Substance misuse


NICE and SIGN advise healthcare professionals to use psychosocial interventions to treat people who misuse alcohol and harmful substances. BAP recommends the involvement of a ‘specialist drug and alcohol team, or dual diagnosis team, if available’. CANMAT provides detailed information about the interactions between medications prescribed for bipolar disorder and alcohol or cocaine.

NICE guideline

People with harmful drug and/or alcohol use: consider a psychosocial intervention targeted at the drug and/or alcohol use (such as psychoeducation and motivational enhancement), delivered by general mental health services, working with specialist substance use services where appropriate.

BAP guideline

The risk of alcohol dependency is another common and clinically significant comorbidity of Bipolar I and II disorder. Drug misuse, especially stimulant misuse, is more relevant to younger patients with mania and is associated with poorer outcome. It can confound the diagnosis and makes engagement with treatment more difficult. Indeed, mania appears to be induced by a range of stimulant drugs. Where elated states are sustained and meet criteria for mania, a diagnosis of ‘drug-induced psychosis’ is likely to be wrong and a diagnosis of bipolar disorder more useful. A true drug-induced psychosis should either wane with the clearance of the offending drug or be a transient effect associated with drug withdrawal.

It is an important principle that bipolar patients with significant substance or alcohol misuse should have these issues appropriately assessed and treated, and consideration given to involving the specialist drug and alcohol team, or dual diagnosis team, if available. There is evidence that effective treatment of substance misuse can improve compliance and bipolar outcomes.

CANMAT guideline

Substance abuse disorders. In patients with bipolar disorder, comorbid substance abuse was associated with lower rates of remission and more psychiatric hospitalizations.

The anticonvulsants lamotrigine, divalproex, carbamazepine and gabapentin, as well as the atypical antipsychotic quetiapine, have been evaluated in the management of patients with bipolar disorder and comorbid substance abuse.

In patients with bipolar disorder and comorbid cocaine dependence, open-label lamotrigine treatment resulted in statistically significant improvements in mood and drug cravings but did not significantly decrease drug use (level 3). In a retrospective chart review, remission rates were higher in bipolar patients with a history of substance abuse who had received divalproex or carbamazepine versus lithium monotherapy (level 4). The presence of alcohol abuse was associated with a positive response to open-label adjunctive gabapentin treatment in patients with bipolar disorder (level 3). Open-label adjunctive quetiapine treatment demonstrated significant improvements in mania and depression scores, and drug cravings in patients with bipolar disorder and cocaine dependence (level 3).

Divalproex, carbamazepine and topiramate have shown efficacy in patients with substance abuse disorders, but have not been evaluated in patients with both bipolar disorder and comorbid substance abuse disorders. In an RCT, divalproex reduced the symptoms of alcohol withdrawal faster than a benzodiazepine (level 2). Carbamazepine demonstrated efficacy equal to lorazepam in decreasing the symptoms of alcohol withdrawal. Patients treated with topiramate demonstrated significantly less alcohol consumption and cravings compared with placebo in the treatment of alcohol dependence.

SIGN guideline

Alcohol and substance misuse: Evidence from a cohort study demonstrates the high lifetime rates of alcohol and drug misuse in patients with bipolar affective disorder. Among the 392 participants rates of substance abuse were high, with a 48.5% rate for lifetime alcohol abuse, a 43.9% rate for lifetime drug abuse and a 59.4% rate for lifetime drug or alcohol abuse. Rates of active substance abuse during the observed episodes were also notable with 28.6% of the cohort actively abusing alcohol, 28.6% actively abusing one or more drugs and 39.3% actively abusing either drugs or alcohol. Current and lifetime substance abuse were more common among men than among women. No differences in any of the substance abuse were more common among men than among women. No differences in any of the substance abuse rates were noted between the patients with pure and the patients with mixed manic subtypes. No evidence was identified on the efficacy of interventions to treat alcohol and or drug misuse problems in patients with bipolar affective disorder.

Care Programme Approach: In 1992 a Scottish Office circular introduced the “Care Programme Approach” (CPA) for people with a mental illness in the care of health boards and local social work authorities. Patients with bipolar affective disorder and a coexisting drug and or alcohol problem may be usefully managed under the Care Programme Approach.


  1. National Institute for Clinical Excellence The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. National Institute for Clinical Excellence. 2006; Jul
  2. Goodwin GM Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology. 2003; 17 (2): 149-173.
  3. Yatham LN et al Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disorders. 2005; 7 (3): 5-69.
  4. Scottish Intercollegiate Guidelines Network Bipolar affective disorder: A national clinical guideline. Scottish Intercollegiate Guidelines Network. 2005; May