Impact of Bipolar Disorder on Girls - Effect of Substance Abuse in Females

Written by Martha Hellander, J.D.

Substance abuse and addiction

The effects of substance abuse are magnified in females; a woman with bipolar disorder is approximately 7 times more likely to have a substance use diagnosis than is a woman without bipolar disorder (the comparable increased risk in men with bipolar disorder is three-fold). Early cigarette smoking appears to prime the brain to be more responsive to other drugs like cocaine, and females addicted to nicotine have a harder time quitting than do males. Teenagers become addicted faster than adults. Street drugs (such as marijuana, cocaine, and ecstasy) as well as nicotine can cause psychiatric symptoms. Smoking pot can cause psychosis and hostility, destroy a girl's motivation for learning and achievement, and render her incapable of concentrating or comprehending what she reads (these are also symptoms of schizophrenia, which typically emerges in the late teens and early twenties). An increase in these symptoms during the teenage years, or any level of known substance abuse, should be a red flag to parents, who may then choose to require mandatory random urine testing and outpatient drug treatment as a condition for living at home. Residential treatment centers with strong recovery programs may offer the best chance to treat the often considerable effects of street drugs on the bipolar adolescent, and research shows that earlier interventions make recovery more likely.

Hyperprolactinemia

Antipsychotic medications may increase the secretion of prolactin by the pituitary gland. Prolactin stimulates the production of breast milk (called galactorrhea when it occurs in non-nursing women and men), and hyperprolactinemia (high levels of prolactin) and may lead to estrogen deficiency and, in turn, bone loss, amenorrhea (absence of periods), and infertility. Prolactin also may elevate testosterone levels in females, leading to acne and/or excess body hair growth. Few of these questions have been studied in children or teenagers receiving these drugs, and it remains unknown what long-term implications there may be in teens who show elevated prolactin without any clinical signs. It is not yet known whether medications taken in childhood will affect future response to female hormones during puberty and adulthood.

Weight gain and acne

Bipolar disorder is associated with obesity, diabetes, and heart disease. Sadly, the side effect profiles of medications currently used to manage bipolar disorder also include significant weight gain and diabetes. Weight gain is likely to leave a girl unwilling to take the prescribed medication. Parents informed in advance of these possibilities can help prevent obesity and promote treatment compliance by providing their daughter with a program of frequent, vigorous exercise, and placing the whole family on a healthy diet free of junk foods and high-calorie sodas (fruit-flavored, no-calorie spritzers are available if your daughter wants something to drink from a can). Consultations with fitness trainers and nutritional experts can be helpful in getting started (and may be covered by insurance). Exercise helps depression by delivering more oxygen to the brain and raising serotonin, a brain chemical found to be abnormally low in people with depression, and is associated with numerous improvements in various measures of mood, cognition, and physical health. No research studies have yet been done to measure the effects of diet and exercise on weight control or cognition in adolescents with bipolar disorder. For some, the appetite is so stimulated by a medication that dieting is impossible.

Acne, a potential (but not inevitable) side effect of lithium, is also distressing to adolescents. Acne in a girl may be a sign of hormonal imbalance. If lithium is working to stabilize mood, dermatologists can usually treat acne with prescription skin care regimens. As with all medications, if side effects become unmanageable, a change of medication may be needed.

Polycystic Ovarian Syndrome

Parents of girls taking valproate (an anticonvulsant sold in the U.S. as Depakote) need to know that it may precipitate hormonal abnormalities and lead to excessive hair growth, ovarian cysts, decreased menstruation, elevated testosterone levels, and central (abdominal) obesity. These symptoms can lead to polycystic ovarian syndrome (PCOS), which in turn increases a woman's risk for infertility, diabetes, and cardiovascular disease. This concern surfaced in a 1993 study from Iceland, in which 20% of women on valproate over the age of 20 with epilepsy had PCOS, as did 60% of women in the study who began taking it in adolescence. "These data are compelling and warrant that families of children and adolescents be fully informed of these findings before valproate is begun, and that menses in girlsand testosterone levels in girls as well as boys are monitored during treatment," says Barbara Geller, M.D., who chairs CABF's Professional Advisory Council. "As PCOS can be associated with infertility, it is important that this potential side effect be discussed with families. Future studies can address the frequency of early PCOS symptoms in children with bipolar disorder who receive valproate." The causes of PCOS are probably many (including weight gain and epilepsy), and some girls may be genetically predisposed to the condition.

Studies of adolescent girls with bipolar disorder on valproate have not yet been conducted; however, a recent review by Dr. Hadine Joffe of Harvard found that adult women with bipolar disorder taking valproate had substantially more treatment-emergent symptoms of PCOS than women taking other medications (10.5% compared to 1.4% for non-users) and the difference in symptoms appeared within the first year of valproate use. "Based on our findings, it is important for doctors prescribing valproate to monitor women taking the drug for signs of PCOS," says Dr. Joffe.

Oral contraceptives with low-androgenic progestins and glucophage, an anti-diabetes medication sometimes used to control insulin resistance and weight gain, may have beneficial effects in girls with PCOS, but data are lacking in this age group.

Residential treatment

Some parents reluctantly conclude that residential treatment is necessary for their vulnerable daughters with bipolar disorder. Residential treatment centers with good clinical care allow girls with bipolar disorder to be educated in a safe, structured, recovery environment that provides therapy, psychiatric care, teaching of coping strategies for impulse control and management of overwhelming feelings, along with round-the-clock staff supervision. If substance use and unsafe sexual behavior is discovered, intervention by placement in a wilderness program for girls or a residential treatment center (typical stays are six to eighteen months) that offers a good substance abuse program may divert a girl from becoming trapped in a lifelong cycle of addiction, hospitalization, and relapse. Intervention is most likely to succeed when done in the early stages of substance abuse and addiction, although no research has been done on the prevention of substance abuse and addiction in children with bipolar disorder as they pass through the age of highest risk. Placement in a residential treatment center is often not covered by health insurance, quality of care varies tremendously, and fees range from $3,500-$7,000 per month (better facilities typically have higher fees). Educational consultants can help with finding a suitable placement, and school districts will sometimes cover the academic costs.

Conclusion

Girls with bipolar disorder face enormous risks. We, as parents and helping professionals and researchers, must educate ourselves about the risks associated with bipolar disorder in girls, including the consequences of lack of treatment and treatment side effects. We must seek or create environments-sometimes, of necessity, away from the home and community-where our girls can be educated, receive medical care and taught self-awareness and management of their symptoms and cycles, in order to help them seize the reins and navigate the territory ahead. We must insist upon vastly increased federal funding of research on all aspects of diagnosis, treatment, and prevention of pediatric bipolar disorder. We must teach our girls, those who survive their sojourn in the underworld, how to use the insight and wisdom they gained there to heal and illuminate the way for others. Like Demeter, we must raise our voices in grief and outrage at the prospect of losing our daughters forever.

About the author: Martha Hellander, J.D. is Child and Adolescent Bipolar Foundation Research Policy Director

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