Identifying SUD Symptoms While Treating Bipolar Disorder

Recently, experts have been discussing how common substance use disorder (SUD) and bipolar disorder comorbidity can be. But when mental health professionals see patients with this comorbidity, how can they differentiate symptoms stemming from bipolar disorder and symptoms stemming from SUD? In a chat with Psych Congress Network on-site at the 2023 NP Institute, Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, clinical professor at the University of Illinois at Chicago, and Arwen Podesta, MD, ABPN, FASAM, ABIHM, a psychiatrist at Podesta Psychiatry LLC, examined how to tell symptom causes apart and why honesty is the best policy when working with this population.

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Read the Transcript: 

Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN: I'm Julie Carbray, clinical professor of nursing and psychiatry at the University of Illinois at Chicago, also the director of our mood disorder clinic and nursing faculty.

Arwen Podesta MD, ABPN, FASAM, ABIHM: I'm Arwen Podesta. I'm a psychiatrist in New Orleans, Louisiana. I specialize in addiction medicine and holistic and integrative psychiatry and also in forensic psychiatry.

Psych Congress Network: What symptoms should clinicians be looking for to diagnose SUD in a patient with bipolar disorder?

Dr Podesta: There are a lot of symptoms that we need to look at at the patient holistically, whatever's cropping up. But if someone is being treated for bipolar or someone is seeing a clinician for bipolar, everyone should also look for substance use disorders. And it's easy enough to do a urine drug screen, right? If you present it correctly, it doesn't undermine your treatment with the patient. Sometimes they might be suspicious, but if you're able to just say, ‘I need to do this to help our relationship,’ that's the very first thing. But another set of symptoms, if someone's in school or having a job, is maybe just shifting in their ability and missing work days and different sleep and occupational patterns.

Dr Carbray: Yeah. You really see a change in functioning over time, and it can be a challenge. You want to set the table for the idea that drug use might be a part of what we're navigating, we're trying to help that person recover from their bipolar illness. So I'll usually pose that percentage. There's a high majority of people, 40 to 60%, they might be using substances as well as they're trying to manage their illness. What's best as a clinician, is that I understand if you're using that we have an honest discussion. And then we try to have that on the table so that I can understand what impact that may have on managing your illness and what we can do moving forward to mitigate your use or to manage your use in the context of your illness and vice versa, how the two might interplay. So honesty is a first policy.

Dr Podesta: That's right. Lack of judgment, lack of stigma, honesty, an open door relationship. Absolutely. I love that.

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.