• One in three teens with bipolar disorder develop substance abuse or dependence within four years of first trying a drug or alcohol.

• Marijuana was the most frequently abused substance, followed by alcohol.

• Early alcohol use, oppositional defiant disorder, family history of substance abuse, and family discord predicted an SUD.

• Adolescents who were taking antimanic or antidepressant medication at intake were less likely to develop an SUD.

Teens with bipolar disorder (BP) should be followed for substance abuse, because their first substance abuse makes them likely to develop a diagnosable substance use disorder (SUD) in four years, according to an article in the current issue of the Journal of the American Academy of Child & Adolescent Psychiatry. Based on data from the Course and Outcome of Bipolar Youth (COBY) study, the researchers, led by Benjamin Goldstein, M.D., of the University of Toronto and the University of Pittsburgh, found that 32% of 167 youth ages 12 to 17 developed abuse or dependence of alcohol or drugs — mainly, marijuana — within four years of follow-up. Any so-called recreational use of alcohol or drugs is like “playing with fire” for teens with BP, says Goldstein.

Study details

The COBY study, funded by the National Institute of Mental Health, enrolls participants at Brown University, the University of California at Los Angeles, and the University of Pittsburgh. COBY is a longitudinal study which will continue to follow these adolescents into adulthood. The participants had no substance use disorder (SUD) at intake, but some had experimented with alcohol or drugs.

The COBY study included 400 children and adolescents aged 7 through 17 years 11 months. For this study, only 167 subjects aged 12 through 17 years 11 months at intake, who did not have an SUD, and who had at least one follow-up assessment, were used. The researchers determined first-onset SUD based on the first week in which the subject met threshold criteria in DSM-IV for abuse or dependence of alcohol or drugs. Nicotine dependence was not included as an SUD.

The participants were interviewed about seven times during the course of the four-year follow-up.


Overall, 32.3% of the participants developed an SUD within four years of intake. On average, abuse or dependence developed 2.7 years from the start of the study, at a mean age of 18 years. The most common SUDs were cannabis (16.8% abuse, 5.4% dependence) followed by alcohol (15.6% abuse, 4.8% dependence). Other drug abuse and dependence did not exceed 1.2%.

The strongest predictor of later substance abuse was repeated early alcohol use, followed by use of marijuana. Other predictors were oppositional defiant disorder, panic disorder, family history of substance abuse, low family cohesiveness, and absence of antidepressant treatment. More than half (54.7%) of teens with three or more risk factors developed substance abuse, compared to 14.1% of teens with two or fewer risk factors.

Adolescents who were taking antimanic or antidepressant medications at intake were less likely to develop SUDs. And the adolescents who did develop SUDs were also significantly more likely to have a family history of mania/hypomania, anxiety, and SUDs.


While SUDs are a cause for concern in all patients, it is particularly important to pay attention to them among adolescents with BP, as the combination is associated with more treatment nonadherence, suicide attempts, legal problems, and academic failure, the authors write.

Family cohesiveness mitigates the risk of SUD among youth with BP, which aligns with previous research finding that family conflict is associated with initiation of substance abuse in adolescents, they note. “Prevention of SUD in this population is a matter of tremendous clinical and public health importance.” They recommend strategies such as “assertive treatment of adolescents with BP, early identification of substance use via repeated screening beginning in late childhood, family-focused preventive interventions, and motivation-enhancing interventions targeting subthreshold substance use.”

Variables researchers should take into account when studying first-onset SUD among patients with BP are mood symptoms, inadequate treatment, recreational alcohol use, and familial factors, the researchers conclude. “These findings, albeit tentative, further suggest that treatment of psychiatric comorbidity, both internalizing and externalizing, and incorporating family therapy may confer benefits with regard to SUD,” they write. “Mood exacerbations, particularly those of hypo/manic polarity, may comprise an interval of risk for escalating substance use, and in such circumstances increased vigilance for excessive substance use appears warranted.” While experimenting with substances is often viewed as developmentally appropriate, and parents and clinicians are “reluctant to promote abstinence,” this study “may help to resolve ambivalence among some clinicians, parents, and perhaps adolescents,” they write. Deferring the first onset of substance use could mitigate the risk of a full-blown SUD in patients with BP, they write. “In addition to yielding a greater understanding of why the prevalence of SUD in BP is so high, advances regarding the neurobiological underpinnings of comorbid SUD in BP may identify novel treatment strategies that may ameliorate the substantial psychiatric burden experienced by these doubly affected patients.”

In an accompanying editorial, Robert Milin, M.D., wrote that the findings suggest that treatment of BP could help mediate against the development of substance use disorder (SUD). “From the study findings of Goldstein et al., one can arrive at the clinical importance of assessing and monitoring for likely high-risk factors, such as recreational alcohol and marijuana use, immediate family history of SUD, and the presence of oppositional-defiant disorder, and providing suitable treatment for BP in adolescents,” he wrote. In addition to treating the BP, clinicians should consider treatment interventions for adolescents’ substance abuse problems, including motivational enhancement therapy, psychoeducational therapy, and specific psychosocial therapies, he said, adding that “the development of SUD is a highly prevalent and serious problem in adolescents in the early course of BP that requires clinical attention and further research.”

“It stands to reason that to provide the requisite treatment for BP in adolescents, it is meaningful to use reliable and valid diagnostic criteria and evidence-based pharmacotherapy/treatment for pediatric BP,” Milin continued. “Likewise, one can turn to the existing literature on effective early intervention and treatment of adolescents with substance use-related problems and SUD for strategies that might be introduced and integrated as clinically relevant into the early course of treatment for adolescents with BP. Such treatment interventions include motivational enhancement therapy, psychoeducational therapy, and specific psychosocial therapies for adolescent SUD.”

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Goldstein BI, Strober M, Axelson D, et al. Predictors of first-onset substance use disorders during the prospective course of bipolar spectrum disorders in adolescents. J Am Acad Child Adolesc Psychiatry 2013 Oct; 52(10):1026–1037. Epub 2013 Jul 31. E-mail: