Q:  How Does Active Alcoholism Affect Diagnosis & Treatment of BP

Hi Dr. Phelps,

I am about to undergo inpatient treatment for alcoholism.  The treatment center deals with dual diagnosis.

My question is, how does active alcoholism affect diagnosis and treatment of bipolar disorder?

I've recently been diagnosed with bipolar 2 after suffering years of major depression. I think the diagnosis was based on how I respond to antidepressants.  I experienced a very uncomfortable period of agitation, hallucinations and insomnia while coming off of cymbalta and ambien, and then was diagnosed with bipolar 2. I  have also been on many, many different antidepressants with no real relief.

I am now on lamictal, lexapro and seroquel;  the seroquel is for sleep.  Should my medications and diagnosis be re-evaluated? I should add that I've tried most of the antidepressants when I was sober, I've been drinking on the new medications (lamictal, lexapro and seroquel that is) for a couple of years now. My psychiatrist knows this and was the one who encouraged evaluation and treatment for alcoholism.

Thanks,
Jan
 

Dear Jan -- 
When treatment is not working as hoped, for any reason, it's good to re-think the diagnosis. If your current treatment was working well overall, that might not be warranted at this point. But if it isn't, and perhaps the need for inpatient treatment suggests that in the big picture it is not, then rethinking is good. The first rethinking I'd be inclined to do under these circumstances, though, would be to wonder whether the antidepressant you're currently on might be part of the reason why you need inpatient treatment, given your reaction to antidepressants before. If you've not had a period on the Lamictal and Seroquel without the antidepressant, that would be the first thing I'd consider. To my knowledge, there has been no report of these agents contributing to a need to drink, whereas antidepressant-induced mixed states are commonly associated with a desire to use drugs that will slow thinking or stop the negative circles of thought or at least help get to sleep, all of which as you know alcohol can do in the right dose and timing, for a few hours anyway (too bad things are usually worse afterward...). 

Later when things are going smoothly and clean/soberly, you could discuss with your doctor a very cautious taper off of whatever you'd accumulated at that point as the question will likely remain in your and her/his mind: how much of the problem was alcohol and not bipolar disorder? However, that must be done extremely cautiously, very slowly (like taking 6 months to a year to get off both agents), and with a very tight safety net ready to catch the earliest signs of mood relapsing, lest the mood relapse lead to alcohol relapse and back into the place you're now trying to leave. Some doc's would be very hesitant to consider this plan. Just yesterday I heard another horror story about a guy who was told he didn't have bipolar disorder after all, when he'd been doing well for a while, that his original problem was just a brief reactive psychosis associated with a stressful life event. His mood stabilizer treatment was stopped, and he had another psychotic episode with considerable personal risk, again.  So be cautious there. Good luck with all that. 

Dr. Phelps