Beyond mood: alcohol and substance use older adults with bipolar disorder

Substance use and substance use disorders (SUD) are common comorbidities in bipolar disorder (BD) and remain clinically consequential in older-age bipolar disorder (OABD), where medical vulnerability increases and detection may be more challenging. This review summarizes epidemiologic and clinical findings on substance use in OABD and highlights implications for assessment and management.

Recent longitudinal studies suggest that fluctuations in alcohol consumption, even when modest, are associated with poorer mood stability and functioning in BD, while worsening mood symptoms do not consistently predict subsequent increases in alcohol use, complicating simple self-medication models. Population-based studies continue to demonstrate elevated rates of SUD in individuals with BD compared with age-matched controls, with risk concentrated among those with earlier-onset illness. Large cohort data link SUD to increased mortality and greater cumulative medical burden. Cannabis use has also been consistently associated with worsened clinical outcomes, including greater symptom severity, poorer treatment adherence, and increased hospitalization risk.

Substance use and SUD substantially worsen psychiatric and medical outcomes in OABD. Routine, repeated screening and integrated treatment approaches addressing psychiatric symptoms, medical comorbidity, cognition, and social context are essential to reduce long-term morbidity and improve functional outcomes in later life.