disorder and attention deficit hyperactivity disorder also have many symptoms in common,4 and distinguishing between the two is a task for an experienced, licensed mental health professional. differences.28 An Introduction to Bipolar Disorder and Co-Occurring Substance Use Disorders Summer 2016, Volume 15, Issue 2 3 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Symptoms that appear to be caused by bipolar disorder may instead be symptoms of acute substance misuse or withdrawal. Chronic use of central nervous system stimulants, such as cocaine and amphetamines, can produce manic-like symptoms, including euphoria, increased energy, grandiosity, and paranoia, whereas withdrawal can produce depression-like symptoms, including apathy, anhedonia (inability to feel pleasure), and thoughts of suicide. Chronic use of central nervous system depressants, such as alcohol, benzodiazepines, and opioids, can result in poor concentration, anhedonia, and sleep problems, whereas withdrawal can make people agitated and anxious.30 Exhibit 1. The Core Patterns of Bipolar Disorder29 Psychosis Mania Euthymia Depression Psychosis Bipolar I Bipolar II Subsyndromal Adapted with permission from John Wiley & Sons, Inc., Copyright © 2009. The Difficulties of Diagnosing Bipolar Disorder in Children and Adolescents Although the onset of bipolar disorder can occur at any age, the average age of onset for bipolar I is 18.4 However, diagnosing bipolar disorder in children and adolescents can be even more difficult than diagnosing it in adults, in part because of the affective shifts that often occur in normal child and adolescent cognitive and emotional development.4,31 For more information, see: American Academy of Child and Adolescent Psychiatry, Bipolar Disorder Resource Center National Institute of Mental Health, Bipolar Disorder in Children and Teens www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-qf-15-6380/index.shtml 4 ADVISORY Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover It is important that a diagnosis of bipolar disorder be made by a mental health professional licensed to diagnose mental disorders and familiar with differential diagnosis (the process of distinguishing between illnesses or disorders with similar characteristics). Bipolar Disorder and Co-Occurring SUDs Results from the National Epidemiologic Survey on Alcohol and Related Conditions showed that SUD co-occurrence was higher among people with bipolar disorder than among people with any of the other mental disorders included in the survey.32 Studies indicate that lifetime co-occurrence of SUDs for individuals with bipolar disorder ranges from 21.7 percent33 to 59 percent34 and that 12-month co-occurrence ranges from 4 percent35 to more than 25 percent.32 However, it is not only individuals meeting full criteria for bipolar disorder who are at risk for SUDs. Hypomania is also associated with an increased risk for SUDs.36 Alcohol is commonly misused by people with bipolar disorder,6,34,35 and people with bipolar disorder and co-occurring alcohol use disorder are less likely to respond and adhere to treatment and more likely to be hospitalized34 and to attempt suicide37,38 than people with bipolar disorder only. In some cases, the combination of bipolar disorder and an SUD may deepen bipolar disorder’s manic and depressive symptoms.34,39,40 Explanations for bipolar disorder and SUDs co-occurrence Researchers have offered several possible explanations for bipolar disorder and SUD co-occurrence. Khantzian41 formulated the self-medication hypothesis, which proposes that people misuse substances to relieve psychological suffering and that the substances they misuse are specific to the type of suffering they experience. Swann42 argues that bipolar disorder and substance misuse can be viewed as overlapping disorders of the systems in the brain that regulate impulsivity, motivation, and the feeling of reward. Another model for co-occurring bipolar disorder and SUDs proposes an underlying shared vulnerability (e.g., genetic liability).43,44 Whatever the etiology, it is clear that SUDs may precede, precipitate, exacerbate, be a consequence of, or have separate etiologies from bipolar disorder,40,45 and the co-occurrence of bipolar disorder and SUDs can complicate both diagnosis and treatment.33,34,40,45 Screening for Bipolar Disorder Because bipolar disorder has a wide range of symptoms, it can be mistaken for other conditions. This can make screening (and diagnosis) difficult. Substance use treatment professionals using screening tools for mental disorders should remember that these tools are not for diagnosis. Clients who screen positive for bipolar disorder—or, in fact, any mental disorder—will need to be referred for an assessment by a behavioral health professional licensed to diagnose and treat mental disorders. The same is true for clients who are not formally screened but who appear to have mental disorders. One well-known screening tool for bipolar disorder is the Composite International Diagnostic Interview (CIDI)-Based Screening Scale for Bipolar Spectrum Disorders. The CIDI-based screening scale consists of questions about symptom clusters and individual symptoms. Researchers have