What is the best treatment strategy for a patient with both bipolar disorder and alcohol abuse?

In treating individuals with bipolar disorder, this question is extremely important to consider. Nearly 50% of individuals with bipolar disorder have problematic alcohol use (1). Further, alcohol use complicates the course and prognosis of bipolar disorder, leading to higher rates of mixed mania, rapid cycling, suicidality, and increased symptom severity (2). Despite the fact that alcohol use affects nearly half of all individuals with bipolar disorder, with a significant impact on their illness, there are limited data to guide treatment of this comorbidity.

To complicate matters further, there is no simple algorithm for treating these individuals. Psychiatrists must often forge into uncharted clinical territory: either the limited data that do exist to guide treatment decisions are not applicable because of severe medical complications of this comorbidity (e.g., cirrhosis) or only anecdotal evidence is available to support treatment decisions in this population (e.g., alcohol pharmacotherapy).

I recommend the following approach, addressing the most pressing clinical issues first and then systematically addressing other areas of the comorbidity. The choice of pharmacotherapy will depend on the individual's constellation of symptoms and associated medical conditions.