Teens with bipolar disorder (BP) should be followed for substance abuse, because any substance abuse at all makes them more likely to develop a diagnosable substance use disorder (SUD) in less than 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 percent of 167 youth ages 12 to 17 developed abuse of or dependence on 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 that will continue to follow these adolescents into adulthood. The participants had no 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 a SUD and had 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 of or dependence on alcohol or drugs. Nicotine dependence was not included as an SUD.

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


Overall, 32.3 percent 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 percent abuse, 5.4 percent dependence) followed by alcohol (15.6 percent abuse, 4.8 percent dependence). Other drug abuse and dependence did not exceed 1.2 percent.

The strongest predictor of later substance abuse was repeated alcohol use early, 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 medication. More than half (54.7 percent) of teens with three or more risk factors developed substance abuse, compared to 14.1 percent 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,” the authors wrote. 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.”

In an accompanying editorial, Robert Milin, M.D., wrote that the findings suggest that treatment management of BP could help mediate against the development of substance use disorder. “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 with 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.”