January 4, 2017

Smoking and Substance Use in Youth With Bipolar Disorder

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Nicholas W. Carrellas, BA, and Timothy E. Wilens, MD

Massachusetts General Hospital (Dr Wilens & Mr Carrellas) and Harvard Medical School (Dr Wilens), Boston, Massachusetts


With colleagues, we evaluated the relative risk for cigarette smoking and substance use disorders (SUDs) in a case-controlled, 5-year, prospective follow-up study of adolescents with and without bipolar disorder (BPD). At baseline, the mean age of the 203 participants was 13 years.

Our data from this study showed that developing adolescents with BPD are at increased risk for cigarette smoking and SUDs compared to their peers without BPD. In agreement with other researchers, we also found high rates of co-occurring psychiatric disorders at follow-up among young adults with BPD, including attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder, and multiple anxiety disorders.

In trying to understand what in BPD is accounting for the increased SUD and cigarette smoking risk, we looked at a number of potential contributors. Whereas ADHD was not driving SUD or smoking, we found that CD was associated with both cigarette smoking and SUD. From a research perspective, BPD plus CD may represent a distinct subtype of BPD that is identifiable in early childhood and associated with high degrees of functional impairment.

In this particular sample, two-thirds of individuals continued to endorse BPD symptoms through adolescence into young adulthood. We found that subjects with persistent BPD manifested the highest risk (and earliest onset) of smoking and SUDs relative to those who lost their symptoms through either treatment or naturalistic remission (ie, the group with nonpersistent BPD) and to control participants. However, our data suggest that even individuals with nonpersistent BPD are at increased risk for SUDs and smoking relative to unaffected peers.

We found that the majority of adolescents and young adults with both BPD and SUD experienced the full onset of their BPD prior to the onset of their SUD, while a minority had onset of their BPD after that of SUD. This finding is in agreement with the work of prior studies and suggests that the poor judgment, limited self-control, and emotional dysregulation and disinhibition associated with BPD contribute to the high risk for SUD in young adulthood. Accordingly, practitioners should identify young individuals with persistent BPD and comorbid CD, who are at the highest risk for SUD, with the intention to treat BPD symptoms in an effort to mitigate the most severe outcomes related to smoking and problematic substance use.

Financial disclosure:Dr Wilens receives or has received grant support from NIH (NIDA); is or has been a consultant for Euthymics/Neurovance, NIH (NIDA), Ironshore, Sunovion, TRIS, US National Football League (ERM Associates), US Minor/Major League Baseball, Bay Cove Human Services, and Phoenix House (Clinical Services); has a published book Straight Talk About Psychiatric Medications for Kids (Guilford Press); has co-edited the books ADHD in Children and Adults (Cambridge Press) and Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and is co-owner of the copyrighted diagnostic tool Before School Functioning Questionnaire (BSFQ), for which he has a licensing agreement with Ironshore. Mr Carrellas had no relevant personal financial relationships to report.​

Category: ADHD , Bipolar Disorder , Substance Use Disorder
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