Managing Comorbid Bipolar Disorder & SUD: Treatment and Communication

In this discussion, Psych Congress Network Bipolar Disorder Section Editor Julie A. Carbray, PhD, PMHNP-BC, clinical professor at the University of Illinois at Chicago, and Arwen Podesta, MD, ABPN, psychiatrist at Podesta Psychiatry LLC, examined the available treatments for bipolar disorder and substance use disorder (SUD), their strategies for managing both illnesses at once, and how they suggest clinicians communicate with patients in this subset.

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Read the Transcript:

Psych Congress Network: What treatments are available, and what advice do you have for clinicians communicating with their patients? How do you monitor that progress?

Julie Carbray, PhD: The most effective treatment is managing the primary illness, so really getting good stability of mood as your first defense and trying to treat bipolar illness. And that can be complicated, but starting there will lead towards better outcomes with mitigating substance use disorders. But I know you know well the world of recovery and other interventions you might employ with somebody with bipolar illness.

Arwen Podesta, MD: I mean, you have to stabilize the mind first so that the action can be taken. And this is true with substance, this is true with bipolar, with all sorts of mental disparities, with mental things. And so you treat the sub... I'm sorry. You treat the bipolar, we get the mood stabilized and get the conversation going so that then we can start attempting for abstinence or really understanding. I always tell my patients that I don't want them to feel like they need the substance that they're using. So if they're low energy, if their mood is low and they think that the drug is elevating their mood or it's actually not just think, 'but if that's how they feel about it, then I want them to feel like they don't need that.' If they're using something for sleep, I want them to feel like they don't need that. So I can treat it more wholly and practically.

Dr Carbray: Absolutely. The worst case scenario is the drug that we're using to treat their primary illness, bipolar disorder, might be contributing to some adverse effects that then they're using substances to counteract. Like, 'Maybe this is making me gain weight and I'm thinking this will help me to mitigate that.' So it's really important to continue to educate too, around what's going on with your treatment and how might the substance use play into it. And then you made a great point too, about engaging their decision making. Is it time? What would you like to do with managing the effect of this use on your current symptoms?

Dr Podesta: I love setting goals with patients and not just reading a PQH-9 or PHQ-9 or an inventory of symptoms, I want to set their actual goals. And so I create goals with them the first time I sit with them. And because their goal might not be pure abstinence, their goal might not be going into 12-step treatment. It may be, but it might be just to feel better. And so how can you and I do this?

Dr Carbray: How do we get there together and really take steps towards that?

Dr Podesta: For addiction, the biggest crisis right now is the opioid crisis. And so for that, we do have medications for opioid use disorder that all clinicians are all prescribers are able to prescribe, like buprenorphine, now that we don't have the X number any longer. So a very interesting time. And it's a really important time for all providers and prescribers to be able to put that in their pocket as a tool, in their toolbox.

Dr Carbray: Exactly. And have that treatment available to patients when they need it immediately.

Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, is a clinical professor of psychiatry and nursing at the University of Illinois at Chicago. Dr Carbray holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago, and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. 

Arwen Podesta, MD, ABPN, FASAM, ABIHM, is a board-certified adult psychiatrist with sub-specializations in addiction medicine, forensic psychiatry, and integrative medicine. A graduate of the University of Southern California Keck School of Medicine, Dr Podesta completed her psychiatry residency in at Louisiana State University before pursuing a fellowship in forensic psychiatry at Tulane University.