estimated that the For more information about general screening for mental disorders, see Treatment Improvement Protocol (TIP) 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders.46 An Introduction to Bipolar Disorder and Co-Occurring Substance Use Disorders Summer 2016, Volume 15, Issue 2 5 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover CIDI-based screening scale identifies between 67 percent and 96 percent of bipolar disorder cases, depending in part on where the cut points for a positive result are set.47 The screening scale is available at www.integration.samhsa.gov/images /res/STABLE_toolkit.pdf. A Brief Overview of Bipolar Disorder Treatment Only a behavioral health professional who is licensed to diagnose and treat mental disorders should provide treatment for bipolar disorder. Treatment can be complex and is often individualized according to a patient’s symptoms, needs, preferences, and responses to treatment. Treatment generally involves both pharmacological and psychosocial therapies, as described below. Pharmacological therapy ● Mood stabilizers—Lithium has been the firstline mood stabilizer for years, but other mood stabilizers, such as divalproex sodium (Depakote) and several other anticonvulsants, are also often prescribed.48,49,50 ● Atypical antipsychotics—Atypical (or “second generation”) antipsychotics such as quetiapine (Seroquel) or olanzapine (Zyprexa) are often used alone or in combination with other medications, such as lithium.49,50 In 2013, the Food and Drug Administration (FDA) approved the atypical antipsychotic lurasidone (Latuda) for the treatment of bipolar depression, alone or in combination with lithium or valproate.51 Atypical antipsychotics are not only used when psychotic symptoms are present. Many are used to treat mania; only one medication (quetiapine) is indicated for treatment of both bipolar mania and depression.49,50 ● Antidepressants—There is no FDA-approved antidepressant monotherapy for bipolar disorder. The selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac), in combination with the atypical antipsychotic olanzapine, is approved for acute bipolar I depression;52 the fluoxetine–olanzapine combination is available in a single capsule (Symbyax). Other SSRIs are also sometimes used (off label) for depressive episodes—but typically in conjunction with a mood stabilizer, because of concerns that antidepressant monotherapy could precipitate a manic or hypomanic episode.49,50 Each of these types of medications has its own potential side effects (such as weight gain with some atypical antipsychotics) or contraindications (e.g., divalproex sodium is contraindicated in pregnant women).48,49 Combining these medications with alcohol or drugs can be quite dangerous. For example, marijuana can cause a dramatic and even toxic increase in lithium levels.53 Mixing alcohol with atypical antipsychotics may result in an extreme level of central nervous system depression and significantly impair psychomotor functioning.54 Psychosocial therapy ● Cognitive–behavioral therapy (CBT)—CBT uses a process called cognitive restructuring, in which an individual learns to identify harmful or negative patterns of thoughts, behaviors, and beliefs and to modify them into more balanced patterns. The goal is to decrease the individual’s degree of emotional distress over troubling situations.1,55 ● Family-focused therapy (FFT)—FFT helps families understand bipolar disorder, develop coping strategies, and learn to recognize when a new depressive or manic/hypomanic episode may be beginning. FFT also focuses on improving family communication and problem-solving skills.1 ● Interpersonal and social rhythm therapy (IPSRT)—IPSRT has three components:56 – Psychoeducation focuses on information about bipolar disorder, treatment options (and possible side effects), and early warning signs of a new depressive or manic/hypomanic episode. 6 ADVISORY Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover – Social rhythm therapy focuses on identifying situations that may upset life routines and developing ways to stabilize life routines, to reduce emotional distress. – Interpersonal psychotherapy focuses on the ways that interpersonal problems (such as grief, role transitions, or disputes) may be related to changes in mood that may signal the beginning of new mood episodes, such as new or increased depression or mania/hypomania. One study found that patients who received any one of these types of psychosocial treatment (CBT, FFT, or IPSRT) had higher levels of life satisfaction, better overall functioning, and better relationship functioning than patients who received a three-session psychoeducational intervention.57 BD [bipolar disorder] is a uniquely challenging disorder to treat, with the most lethality, the most recurrences, and the most varied clinical presentations of any major psychiatric disorder.58 Treatment of Co-Occurring Bipolar Disorder and SUDs Because SUDs are chronic and progressive illnesses and because SUDs (both past and current) tend to contribute to poorer treatment outcomes for individuals with bipolar disorder, early intervention can be an important part of improving treatment outcomes for individuals with