When a bipolar patient is a comorbid substance abuser; which do you treat first?
The answer is neither and both. Unless there is a very clear history to support a substance-induced mood disorder in the patient with a substance use disorder, clinicians should err on the side of diagnosing and treating both bipolar disorder and the substance use disorder concurrently. We know that the lifetime prevalence of substance use disorders in patients with bipolar disorder is over 50%, perhaps as high as 70%. So comorbid substance use disorders are the rule in bipolar disorder, not the exception. Parallel treatment with mood stabilizers and chemical dependency rehabilitation should be the standard of care. Withholding mood stabilizers in such patients with comorbidity because they fail to pursue chemical dependency rehabilitation is not advised.
