age of onset and more hospitalisations.

Abstract

Background

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

Methods

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

Results

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

Limitations

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

Conclusions

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

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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