Review articleComorbidity of bipolar and substance use disorders in national surveys of general populations, 1990–2015: Systematic review and meta-analysis
Introduction
People with a bipolar disorder (BD) have high, if not one of the highest, rates of substance use disorders (SUDs) of all the mental health disorders (Kessler, 2004, Levin and Hennessy, 2004, Regier et al., 1990). Current reasoning to explain the high rates of comorbidity in BD (as well as other mental health disorders) are that one mental disorder may directly influence another, such as heavy alcohol use may produce depression in those who are alcohol dependent (Cerda et al., 2008, Hall et al., 2009). Comorbidity may also arise indirectly for instance when substances are used for self-medication or for relieving mental distress associated with a psychiatric disorder – leading in some cases to dependence (Goldstein and Bukstein, 2010). Other possibilities include developmental, socioeconomic factors and genetic factors resulting from poverty, trauma or inherited traits within the family (Cerda et al., 2008, Farren et al., 2012, Mueser et al., 1998, Raimo and Schuckit, 1998). The high comorbidity rates may also be due to cultural or social reasons such as increased access and opportunity to use illicit drugs in the community (Liang et al., 2011). Recent research indicates that cannabis use is highly prevalent in BD and may trigger or induce manic symptoms resulting in earlier age of onset of bipolar illness (Bally et al., 2014, Gibbs et al., 2015, Leweke and Koethe, 2008). Identification of those at risk of developing a SUD at an early age is important because the onset of BD often precedes the development of a SUD, thus, there is a narrow window of opportunity for prevention (Goldstein and Bukstein, 2010).
Comorbid BD and SUDs are usually associated with high levels of health service utilisation and destabilising the course of bipolar illness results in poor treatment outcomes (Kessler et al., 1994, Kessler, 2004, Merikangas and Gelernter, 1990, Rakofsky and Dunlop, 2013, Salloum and Thase, 2000). Yet despite the high rates of comorbidity between substance use and mood disorders, the problem remains poorly understood (Strakowski and DelBello, 2000), causality is unclear and comorbidity is often misdiagnosed among clinicians practising in either field (Brown et al., 2001, Cuffel, 1996, Cuffel, 1996, Tickell, 1999). A better understanding of comorbidity is needed to identify the correlational and/or potential causal relationships among symptoms and treatment in comorbid patients. Such knowledge will also make an important contribution to treatment and prevention strategies for mood disorders.
In epidemiologic surveys, comorbid prevalence rates can be expressed in two ways: the prevalence of SUDs among respondents with a mental health disorder or the prevalence of psychiatric cases among respondents with a SUD. The prevalence rates between the two populations can vary considerably due to their frequency of occurrence. Take for instance the prevalence of BD and illicit drug dependence reported by Grant et al. (2004). The prevalence of any SUD in respondents with mania was approximately 30% compared to the prevalence of mania (~5%) in respondents with a SUD (Grant et al., 2004).
The aim of this systematic review is to report and combine the findings of large national or international surveys based on general populations reporting prevalence rates of SUDs comorbid with bipolar disorders from studies conducted between 1990 and 2015. We chose 1990 as a starting point to include the influential Epidemiologic Catchment Area (ECA) study and subsequent surveys using similar large-scale census techniques and face-to-face interviews to report prevalence rates using American Psychiatric Association- Diagnostic and Statistical Manual (DSM) or World Health Organisation- International Classification (WHO-ICD) diagnostic instruments from diverse geographic sites. Prevalence of having BD in respondents with an SUD, or prevalence of SUDs in respondents with BD were collated for lifetime and/or 12 month (12 M) abuse or dependence of alcohol or illicit drugs.
The odds (or odds ratio, OR) of having an alcohol or illicit drug use disorder in respondents with BD was used in the meta-analysis because it is not affected by differences in calculating prevalence rates of SUDs within populations with mental health disorders or vice versa. The current review excludes bipolar studies of clinical or treatment-seeking populations and these are the subject of a companion paper (Hunt et al., in press).
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 118 titles were found from searches conducted in January 2016 for comorbid prevalence studies using keyword combinations and Boolean logic (AND, OR) for searches of bipolar-related terms (bipolar or mania or hypomania) studies, prevalence and SUDs. The outcome of this search was compared to previous ones which found 27 unique household surveys describing prevalence rates of city, national or international populations with 88 papers providing supplementary material reporting sub-group
Discussion
This systematic review and meta-analysis found strong associations between co-occurring SUDs and BD. Of the illicit substances, cannabis had the highest mean prevalence (17%) followed by cocaine (6.6%) and opiates (4.3%). The mean prevalence for any DUD was 17%, for any AUD it was 24% and for any SUD it was 33%. The strongest comorbid associations were found between BD and illicit drug use (pooled OR 4.96) followed closely by BD and AUD (pooled OR 4.09). Sub-analyses indicated ORs for alcohol
Conclusions
This systematic review of epidemiological studies in general populations over the last 25 years shows comorbidity between SUDs and bipolar disorders are highly prevalent across countries. The meta-analysis revealed that people with an alcohol use disorder (abuse or dependence) were 4.1 times of greater risk of having BD compared to those without an AUD. The risks were even higher for illicit drug users where they were 5.0 times of greater risk of having BD compared to non-users. The greater
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.
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