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Journal of the Canadian Academy of Child and Adolescent Psychiatry logoLink to Journal of the Canadian Academy of Child and Adolescent Psychiatry
. 2018 Jul 1;27(3):159–166.

Dimensional and Categorical Correlates of Substance Use Disorders among Canadian Adolescents with Bipolar Disorder

Antonette Scavone 1,2, Vanessa Timmins 1, Jordan Collins 1, Brenda Swampillai 1, Trehani M Fonseka 1, Dwight Newton 1, Melanie Naiberg 1, Rachel Mitchell 1, Athena Ko 1, Joshua Shapiro 1, Katelyn Collinger 1, Carolyn Boulos 1, Benjamin I Goldstein 1,✉
PMCID: PMC6054285  PMID: 30038653

Abstract

Objectives

Despite increasing evidence of excessive substance use disorder (SUD) prevalence among adolescents with bipolar disorder (BP), little is known about this topic among Canadian adolescents with BP. We therefore sought to examine the clinical characteristics and dimensional measures of psychopathology associated with comorbid SUD among Canadian BP adolescents.

Method

Participants were 100 adolescents, ages 13–19 years, with BP I, II, or not otherwise specified (NOS). Diagnoses (current and lifetime) were determined via the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime version (KSADS-PL). Participants were considered to have lifetime SUD if they met DSM-IV criteria for abuse of or dependence on alcohol or any drug other than nicotine. Chi-square analyses and independent samples t-tests were followed by logistic regression analyses.

Results

The lifetime prevalence of SUD was 33% (primarily alcohol and cannabis use disorders). In univariate analyses, SUD was associated with greater lifetime prevalence of conduct disorder, oppositional defiant disorder, panic disorder, assault of others, and a greater number of stressful life events. SUD was significantly associated with greater self-reported impulsivity and parent-report of anger/depression in the adolescent. In multivariable analyses, SUD was associated with panic disorder and oppositional defiant disorder.

Conclusion

SUD is highly prevalent among Canadian adolescents with BP and is associated with anxiety disorders, behavioural disorders, and trait impulsivity. Targeting these clinical characteristics may help guide preventative and treatment strategies for this population.

Keywords: bipolar disorder, substance use disorder, adolescents, drug, alcohol, predictor

Introduction

Comorbid substance use disorders (SUD; i.e. alcohol or drug abuse or dependence) are highly prevalent among adults with bipolar disorder (BP), even compared to other psychiatric illnesses, with lifetime rates in excess of 50% (Bizzarri et al., 2007; Cerullo & Strakowski, 2007; Goldstein & Levitt, 2007; Regier et al, 1990; Swann, 2010). Comorbid SUD among adults with BP is associated with numerous proxies for increased salient clinical and demographic characteristics including anxiety disorders (Goldstein & Levitt, 2007), suicidality (Dalton, Cate-Carter, Mundo, Parikh, & Kennedy, 2003), and physical (Richardson, 2011) and sexual abuse (Kolodziej et al., 2005).

Over the past decade, there has been increasing evidence that rates of SUD are also excessive among adolescents with BP (Geller & Luby, 1997; Goldstein et al. 2008; Merikangas & McClair, 2012; Wilens et al., 2004). Similarly, SUD among adolescents with BP are associated with legal problems (Goldstein et al. 2008), suicidality (Goldstein et al. 2008; Goldstein et al., 2012), anxiety disorders (Wilens et al., 2004), post-traumatic stress disorder (PTSD; Goldstein et al. 2008; Steinbuchel et al., 2009), conduct disorder (Wilens et al., 2008), physical and sexual abuse (Goldstein et al., 2008), and pregnancy and abortion (Goldstein et al., 2008; Heffner et al., 2012). Importantly, the prevalence of SUD among youth with BP appears to be similar across BP subtypes (Goldstein et al., 2008; Goldstein et al., 2013). A study by Duffy and colleagues (Duffy, Alda, Crawford, Milin, & Grof, 2007) found that SUDs appeared to be a complication of a pre-existing mood disorder among offspring of individuals with BP.

Most previous studies examining SUD among adolescents with BP have included samples from the U.S. Canadian epidemiologic data confirm increased rates of SUD among adolescents with BP (Kozloff et al., 2010), however no previous clinical study has examined this topic among Canadian adolescents with BP, nor have any studies examined for correlates of SUD among Canadian adolescents with BP. Moreover, findings from offspring of parents with BP (Duffy, Grof, Grof, Zvolsky, & Alda, 1998; Duffy et al., 2007; Duffy et al., 2012) demonstrate the peak hazard of SUD was between 14–20 years of age, and that in addition to having a mood disorder, male sex, parental SUD, and psychosis were significantly associated with SUD. Similar to other findings among adolescents with BP, mood disorders among BP offspring most commonly predated SUD (Goldstein & Bukstein, 2010). However, only 11–33% of the high-risk offspring in these studies had BP. As such, no previous clinical study has examined the prevalence and correlates of SUD among Canadian adolescents with BP.

Findings from adults with BP suggest that there may be cross-national differences in comorbidities in general, and SUD specifically. Whereas a cross-national comparison of epidemiologic studies did not find differences in SUD prevalence (Merikangas et al., 2011), there do appear to be cross-national differences in SUD prevalence in clinically-derived samples (Post et al., 2011). These differing findings may be due to the worse course of illness and increased comorbidities among clinical samples, which result in the individuals seeking treatment. Post and colleagues compared BP characteristics and comorbidities in clinical BP samples from the U.S. and Europe (Post et al., 2011). Compared with Germany and the Netherlands, participants in the U.S. reported greater rates of SUD, and this difference appeared to be explained in part by higher rates of anxiety disorders and a history of physical or sexual abuse in the U.S. (Post et al., 2011).

Dimensional measures of psychopathology in relation to comorbid SUD among adults with BP have also been receiving increased attention in recent years. For example, trait impulsivity has been shown to be prominent in both SUD and BP (Swann, Dougherty, Pazzaglia, Pham, & Moeller, 2004). Indeed, a recent meta-analysis found that BP individuals with SUD were more impulsive than those without SUD (Richardson, 2011). Similarly, SUD among adults with BP has also been associated with greater levels of trait aggression (Grunebaum et al., 2006).

Due to marked international differences in clinical characteristics observed among adults with BP, and meaningful differences in the healthcare systems in Canada and the U.S. (Vasiliadis, Lesage, Adair, Wang, & Kessler, 2007), we sought to examine this topic in a Canadian sample of BP adolescents. The differing healthcare systems in Canada and the U.S. may contribute to the willingness of adolescents to seek treatment, as well as the type of treatment they are provided, thus impacting their disorder progression. In addition, we sought to investigate dimensional measures of psychopathology, with an emphasis on mood dysregulation/lability, in relation to comorbid SUD among adolescents with BP.

Method

Sample

The present study includes 100 participants, ages 13–19, with BP I, II, or not otherwise specified (NOS). Participants were seeking assessment and/or treatment at a sub-specialty clinic in a tertiary academic health sciences centre. At least one parent/guardian for each adolescent also participated. Prior to study commencement, all participants and their parent/s provided written informed consent. Participants were a consent-giving subgroup of consecutive admissions. Research Ethics Board approval was obtained.

Procedure

Diagnoses (current and lifetime) were determined via the Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version (KSADS-PL; Kaufman et al., 1997), which incorporates information from adolescents and their parent/s. All interviewers have a bachelor’s or master’s degree in the health sciences field and completed KSADS training under the supervision of the senior author (B.G). The mood sections of the KSADS-PL were replaced with extended mood sections, the KSADS Depression Rating Scale (DRS; Chambers et al., 1985) and KSADS Mania Rating Scale (MRS; Axelson et al., 2003). Diagnoses were determined with the consideration of all available information, with clinical judgment used when conflicting information was provided. Diagnoses were confirmed by a consensus meeting with a child psychiatrist following completion of the KSADS-PL interview (B.G).

As BP-NOS criteria are not specified in DSM-IV, our study operationalized BP-NOS using the following criteria from the Course and Outcome of Bipolar Youth (COBY) study (Birmaher et al., 2006): elevated and /or irritable mood, plus: (i) two DSM-IV manic symptoms (three if only irritable mood is reported), (ii) change in functioning, (iii) mood and symptom duration of at least 4 h during a 24-h period, and (iv) at least four cumulative 24-h periods of episodes over the participant’s lifetime that meet the mood, symptom, and functional change criteria. Participants were considered to have lifetime SUD if they met DSM-IV criteria for abuse of or dependence on alcohol or any drug other than nicotine.

The age of onset of BP was considered to be when the participant first met DSM-IV criteria for a manic, mixed, or hypomanic, or when he /she first met study criteria for BP-NOS. The age of onset of an individual’s SUD was considered to be when the participant first met DSM-IV criteria for alcohol or substance abuse or dependence.

History of physical and sexual abuse was obtained with an interviewer-administered medical history questionnaire and from the PTSD screen within the KSADS-PL. An interviewer-administered Safety Assessment Form was used to determine lifetime aggression and suicidality that may have occurred outside of the context of a depressive episode, with information on suicide attempts also obtained via the KSADS DRS.

The self-report Life Problems Inventory (LPI) was used to identify dimensional impulsivity, emotional dysregulation, identity confusion, and interpersonal problems (Rathus & Miller, 1995). The self-reported Children’s Affective Lability Scale (CALS) was completed by the participant, and one parent completed the measure regarding the adolescent (Gerson et al., 1996). This self-report has two subscales, including angry/depressed and disinhibited/persistent.

Participants completed the self-report Stressful Life Events Schedule (SLES) to identify the occurrences of various stressful events (e.g. ran away from home, broke up with boyfriend/girlfriend) and the perceived impact of each event (Williamson et al., 2003). Parents also completed the SLES about their adolescent. Psychiatric history of first- and second-degree relatives was obtained through an interview with parents and the adolescent, using the Family History Screen (Weissman et al., 2000).

Analyses

Chi square analyses and Fisher’s Exact test were used for categorical variables and independent samples t-tests were used for dimensional measures. The threshold for statistical significance was set at p<0.05. The clinical characteristics and comorbidities that were at least marginally associated with SUD (p<0.1) in the univariate analyses were included in the regression analyses, with SUD as the dependent variable. False discovery rate (FDR) was utilized to control for multiple comparisons. Statistical analyses were conducted with SPSS version 21.

Results

SUD Prevalence

The lifetime prevalence of SUD was 33% (33/100). Nineteen percent of all adolescents reported a lifetime alcohol use disorder (11% abuse, 8% dependence) and 25% reported a lifetime drug use disorder (4% abuse, 21% dependence). Eight percent of the sample reported only a lifetime alcohol use disorder, 14% reported only a lifetime drug use disorder, and 11% reported both a lifetime alcohol use disorder and a lifetime drug use disorder. Cannabis abuse or dependence was reported by all participants who reported a lifetime drug use disorder. SUD onset preceded BP onset for 61% of the sample, BP preceded SUD for 18% of the sample, and SUD and BP onset were concurrent for 21% of the sample.

Univariate Analyses

Univariate analyses are presented in Table 1. Participants with SUD, as compared to those without SUD, reported significantly greater lifetime prevalence of conduct disorder (24.2% vs. 3%; p = 0.02) and oppositional defiant disorder (ODD) (63.6% vs. 22.4%; p = 0.01). As compared to participants without SUD, those with SUD reported greater assault of others (50% vs. 20%; p = 0.03) and a greater number of stressful life events (p = 0.01). SUD was significantly associated with greater self-reported impulsivity (p = 0.01).

Table 1.

Demographics and clinical characteristics of adolescents with bipolar disorder (BP) with versus without substance use disorders (SUD)

Overall sample
n = 100
n (%)		 SUD
n = 33
n (%)		 No SUD
n = 67
n (%)		 Statistic p-value p-value (FDR corrected)
Demographics
 Agea 16.2 ± 1.5 16.5 ± 1.4 16.0 ± 1.5 t = −1.70 0.09 0.29
 Gender (Female) 67 (67%) 24 (63.6%) 46 (68.7%) X2= 0.25 0.62 0.86
 Race (White) 85 (86%) 26 (81.8%) 59 (88.1%) X2 = 0.71 0.34 0.72
 Living with Both Biological Parents 56 (56%) 18 (54.5%) 38 (56.7%) X2= 0.04 0.84 0.92
Clinical Characteristics
 BP subtype
  BP-I 26 (26%) 8 (24.2%) 18 (26.9%) X2= 0.13 0.71 0.88
  BP-II 40 (40%) 25 (45.5%) 15 (37.3%) X2= 0.52 0.47 0.82
  BP-NOS 34 (34%) 10 (30.3%) 24 (36.4%) X2= 0.36 0.55 0.86
 BP onset age 14.3 ± 2.5 14.6 ± 2.7 14.2 ± 2.5 t = −0.70 0.48 0.82
 SUD onset age 14.1 ± 1.7 13.9 ± 1.8 - - - -
 Baseline depression (current episode) 18.5 ± 12.7 19.1 ± 12.2 18.2 ± 3.0 t = −0.46 0.64 0.86
 Baseline mania (current episode) 15.93 ± 11.6 15.2 ± 11.3 16.3 ± 11.8 t = 0.43 0.67 0.86
 Lifetime CGAS (most severe past episode) 41.1 ± 7.4 40.0 ± 6.3 41.5 ± 7.9 t = 0.90 0.37 0.72
 CALS (adolescent)
  Disinhibited/persistant 11.6 ± 6.5 11.1 ± 6.7 11.8 ± 6.4 t = 0.44 0.66 0.86
  Angry/depressed 18.5 ± 11.8 20.5 ± 12.9 17.5 ± 11.2 t = −1.10 0.27 0.69
 CALS (parent)
  Disinhibited/persistant 11.6 ± 6.5 7.9 ± 5.8 7.0 ± 6.1 t = −0.59 0.55 0.86
  Angry/depressed 16.9 ± 12.1 21.9 ± 11.8 15.4 ± 11.8 t = −2.6 0.009 0.07
 LPI (total score) 148.67 ± 63.66 164.03 ± 70.83 140.87 ± 58.77 t = −1.67 0.10 0.31
  Impulsivity 33.1 ± 17.1 40.4 ± 17.3 29.3 ± 14.1 t = −3.29 0.001 0.01
  Emotional Dysregulation 38.0 ± 17.9 40.5 ± 19.4 36.7 ± 17.1 t = −0.98 0.33 0.72
  Identity Confusion 40.7 ± 17.9 41.8 ± 19.2 40.1 ± 17.4 t = −0.42 0.67 0.86
  Interpersonal Problems 36.9 ± 17.1 41.2 ± 18.0 34.7 ± 16.3 t = −1.74 0.08 0.28
 Number of stressful life events 8.5 ± 5.4 10.9 ± 6.1 7.2 ± 4.5 t = −3.30 0.001 0.01
 Wong-Baker score (pain past month) 1.5 ± 1.6 1.4 ± 1.5 1.5 ± 1.6 t = 0.28 0.77 0.92
 Psychiatric hospitalizations (yes) 50 (50%) 20 (60.6%) 30 (44.8%) X2= 2.20 0.14 0.40
 Suicidal Ideation 61 (61%) 19 (57.6%) 42 (62.7%) X2= 0.24 0.62 0.86
 Suicide attempt 25 (25%) 10 (30.3%) 15 (22.4%) X2= 0.74 0.39 0.72
 Physical abuseb 9 (9%) 6 (18.2%) 3 (4.5%) FET2 0.06 0.23
Sexual abuse 12 (12%) 7 (21.2%) 5 (7.5%) FET2 0.06 0.23
Open in a new tab
a

Values for all continuous variables are written as mean ± SD.

b

Fishers Exact Test

FDR = false discovery rate

Table 2.

Comorbidities and clinical characteristics of adolescents with bipolar disorder (BP) with versus without substance use disorders (SUD)

Overall sample
n = 100
n (%)		 SUD
n = 33
n (%)		 No SUD
n = 67
n (%)		 Statistic p-value p-value (FDR corrected)
Co-Morbidity
 Any anxiety 72(72%) 24(72.7%) 48(71.6%) X2= 0.01 0.91 0.95
 ADHD 41(41%) 18(54.5%) 23(34.3%) X2= 3.7 0.053 0.23
 Conduct disorder 10(10%) 8(24.2%) 2(3%) FET2 0.002 0.02
 ODD 36(36%) 21(63.6%) 15(22.4%) X2= 16.3 <0.001 0.01
 Panic disorder 17(17%) 10(30.3%) 7(10.4%) X2= 6.2 0.013 0.07
 PTSD 4(4%) 2(6.1%) 2(3%) FET2 0.60 0.86
 Bulimia nervosa 9(9%) 6(18.2) 3(4.5%) FET2 0.06 0.23
 Psychosis 24(24%) 6(18.2%) 18(26.9%) X2= 0.91 0.34 0.72
Legal Problems
 Police contact or arrest 43(43%) 20(60.6%) 23(34.3%) X2= 6.2 0.013 0.07
 Assault of others 27(30%) 15(50%) 12(20%) X2= 8.6 0.003 0.03
Lifetime Medication
 Second generation antipsychotic 53(53%) 18(54.5%) 35(52.2%) X2= 0.05 0.83 0.92
 Lithium 20(20%) 5(15.2%) 15(22.4%) X2= 0.72 0.39 0.72
 Antimanic 59(59 %) 19(57.6%) 40(59.7%) FET2 1.00 1.00
 Lamotrigine 6(6%) 2(6.1%) 4(6%) FET2 1.00 1.00
 SSRI antidepressants 32(32%) 11(33.3%) 21(31.3%) X2= 0.04 0.84 0.92
 Stimulants 16(16%) 5(15.2%) 11(16.4%) X2= 0.03 0.87 0.93
Family Psychiatric History
 Family history of mood disorder (MDE) 78(78%) 28(84.8%) 50(74.6%) X2= 1.35 0.25 0.68
 Family history of mood disorder (hypomania/ mania) 53(53%) 18(54.5%) 35(52.2%) X2= 0.05 0.83 0.92
 Family history of SUD 45(45%) 17(51.5%) 28(41.8%) X2= 0.84 0.36 0.72
Open in a new tab
a

Values for all continuous variables are written as mean ± SD.

b

Fishers Exact Test

FDR = false discovery rate

Multivariable Analyses

In multivariable analyses, the following variables were significantly associated with SUD: panic disorder ([odds ratio (OR) = 8.45, 95% confidence interval (CI): 1.64–43.43, p = 0.01] and ODD (OR = 4.97, 95% CI = 1.22–20.27, p = 0.02).

Discussion

The present study of Canadian adolescents with BP found SUD to be associated with higher rates of multiple comorbidities including conduct disorder, ODD, and panic disorder, as well as violence, impulsivity, and stressful life events. Specifically, SUD was associated with greater rates of assault, as well as greater mood lability, as reported by their parents. In the present sample, one third of adolescents had an SUD. In multivariable analyses, SUD was independently significantly associated with comorbid panic disorder and ODD. These findings, from a clinical sample of Canadian adolescents with BP, largely converge with previous findings from U.S. clinical samples, and expand the literature regarding dimensional phenotypes associated with comorbid SUD among adolescents with BP.

The limitations of the current study must be considered in interpreting these results. First, a cross-sectional methodology was utilized, thus precluding any inferences regarding causation. Second, urine toxicology was not used. Although it would only confirm current SUD, as opposed to lifetime SUD, urine toxicology may have optimized diagnostic accuracy. Third, the majority of cases of SUD had cannabis or alcohol use disorders. Correlates of SUDs related to less commonly used substances such as cocaine may differ from those reported here (Services US, 2012). Fourth, the present sample was drawn from a tertiary clinical setting and therefore may not be representative of other samples such as untreated community samples. Fifth, although the present sample is among the larger ones in the current literature in adolescent BP, the sample size was not adequate to detect small effect sizes as significant. Lastly, the present study is based on a treatment seeking sample at a tertiary centre, and may therefore not generalize to the general population. However, the high SUD rates found in the present study are similar to the rates reported among adolescents in the general population (Kozloff et al., 2010).

The prevalence of SUD in the current samples is consistent with rates reported in U.S. clinical samples (32–34%) (Goldstein et al., 2013; Wilens et al., 2008) and in a Canadian epidemiologic sample (32%) (Kozloff et al., 2010). Moreover, the prevalence of SUD of the current sample is similar to rates reported by some U.S. studies of adolescents with BP (Goldstein et al., 2008).

The association of panic disorder with SUD in the current study converges with numerous previous studies of adults with BP, (Chen & Dilsaver, 1995; Simon et al., 2004) as well as previous studies of adolescents with BP (Goldstein et al., 2013; Wilens et al., 2008). Panic disorder has been found to be strongly associated with SUD among BP adolescents and adults even more so than anxiety disorders in general (Goldstein & Levitt, 2008; Goldstein et al., 2013; Goodwin & Hoven, 2002).

There have been mixed findings regarding the association of ODD and SUD among BP youth. Some past studies have not found ODD to be associated with SUD among BP adolescents or adults (Goldstein et al., 2008; Kenneson, Funderburk, & Maisto, 2013). However, a recent study found ODD to be a strong predictor of first-onset SUD among BP adolescents (Goldstein et al., 2013). Data from the National Comorbidity Survey Replication study found ODD to be associated with SUD among adults with early-onset BP (Kenneson et al., 2013). The association of CD with SUD did not remain significant after controlling for other variables, likely due in part to the relatively low prevalence of CD as compared to ODD.

This study’s finding of a strong and independent association between impulsivity and SUD substantiates and expands upon the previous findings from adults with BP (Grunebaum et al. 2006; Swann, 2010; Swann et al., 2004). Increased rates of police contact among BP adolescents with SUD in the current study converge with previous findings in adults (Quanbeck et al., 2004) and adolescents (Goldstein et al., 2008) in the U.S, although there are also discrepant findings (Barzman, DelBello, Fleck, Lehmkuhl, & Strakowski, 2007).

Contrary to the literature (Goldstein & Bukstein, 2010) SUD onset preceded BP onset for 61% of the sample, SUD and BP onset were concurrent for 21%, and BP preceded SUD for 18% of the sample. Although this finding may reflect true cross-national differences, replication in other samples is warranted.

Consistent with past findings, psychiatric hospitalizations were not found to be significantly associated with SUD in the present study, although mixed findings have been found in past studies. In a youth BP sample (Goldstein et al., 2008), psychiatric hospitalizations were not associated with SUD, whereas in adult samples (Cassidy, Ahearn, & Carroll, 2001; Sonne, Brady, & Morton, 1994), those with SUD had more psychiatric hospitalizations. Reasons for this discrepancy are uncertain given the cross-sectional methodology and lack of information about the timing of hospitalization in relation to SUD. It is plausible that hospitalization may lead to after-care that helps prevent SUD in some cases, whereas in other cases SUD may precipitate behaviors that lead to hospitalization, yielding a null finding across the entire group. Future longitudinal studies are warranted to address this topic.

Conclusions

The findings of the current study suggest that interventions treating comorbid disorders and dimensional lability may be beneficial among those with SUD. Family focused treatment is efficacious for BP adolescents without SUD, and a pilot study of adolescents with comorbid BP and SUD found that family focused treatment modified for use in this population led to improved depressive and manic symptoms (Goldstein et al., 2015). However, to our knowledge, no psychosocial treatment study to date has yielded significant reductions of substance use among adolescents with BP. Further research examining early interventions among BP adolescents with or at risk for SUD is warranted.

The results of the current study suggest some potential clinical implications for youth with BP. Early interventions targeting comorbid disorders and dimensional liability traits associated with SUD may improve BP course of illness. More specifically, ameliorating panic disorder, disruptive behavior disorders, and impulsivity may prevent or delay SUD onset. It is important to acknowledge that while impulsivity may have predisposed those with BP to SUD, the cross-sectional methodology does not allow us to rule out the reverse association. Replication utilizing a larger sample and longitudinal methodology is necessary to better understand factors associated with the development of SUD as well as the impact of SUD on the course of BP among Canadian adolescents. As has previously been done with adults (Baethge et al., 2008) future prospective studies are warranted to determine the bidirectional associations between mood and substance use in BP. Utilizing neuroimaging and biomarkers to further examine the association between mood and substance use among adolescents with BP is also warranted, to better parse the biological underpinning of the association. Given the pernicious effect of SUD on the course of BP among adults, strategies that effectively reduce the incidence and burden of SUD among youth have the potential to mitigate the symptomatic, functional, and risk-related burden of BP.

Acknowledgments / Conflict of Interest

The authors thank the staff at the Centre for Youth Bipolar Disorder at Sunnybrook Health Sciences Centre for their contributions to this manuscript. Dr. Collins reports personal fees from Apotex, outside the submitted work; his engagement with Apotex commenced after his contributions to the submitted work. The remaining authors report no conflicts of interest.

References

  1. Axelson D, Birmaher BJ, Brent D, Wassick S, Hoover C, Bridge J, Ryan N. A preliminary study of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children mania rating scale for children and adolescents. Journal of Child and Adolescent Psychopharmacology. 2003;13(4):463–470. doi: 10.1089/104454603322724850. Epub 2004/02/24. [DOI] [PubMed] [Google Scholar]
  2. Barzman DH, DelBello MP, Fleck DE, Lehmkuhl H, Strakowski SM. Rates, types, and psychosocial correlates of legal charges in adolescents with newly diagnosed bipolar disorder. Bipolar Disorders. 2007;9(4):339–344. doi: 10.1111/j.1399-5618.2007.00423.x. Epub 2007/06/06. [DOI] [PubMed] [Google Scholar]
  3. Baethge C, Hennen J, Khalsa HM, Salvatore P, Tohen M, Baldessarini RJ. Sequencing of substance use and affective morbidity in 166 first-episode bipolar I disorder patients. Bipolar Disorder. 2008;10:738–741. doi: 10.1111/j.1399-5618.2007.00575.x. [DOI] [PubMed] [Google Scholar]
  4. Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, … Keller M. Clinical course of children and adolescents with bipolar spectrum disorders. Archives of General Psychiatry. 2006;63(2):175–183. doi: 10.1001/archpsyc.63.2.175. Epub 2006/02/08. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bizzarri JV, Sbrana A, Rucci P, Ravani L, Massei GJ, Gonnelli C, … Cassano GB. The spectrum of substance abuse in bipolar disorder: Reasons for use, sensation seeking and substance sensitivity. Bipolar Disorders. 2007;9(3):213–220. doi: 10.1111/j.1399-5618.2007.00383.x. Epub 2007/04/14. [DOI] [PubMed] [Google Scholar]
  6. Cassidy F, Ahearn EP, Carroll BJ. Substance abuse in bipolar disorder. Bipolar Disorders. 2001;3(4):181–188. [PubMed] [Google Scholar]
  7. Cerullo MA, Strakowski SM. The prevalence and significance of substance use disorders in bipolar type I and II disorder. Substance Abuse Treatment, Prevention, and Policy. 2007;2:29. doi: 10.1186/1747-597x-2-29. Epub 2007/10/03. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Chambers WJ, Puig-Antich J, Hirsch M, Paez P, Ambrosini PJ, Tabrizi MA, … Davies M. The assessment of affective disorders in children and adolescents by semistructured interview Test-retest reliability of the schedule for affective disorders and schizophrenia for school-age children, present episode version. Archives of General Psychiatry. 1985;42(7):696–702. doi: 10.1001/archpsyc.1985.01790300064008. [DOI] [PubMed] [Google Scholar]
  9. Chen YW, Dilsaver SC. Comorbidity of panic disorder in bipolar illness: Evidence from the Epidemiologic Catchment Area Survey. The American Journal of Psychiatry. 1995;152(2):280–282. doi: 10.1176/ajp.152.2.280. [DOI] [PubMed] [Google Scholar]
  10. Dalton EJ, Cate-Carter TD, Mundo E, Parikh SV, Kennedy JL. Suicide risk in bipolar patients: The role of co-morbid substance use disorders. Bipolar Disorders. 2003;5(1):58–61. doi: 10.1034/j.1399-5618.2003.00017.x. [DOI] [PubMed] [Google Scholar]
  11. Duffy A, Alda M, Crawford L, Milin R, Grof P. The early manifestations of bipolar disorder: A longitudinal prospective study of the offspring of bipolar parents. Bipolar Disorders. 2007;9:828–838. doi: 10.1111/j.1399-5618.2007.00421.x. [DOI] [PubMed] [Google Scholar]
  12. Duffy A, Grof P, Grof E, Zvolsky P, Alda M. Evidence supporting the independent inheritance of primary affective disorders and primary alcoholism in the families of bipolar patients. Journal of Affective Disorders. 1998;50:91–96. doi: 10.1016/s0165-0327(98)00017-2. [DOI] [PubMed] [Google Scholar]
  13. Duffy A, Horrocks J, Milin R, Doucette S, Persson G, Grof P. Adolescent substance use disorder during the early stages of bipolar disorder: A prospective high-risk study. Journal of Affective Disorders. 2012;142:57–64. doi: 10.1016/j.jad.2012.04.010. [DOI] [PubMed] [Google Scholar]
  14. Geller B, Luby J. Child and adolescent bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(9):1168–1176. doi: 10.1097/00004583-199709000-00008. [DOI] [PubMed] [Google Scholar]
  15. Gerson AC, Gerring JP, Freund L, Joshi PT, Capozzoli J, Brady K, … Denckla MB. The Children’s Affective Lability Scale: A psychometric evaluation of reliability. Psychiatry Research. 1996;65(3):189–198. doi: 10.1016/s0165-1781(96)02851-x. [DOI] [PubMed] [Google Scholar]
  16. Goldstein BI, Bukstein OG. Comorbid substance use disorders among youth with bipolar disorder: Opportunities for early identification and prevention. Journal of Clinical Psychiatry. 2010;71(3):348–358. doi: 10.4088/JCP.09r05222gry. [DOI] [PubMed] [Google Scholar]
  17. Goldstein BI, Levitt AJ. Prevalence and correlates of bipolar I disorder among adults with primary youth-onset anxiety disorders. Journal of Affective Disorders. 2007;103(1–3):187–195. doi: 10.1016/j.jad.2007.01.029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Goldstein BI, Levitt AJ. The specific burden of comorbid anxiety disorders and of substance use disorders in bipolar I disorder. Bipolar Disorders. 2008;10(1):67–78. doi: 10.1111/j.1399-5618.2008.00461.x. [DOI] [PubMed] [Google Scholar]
  19. Goldstein BI, Strober M, Axelson D, Goldstein TR, Gill MK, Hower H, … Birmaher B. Predictors of first-onset substance use disorders during the prospective course of bipolar spectrum disorders in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(10):1026–1037. doi: 10.1016/j.jaac.2013.07.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Goldstein BI, Strober MA, Birmaher B, Axelson DA, Esposito-Smythers C, Goldstein TR, … Keller MB. Substance use disorders among adolescents with bipolar spectrum disorders. Bipolar Disorders. 2008;10(4):469–478. doi: 10.1111/j.1399-5618.2008.00584.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Goldstein TR, Fersch-Podrat RK, Rivera M, Axelson DA, Merranko J, Yu H, … Birmaher B. Dialectical behavior therapy for adolescents with bipolar disorder: Results from a pilot randomized trial. Journal of Child and Adolescent Psychopharmacology. 2015;25(2):140–149. doi: 10.1089/cap.2013.0145. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Goldstein TR, Ha W, Axelson DA, Goldstein BI, Liao F, Gill MK, … Birmaher B. Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Archives of General Psychiatry. 2012;69(11):1113–1122. doi: 10.1001/archgenpsychiatry.2012.650. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Goodwin RD, Hoven CW. Bipolar-panic comorbidity in the general population: Prevalence and associated morbidity. Journal of Affective Disorders. 2002;70(1):27–33. doi: 10.1016/s0165-0327(01)00398-6. Epub 2002/07/13. [DOI] [PubMed] [Google Scholar]
  24. Grunebaum MF, Galfalvy HC, Nichols CM, Caldeira NA, Sher L, Dervic K, … Oquendo MA. Aggression and substance abuse in bipolar disorder. Bipolar Disorders. 2006;8(5):496–502. doi: 10.1111/j.1399-5618.2006.00349.x. [DOI] [PubMed] [Google Scholar]
  25. Heffner JL, DelBello MP, Fleck DE, Adler CM, Strakowski SM. Unplanned pregnancies in adolescents with bipolar disorder. The American Journal of Psychiatry. 2012;169(12):1319. doi: 10.1176/appi.ajp.2012.12060828. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, … Ryan N. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(7):980–988. doi: 10.1097/00004583-199707000-00021. [DOI] [PubMed] [Google Scholar]
  27. Kenneson A, Funderburk JS, Maisto SA. Risk factors for secondary substance use disorders in people with childhood and adolescent-onset bipolar disorder: Opportunities for prevention. Comprehensive Psychiatry. 2013;54(5):439–446. doi: 10.1016/j.comppsych.2012.12.008. [DOI] [PubMed] [Google Scholar]
  28. Kolodziej ME, Griffin ML, Najavits LM, Otto MW, Greenfield SF, Weiss RD. Anxiety disorders among patients with co-occurring bipolar and substance use disorders. Drug and Alcohol Dependence. 2005;80(2):251–257. doi: 10.1016/j.drugalcdep.2005.04.003. [DOI] [PubMed] [Google Scholar]
  29. Kozloff N, Cheung AH, Schaffer A, Cairney J, Dewa CS, Veldhuizen S, … Levitt AJ. Bipolar disorder among adolescents and young adults: Results from an epidemiological sample. Journal of Affective Disorders. 2010;125(1–3):350–354. doi: 10.1016/j.jad.2010.02.120. [DOI] [PubMed] [Google Scholar]
  30. Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, … Zarkov Z. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of General Psychiatry. 2011;68(3):241–251. doi: 10.1001/archgenpsychiatry.2011.12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Merikangas KR, McClair VL. Epidemiology of substance use disorders. Human Genetics. 2012;131(6):779–789. doi: 10.1007/s00439-012-1168-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Post RM, Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck PE, … Rowe M. Differential clinical characteristics, medication usage, and treatment response of bipolar disorder in the US versus The Netherlands and Germany. International Clinical Psychopharmacology. 2011;26(2):96–106. doi: 10.1097/YIC.0b013e3283409419. [DOI] [PubMed] [Google Scholar]
  33. Quanbeck CD, Stone DC, Scott CL, McDermott BE, Altshuler LL, Frye MA. Clinical and legal correlates of inmates with bipolar disorder at time of criminal arrest. The Journal of Clinical Psychiatry. 2004;65(2):198–203. doi: 10.4088/jcp.v65n0209. [DOI] [PubMed] [Google Scholar]
  34. Rathus J, Miller A. Unpublished manuscript. New York, NY: Montefiore Medical Center/Einstein College of Medicine; 1995. Life problems inventory. [Google Scholar]
  35. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, … Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990;264(19):2511–2518. [PubMed] [Google Scholar]
  36. Richardson T. Correlates of substance use disorder in bipolar disorder: A systematic review and meta-analysis. Mental Health and Substance Use. 2011;4(3):239–255. [Google Scholar]
  37. Services USDoHaH, Administration SAaMHS, Quality CfBHSa. National Survey on Drug Use and Health. Inter-university Consortium for Political and Social Research; Ann Arbor, MI: 2012. 2013. [Google Scholar]
  38. Simon NM, Otto MW, Wisniewski SR, Fossey M, Sagduyu K, Frank E, … Pollack MH. Anxiety disorder comorbidity in bipolar disorder patients: Data from the first 500 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) The American Journal of Psychiatry. 2004;161(12):2222–2229. doi: 10.1176/appi.ajp.161.12.2222. [DOI] [PubMed] [Google Scholar]
  39. Sonne SC, Brady KT, Morton WA. Substance abuse and bipolar affective disorder. Journal of Nervous Mental Disorders. 1994;182(6):349–352. doi: 10.1097/00005053-199406000-00007. [DOI] [PubMed] [Google Scholar]
  40. Steinbuchel PH, Wilens TE, Adamson JJ, Sgambati S. Posttraumatic stress disorder and substance use disorder in adolescent bipolar disorder. Bipolar Disorders. 2009;11(2):198–204. doi: 10.1111/j.1399-5618.2008.00652.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Swann AC. The strong relationship between bipolar and substance-use disorder. Annals of the New York Academy of Sciences. 2010;1187:276–293. doi: 10.1111/j.1749-6632.2009.05146.x. [DOI] [PubMed] [Google Scholar]
  42. Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Moeller FG. Impulsivity: A link between bipolar disorder and substance abuse. Bipolar Disorders. 2004;6(3):204–212. doi: 10.1111/j.1399-5618.2004.00110.x. [DOI] [PubMed] [Google Scholar]
  43. Vasiliadis HM, Lesage A, Adair C, Wang PS, Kessler RC. Do Canada and the United States differ in prevalence of depression and utilization of services? Psychiatric Services. 2007;58(1):63–71. doi: 10.1176/ps.2007.58.1.63. [DOI] [PubMed] [Google Scholar]
  44. Weissman MM, Wickramaratne P, Adams P, Wolk S, Verdeli H, Olfson M. Brief screening for family psychiatric history: The family history screen. Archives of General Psychiatry. 2000;57(7):675–682. doi: 10.1001/archpsyc.57.7.675. [DOI] [PubMed] [Google Scholar]
  45. Wilens TE, Biederman J, Adamson JJ, Henin A, Sgambati S, Gignac M, … Monuteaux MC. Further evidence of an association between adolescent bipolar disorder with smoking and substance use disorders: A controlled study. Drug and Alcohol Dependence. 2008;95(3):188–198. doi: 10.1016/j.drugalcdep.2007.12.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Wilens TE, Biederman J, Kwon A, Ditterline J, Forkner P, Moore H, … Faraone SV. Risk of substance use disorders in adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2004;43(11):1380–1386. doi: 10.1097/01.chi.0000140454.89323.99. [DOI] [PubMed] [Google Scholar]
  47. Williamson DE, Birmaher B, Ryan ND, Shiffrin TP, Lusky JA, Protopapa J, … Brent DA. The stressful life events schedule for children and adolescents: Development and validation. Psychiatry Research. 2003;119(3):225–241. doi: 10.1016/s0165-1781(03)00134-3. [DOI] [PubMed] [Google Scholar]

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