Pharmacotherapy is the first-line approach to treating bipolar disorders as single disorders [1024–1027]. It is therefore not surprising that the vast majority of research regarding the treatment of co-occurring bipolar and AOD use disorders has focused on pharmacotherapies. Nevertheless, the evidence base is limited making it difficult to draw firm conclusions. Most studies have been conducted with a small number of people, lacked comparison groups, and involved the use of a variety of concomitant medications, making it difficult to clearly attribute effects to the medication examined [1023, 1036]. Multiple medications are often used to treat each specific disorder, such as the use of mood stabilisers (see Table 45), antipsychotics (see Table 42), and/or antidepressants (see Table 47) for the bipolar disorder, in conjunction with medication specifically to treat the AOD use disorder (e.g., naltrexone for alcohol use disorder) [1037], but care should be taken to avoid unnecessary polypharmacy due to the potential for interaction effects.
Table 45: Mood stabiliser medications
Drug name |
Brand names |
Aripiprazole |
Abilify, Abyraz, Tevaripiprazole |
Asenapine |
Saphris |
Carbamazepine |
Tegretol |
Lamotrigine |
Lamictal, Lamidus, Lamitan, Lamotrust, Logem, Reedos, Torlemo |
Lithium |
Lithicarb, Quilonum |
Olanzapine |
Olanzacor, Ozin, Pryzex, Zypine, Zyprexa |
Paliperidone |
Ivenga |
Quetiapine |
Delucon, Kaptan, Quetia, Seroquel, Syquet, Tevatiapine |
Risperidone |
Ozidal, Rispa, Risperdal, Rispernia, Rixadone |
Sodium valproate |
Epilim, Valprease, Valpro |
Solian |
Amisulpride |
Ziprasidone |
Zeldox, Ziprox |
Adapted from Khoo [1038]. For a full list of generic brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au).
Research to date has largely focused on the use of quetiapine among people with co-occurring bipolar and alcohol use disorders. Although initial open-label uncontrolled trials largely found quetiapine to have a positive impact on both psychiatric symptoms and AOD use, most RCTs have demonstrated that these improvements tend to be no greater than those achieved with a placebo [1036]. A similar pattern has been observed for sodium valproate among people with co-occurring bipolar and alcohol, cocaine and/or cannabis use disorders; although findings from one RCT suggest that greater reductions in alcohol use may be obtained by adding sodium valproate to lithium and individual counselling [1039].
Lithium itself has been examined in a small RCT conducted among adolescents which found significantly greater reductions in AOD use and depressive symptoms among those who received lithium relative to those who received placebo [1040]. A further study demonstrated that lithium had an impact on reducing cannabis and cocaine use among people with co-occurring bipolar disorder, but it is difficult to generalise the findings of this study due to less than one-quarter of the original sample completing the stabilisation phase and continuing into the main portion of the study [1041].
Lamotrigine has been shown to have mixed results in uncontrolled trials with regard to symptoms of bipolar, cocaine and alcohol use, but the only RCT conducted to date found no significant differences in outcomes for those who received lamotrigine compared to those who received a placebo medication [1036]. Topiramate has also been examined in an RCT and was not found to be superior to placebo with respect to reductions in AOD use and mood [1036]. Aripiprazole, olanzapine, and asenapine have all undergone preliminary testing, and all have been associated with reductions in cravings and improvements in bipolar symptoms but are yet to be examined in controlled trials [1036]. Over the past several years, studies have widened their focus to include non-traditional pharmacotherapies, such as memantine (an NMDA-receptor agonist typically used in the treatment of Alzheimer’s disease) [1042] and ondansetron (an antiemetic usually used in the treatment of nausea) [1043]. Although this is an area that is still developing, some promising findings have emerged.
It is also important to bear in mind that people with a co-occurring bipolar disorder may be less likely to take their medication if they lack insight, do not recognise their manic episodes, or enjoy their manic episodes. Measures to increase medication adherence may be particularly pertinent (discussed in Chapter B6). Other strategies to promote medication adherence among clients with co-occurring bipolar disorder include the Integrated Treatment Adherence Program described earlier in this chapter, which is an adjunctive psychosocial approach designed to improve treatment adherence [1032].