Research has shown that increased alcohol consumption in individuals with bipolar disorder can exacerbate their symptoms over time. Contrary to the belief that alcohol acts as a self-medication, the study did not show an increase in alcohol consumption due to heightened mood symptoms. This highlights the importance of consistent alcohol use habits for better mental health management.
Bipolar disorder (BD) is a mental health condition characterized by extreme mood swings, ranging from episodes of depression to mania (or hypomania, a milder form). During the depressive phase, the person may experience profound sadness, lack of energy, and loss of interest in daily activities. In the manic phase, there is excessive euphoria, increased energy, impulsivity,y and, sometimes, risky behavior.
The incidence of the disorder is approximately 1 to 3% of the world's population. There are two main types: bipolar disorder type I (BD), which involves full-blown manic episodes, and type II (BDII), which involves hypomania alternating with severe depression.
Nearly half of people with bipolar disorder also have alcohol use disorder (AUD), which further exacerbates the problems associated with BD. This combination of disorders can lead to even worse clinical outcomes, such as increased risk of suicide, poorer social functioning, more frequent hospitalizations, and more expensive treatments.
Despite this significant association, treatments for BD rarely consider or include the management of AUD. Furthermore, many studies and clinical trials of BD exclude patients with problematic alcohol use, which means that much of the population affected by these problems is not being represented in research.
The co-occurrence of AUD and BD has been associated with many more serious complications, such as prolonged episodes of alcohol withdrawal, more complex mood symptoms such as mixed mania (characterized by simultaneous agitation and depression), and rapid cycling (rapid shifts between manic and depressive states).
Patients with this combination of disorders are also more likely to have more severe relapses and suicidal behaviors and have greater difficulty recovering from manic episodes.
Longitudinal studies have shown that the presence of AUD worsens BD outcomes over time. For example, in one 4-year study, patients with a history of AUD had a slower recovery from manic episodes. Another 5-year follow-up study showed that individuals with type I BD and AUD had poorer social functioning and more suicidal behaviors than those without AUD.
However, there are still many knowledge gaps about how alcohol use fluctuates over time in people with BD and how it interacts with mood symptoms (depression, mania, hypomania) and anxiety. Understanding these dynamics is key to knowing when and how to intervene.
This is all the more important given the lack of longitudinal research showing whether alcohol is used by BD patients primarily as a form of self-medication, which many healthcare professionals believe but has not yet been fully proven. This was the goal of researchers at the University of Michigan and their results were published in JAMA.
They applied sophisticated computational approaches required for this type of intensive longitudinal data. The researchers sought to characterize longitudinal patterns of alcohol use in BD and examine temporal associations between alcohol use, mood, anxiety, and functioning over time.
This cohort study selected participants and analyzed data from the Prechter Longitudinal Study of Bipolar Disorder (PLS-BD), an ongoing cohort study that recruits through psychiatric clinics, mental health centers, and community outreach events in Michigan and collects repeated phenotypic data.
A total of 584 individuals (386 women and 198 men) with a mean age of 40 years were included. These participants had a diagnosis of TBI (445) or TBII (139), with or without a lifetime diagnosis of AUD, and a median follow-up of 9 years. Data were extracted from February 2006 to April 2022, and follow-up ranged from 5 to 16 years.
Alcohol use was measured using the Alcohol Use Disorders Identification Test. Depression, mania or hypomania, anxiety, and functioning were measured using the 9-Item Patient Health Questionnaire, the Altman Mania Self-Rating Scale, the 7-Item Generalized Anxiety Disorder Rating Scale, and the Life Functioning Questionnaire, respectively.
Longitudinal patterns of alcohol use disorder. Shaded regions reflect SE around the mean. AUDIT stands for Alcohol Use Disorder Identification Test; BDI, bipolar I disorder; BDII, bipolar II disorder. The AUDIT score ranges from 0 to 40, with 8 or higher indicating that AUD is highly likely; 8 to 14 indicating hazardous or harmful drinking; and 15 to 40 indicating severe drinking or dependence. doi:10.1001/jamanetworkopen.2024.15295
The researchers demonstrated that even a short-term increase in alcohol consumption can have lasting effects, even among those who drink fewer drinks than experts consider problematic. But the opposite was not true: Those who experienced an increase in their symptoms did not go on to have an increase in alcohol consumption that would indicate self-medication.
More problematic alcohol use was associated with worse depressive and manic or hypomanic symptoms, as well as lower workplace functioning over the next 6 months, but increased depressive and manic or hypomanic symptoms were not associated with greater subsequent alcohol use. These latter 2 associations were more pronounced in IIBD than in TBI. Alcohol use was not associated with anxiety over time.
This study found that alcohol use, regardless of diagnostic status, was associated with mood instability and poorer work functioning in BD, but increased mood symptoms were not associated with subsequent alcohol use.
Given its prevalence and impact, dimensional and longitudinal assessment and management of alcohol use are needed and should be integrated into standard BD research and treatment.
READ MORE:
Longitudinal Interplay Between Alcohol Use, Mood, and Functioning in Bipolar Spectrum Disorders
Sarah H. Sperry; Audrey R. Stromberg; Victoria A. Murphy, B.S; et al
JAMA. 2024. doi:10.1001/jamanetworkopen.2024.15295
Abstract:
Importance:
Alcohol use disorder (AUD) is present in nearly half of individuals with bipolar disorder (BD) and is associated with markedly worsening outcomes. Yet, the concurrent treatment of BD and AUD remains neglected in both research and clinical care; characterizing their dynamic interplay is crucial in improving outcomes.
Objective:
To characterize the longitudinal alcohol use patterns in BD and examine the temporal associations among alcohol use, mood, anxiety, and functioning over time.
Design, Setting, and Participants:
This cohort study selected participants and analyzed data from the Prechter Longitudinal Study of Bipolar Disorder (PLS-BD), an ongoing cohort study that recruits through psychiatric clinics, mental health centers, and community outreach events across Michigan and collects repeated phenotypic data. Participants selected for the present study were those with a diagnosis of BD type I (BDI) or type II (BDII) who had been in the study for at least 5 years. Data used were extracted from February 2006 to April 2022, and follow-up ranged from 5 to 16 years.
Main Outcomes and Measures:
Alcohol use was measured using the Alcohol Use Disorders Identification Test. Depression, mania or hypomania, anxiety, and functioning were measured using the 9-item Patient Health Questionnaire, the Altman Self-Rating Mania Scale, the 7-item Generalized Anxiety Disorder assessment scale, and the Life Functioning Questionnaire, respectively.
Results:
A total of 584 individuals (386 females (66.1%); mean [SD] age, 40 [13.6] years) were included. These participants had a BDI (445 [76.2%]) or BDII (139 [23.8%]) diagnosis, with or without a lifetime diagnosis of AUD, and a median (IQR) follow-up of 9 (0-16) years. More problematic alcohol use was associated with worse depressive (β = 0.04; 95% credibility interval [CrI], 0.01-0.07) and manic or hypomanic symptoms (β = 0.04; 95% CrI, 0.01-0.07) as well as lower workplace functioning (β = 0.03; 95% CrI, 0.00-0.06) over the next 6 months, but increased depressive and manic or hypomanic symptoms were not associated with greater subsequent alcohol use. These latter 2 associations were more pronounced in BDII than BDI (mania or hypomania: β = 0.16 [95% CrI, 0.02-0.30]; workplace functioning: β = 0.26 [95% CrI, 0.06-0.45]). Alcohol use was not associated with anxiety over time.
Conclusions and Relevance:
This study found that alcohol use, regardless of diagnostic status, was associated with mood instability and poorer work functioning in BD, but increased mood symptoms were not associated with subsequent alcohol use. Given its prevalence and repercussions, dimensional and longitudinal assessment and management of alcohol use are necessary and should be integrated into research and standard treatment of BD.
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