Bipolar Disorder and Its Comorbidities in Youth

April 25, 2012 · Posted in Risk Factors 

A symposium on bipolar disorder and its comorbidities in children and adolescents was held at the annual meeting of the American Academy of Child and Adolescent Psychiatry in 2011. The following findings were reported there.


Researcher Janet Wozniak discussed the relationship of bipolar illness and attention deficit hyperactivity disorder (ADHD). Based on interviews of family members of children with bipolar illness alone, bipolar illness plus ADHD, ADHD alone, and controls, she concluded that bipolar illness occurred more often in families of children with bipolar illness with or without ADHD. Similarly, she showed that there was more ADHD in relatives of children with either ADHD alone or ADHD comorbid with bipolar illness. She concluded that the comorbidity of bipolar illness and ADHD is a unique subtype of bipolar disorder and requires further study.

Emotional Dysregulation and Substance Abuse

In another presentation, Tim Wilens indicated that those with bipolar disorder and emotional dysregulation had an 8- to 20-fold increased risk of having a substance abuse comorbidity with their bipolar disorder.

teen drinking

Substance Abuse Comorbidity

In a third presentation, Ben Goldstein reported that the onset of bipolar illness predates the onset of substance abuse in 60 to 83% of instances of comorbid illness. He emphasized the dramatic negative impact of comorbid substance use in children with bipolar disorder in terms of increasing legal entanglements, pregnancy, academic failure, suicide, and decreased compliance with medications. He reported that in the multi-site, National Institute of Mental Health (NIMH)-funded Course and Outcome of Bipolar Illness in Youth (COBY) study, the largest longitudinal study to date of youth with bipolar disorder, the risk of new onset substance abuse over the course of 4 years of follow-up was 32%. These data taken with the 15% of children who already had substance abuse at intake indicates that in this study approximately half of the children with bipolar illness had or acquired a substance abuse problem near the beginning of their illness. Two-thirds of the children in the study had abused both alcohol and cannabis.

Predictors of having already acquired a diagnosis of substance abuse at study intake included: experimental (casual) alcohol use, panic disorder, family history of substance abuse disorder, history of oppositional defiant disorder or conduct disorder, decreased family cohesion, and less exposure to antidepressants.

In those who developed substance abuse after entering the study, there was a gap of an average of 2.7 years prior to the initiation of substance abuse. This provides a window of opportunity for invention. The predictor variables for acquiring substance abuse during follow-up included: less time euthymic, more time manic, increased incidence of panic disorder, and treatment with fewer medications.

Goldstein emphasized that 1 in 3 children experienced onset of substance abuse within 3 or 4 years of follow-up, and predictor variables included: increasing symptomatology, decreasing use of medications, recreational use of drugs, and a parent with a history of substance abuse (particularly active substance abuse). He suggested that making sure a parent with substance abuse was in treatment is one of the most important variables in preventing the new onset of substance abuse in their offspring with bipolar disorder. A second crucial factor is emphasizing medication adherence in order to decrease manic and anxious symptomatology, which are also independent predictors of new onset of substance abuse in children with bipolar disorder.

In the last presentation, Dr. Caleb Adler from the Lindner Center of HOPE in Cincinnati presented data indicating that those who experienced onset of bipolar illness first, followed by onset of substance abuse, had a more difficult course of illness than those who first had substance abuse and then bipolar disorder. These data emphasize the importance of primary prevention of substance abuse acquisition in adolescents and young adults with bipolar disorder, who are at extraordinarily high risk for this comorbidity. In Adler’s research the most common abused substances were cannabis in 30%, alcohol in 27%, both cannabis and alcohol in 18%, cocaine in 4%, and opiates in 3%.

Adler reported that 40% of bipolar adolescents who were well on entry to his study acquired substance abuse. He found that activity in the prefrontal cortex, insula, and the anterior cingulate was lower prior to the acquisition of substance abuse in those who went on to abuse substances compared to those who did not begin abusing substances. This suggests that there may be alterations in the brain that convey a vulnerability to the new onset of substance abuse. Surprisingly, he also found that some of the changes associated with marijuana abuse were in the direction of the normalization of brain abnormalities.  Those changes could be positive and compensatory.


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