distractions, such as walks, outings, and other activities Remind your friend or relative that, with time and treatment, he or she can get better. Never ignore comments about your friend or relative harming himself or herself. Always report such comments to his or her therapist or doctor. Support for caregivers Like other serious illnesses, bipolar disorder can be difficult for spouses, family members, friends, and other caregivers. Relatives and friends often have to cope with the person’s serious behavioral problems, such as wild spending sprees during mania, extreme withdrawal during depression, poor work or school performance. These behaviors can have lasting consequences. Caregivers usually take care of the medical needs of their loved ones. The caregivers have to deal with how this affects their own health. The stress that caregivers are under may lead to missed work or lost free time, strained relationships with people who may not understand the situation, and physical and mental exhaustion. Stress from caregiving can make it hard to cope with a loved one’s bipolar symptoms. One study shows that if a caregiver is under a lot of stress, his or her loved one has more trouble following the treatment plan, which increases the chance for a major bipolar episode.50 It is important that people caring for those with bipolar disorder also take care of themselves. How can I help myself if I have bipolar disorder? It may be very hard to take that first step to help yourself. It may take time, but you can get better with treatment. To help yourself: Talk to your doctor about treatment options and progress Keep a regular routine, such as eating meals at the same time every day and going to sleep at the same time every night Try to get enough sleep Stay on your medication Bipolar Disorder • 21 Learn about warning signs signaling a shift into depression or mania Expect your symptoms to improve gradually, not immediately. Where can I go for help? If you are unsure where to go for help, ask your family doctor. Others who can help are listed below. Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors Health maintenance organizations Community mental health centers Hospital psychiatry departments and outpatient clinics Mental health programs at universities or medical schools State hospital outpatient clinics Family services, social agencies, or clergy Peer support groups Private clinics and facilities Employee assistance programs Local medical and/or psychiatric societies. You can also check the phone book under “mental health,” “health,” “social services,” “hotlines,” or “physicians” for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help. What if I or someone I know is in crisis? If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately. Call your doctor. Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things. Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1–800–273–TALK (1–800–273–8255); TTY: 1–800–799–4TTY (4889) to talk to a trained counselor. Make sure you or the suicidal person is not left alone. e MA, Keck PE, Jr., Leverich GS, Rush AJ, Suppes T, Pollio C, Drexhage HA. High rate of autoimmune thyroiditis in bipolar disorder: lack of association with lithium exposure. Biol Psychiatry. 2002 Feb 15;51(4):305-311. 23. Bowden CL, Calabrese JR, McElroy SL, Gyulai L, Wassef A, Petty F, Pope HG, Jr., Chou JC, Keck PE, Jr., Rhodes LJ, Swann AC, Hirschfeld RM, Wozniak PJ, Group DMS. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatient An Introduction to Bipolar Disorder and Co-Occurring Substance Use Disorders Bipolar disorder is a serious, chronic mental illness characterized by unusual changes in mood, energy, and activity levels. Early diagnosis and appropriate treatment of bipolar disorder are important because the illness carries a high risk of suicide and can severely impair academic and work performance, social and family relationships, and quality of life.1,2 Research suggests that from 30 percent3 to more than 50 percent4,5,6,7,8 of people with bipolar disorder (bipolar I or bipolar II) will develop a substance use disorder (SUD) sometime during their lives. This co-occurrence complicates the course, diagnosis, and treatment of SUDs. However, treatment for bipolar disorder and SUDs is available, and remission and recovery are possible—especially with early intervention.9,10,11 This Advisory provides behavioral health professionals with information on the symptoms of bipolar disorder and the potential complications of co-occurring bipolar disorder and SUDs. Readers will also learn about screening for bipolar disorder, challenges in diagnosing it, theories about its co-occurrence with SUDs, and research on treatment for these co-occurring conditions. Although treatment for bipolar disorder is highly individualized and therefore beyond the scope of this Advisory, a brief overview is included to provide basic information. An Overview of Bipolar Disorder The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR),12 classified bipolar disorder as a mood disorder, along