Bipolar disorder affects an estimated 2.8% of adults and 2.9% of adolescents in the U.S. annually, and the World Health Organization estimates 45 million people worldwide suffer from the disorder.1,2 Bipolar disorder is a mental illness characterized by shifting moods of major depression, hypomania, or manic episodes that are more severe than the “ups and downs” most experience.1
There are three types of bipolar disorder:1
- Bipolar I disorder is characterized by manic episodes lasting at least 7 days, with symptoms so severe a person needs immediate hospital care.
- Bipolar II disorder is defined by a pattern of alternating depressive and hypomanic episodes that are less in severity than those with bipolar I.
- Cyclothymic disorder is characterized by periods of hypomania and periods of depression lasting for at least two years, with symptoms that don’t meet the diagnostic requirements for hypomanic or depressive episodes.
Episodes of Mania and Depression
Mood swings are a part of life for everyone, but a person with bipolar disorder has mood swings that are extreme, affect daily functioning, and outside the range of normal behavior.1
Manic episodes are identified by elevated moods, energy levels, or irritability, and sometimes even by psychosis.1 Full-blown mania may last for at least a week, with persistent symptoms and a state of high energy.3 It’s often accompanied with little or no sleep.1,3 Manic episodes are also marked by an increase in goal-directed activity or energy, although these goals may display seemingly poor judgment.1,3 During a manic episode, a person with bipolar disorder may appear to be more talkative or agitated and be easily distracted.1,3
Severe episodes of mania that are marked by psychosis may include hallucinations or delusions.1 A person in this state might believe they are famous or have special powers. Depressive episodes may also include psychosis, such as believing they have committed a crime or that they have a serious illness.1
Hypomania is a milder form of mania where psychosis isn’t present and there’s less functional impairment.3
Depressive episodes in people with bipolar disorder are recognized by fatigue, sadness, suicidal ideations, and hopelessness.1 Little interest is displayed in most activities, and speech may be slowed.1 Depression may also be characterized by weight gain, trouble falling asleep or sleeping too much, and trouble concentrating.1
It’s possible to have a “mixed mood episode” as well. These are episodes containing simultaneous depressive and manic features.1,3
Co-Occurring Bipolar and Substance Use Disorders
Individuals suffering from bipolar disorder often (approximately 65-95% of the time) have at least one co-occurring mental health disorder.4 They are also more likely than the general population to battle a substance use disorder.3 It’s estimated that anywhere from 40% to 60% of those with bipolar disorder have a co-occurring substance abuse disorder.3 Those with cooccurring bipolar and substance use disorders are also likely to suffer from anxiety disorders, such as panic disorder or social anxiety disorder.5
Individuals with rapid-cycling bipolar disorder—or at least four episodes in a year—are more highly at risk of developing a substance use disorder, however, it can be difficult to discern mood shifts if the individual is alternating between periods of intoxication and withdrawal.3
Treatment for a substance use disorder is more complex when an individual has also been diagnosed with bipolar disorder (and vice versa).3,6 Substance abuse is more severe in those with childhood onset of bipolar disorder vs. those diagnosed later in life.6
Substance abuse is likely to worsen the effects of bipolar disorder and may trigger rapid cycling between mania, depression, or hypomania. Mood swings may occur more frequently, and manic, hypomanic, or depressive episodes may be more intense due to the influence of drugs or alcohol. Even a small amount of alcohol can lead to a worsening of bipolar disorder.
In a person with both a substance use disorder and bipolar disorder, the use of substances of abuse compounds the effects of bipolar disorder, making these individuals more likely to be hospitalized, attempt suicide, and accelerate the course of mental illness, worsening the mania and depressive states experienced as a result of bipolar disorder.7
Substance Abuse-Induced Bipolar Disorder
Substance users who aren’t currently diagnosed with bipolar disorder may experience symptoms that are similar to mania or hypomania as well as depression due to the use of certain substances. These symptoms may be a side effect of intoxication and withdrawal, and not actually be bipolar disorder.
Stimulant intoxication, for example, is frequently characterized by euphoria along with impaired functioning, agitation and paranoia. This state can mimic mania. Likewise, stimulant withdrawal may induce a state of unease or dissatisfaction along with fatigue and insomnia. This mimics a depressive state that’s similar to one that’s experienced by someone with bipolar disorder.3
If a person hasn’t yet been diagnosed with bipolar disorder, it may be necessary to maintain a period of abstinence for drugs and alcohol in order to determine if bipolar symptoms are actually caused by substance abuse.3
It’s important to determine if bipolar disorder exists independent of substance abuse, as medications treating the symptoms associated with bipolar disorder differs than drugs that might be used to treat similar symptoms that are actually attributed to drug or alcohol intoxication or withdrawal.3
If bipolar disorder co-occurring with a substance use disorder is suspected, medical and mental health professionals can determine the best course of action and develop a safe detox and treatment plan.3,9
Both bipolar disorder and addiction are serious illnesses that may have serious and potentially life-threatening consequences when left untreated.3,9 Self-harm and suicide are very real risks for individuals suffering from co-occurring bipolar and substance use disorders.10
Despite the increased risk of worsening illness, hospitalization, and suicide, addiction and bipolar disorder are both treatable, and the risks may be minimized or mitigated with comprehensive, long-term and ongoing care.9
Although medication is typically essential in the treatment of bipolar disorder, behavioral therapy is also a critical component in its successful management.3 Behavioral therapy is also important when treating a substance use disorder. Integrated group therapy—a group-based behavioral approach that addresses the unique interrelationships between bipolar disorder and substance abuse called integrated group therapy has demonstrated consistent beneficial effects for these cooccurring disorders.3,7
Residential treatment options are generally the most comprehensive and provide the highest number of options and programs. They often include nutrition plans and exercise programs that can supplement treatment and enhance recovery.9 Yoga, meditation, and mindfulness techniques may also be beneficial during treatment programs to enhance spirituality by focusing on the self and developing internal motivation and drive.
Peer support and mutual-help programs may also be beneficial in preventing relapse and greatly enhance recovery.7
- National Institute on Mental Health. (2017). Mental Health Information: Statistics: Bipolar Disorder.
- World Health Orgnization. (2019). Mental Disorders.
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
- Gold, A. K., Peters, A. T., Otto, M. W., Sylvia, L. G., Magalhaes, P., Berk, M., Dougherty, D. D., Miklowitz, D. J., Frank, E., Nierenberg, A. A., & Deckersbach, T. (2018). The impact of substance use disorders on recovery from bipolar depression: Results from the Systematic Treatment Enhancement Program for Bipolar Disorder psychosocial treatment trial. The Australian and New Zealand Journal of Psychiatry, 52(9), 847–855.
- Sasson, Y., Chopra, M., Harrari, E., Amitai, K., & Zohar, J. (2003). Bipolar comorbidity: From diagnostic dilemmas to therapeutic challenge. The International Journal of Neuropsychopharmacology, 6(2), 139–144.
- Post, R. M., & Kalivas, P. (2013). Bipolar disorder and substance misuse: pathological and therapeutic implications of their comorbidity and cross-sensitisation. The British Journal of Psychiatry, 202(3), 172–176.
- Gold, A. K., Otto, M. W., Deckersbach, T., Sylvia, L. G., Nierenberg, A. A., & Kinrys, G. (2018). Substance use comorbidity in bipolar disorder: A qualitative review of treatment strategies and outcomes. The American Journal on Addictions, 27(3), 188–201.
- Ostacher, M. J., Perlis, R. H., Nierenberg, A. A., Calabrese, J., Stange, J. P., Salloum, I., Weiss, R. D., Sachs, G. S., & STEP-BD Investigators (2010). Impact of substance use disorders on recovery from episodes of depression in bipolar disorder patients: Prospective data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The American Journal of Psychiatry, 167(3), 289–297.
- National Institute on Mental Health. (2020). Mental Health Information: Health Topics: Bipolar Disorder.
- Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use disorder: A complex comorbidity. Science & Practice Perspectives, 3(1), 13–21.