Bipolar disorder is considered the sixth leading cause of disability in the world and affects 60 million people globally the World Health Organization (WHO) publishes. In the United States, NAMI estimates that just over 6 million people suffer from a version of bipolar disorder, which is a mental illness characterized by the episodes of major depression, hypomania, or manic episodes. It is sometimes referred to as manic-depressive disorder.
There are two main types of bipolar disorder: bipolar I and bipolar II. There is also a subtype for bipolar disorder termed related and other specified bipolar disorder by the most current Diagnostic and Statistical Manual of Mental Disorders, DSM-5. Cyclothymic disorder is considered a milder form of bipolar disorder while rapid-cycling bipolar disorder is considered a severe form by the National Institute of Mental Health (NIMH).
Mania is identified by elevated moods, energy levels, or irritability, and sometimes even by psychosis, while depression is recognized by fatigue, sadness, suicidal ideations, and hopelessness. Mood swings are a part of life for everyone, but when these swings are extreme, affect daily functioning, and outside the range of a person’s normal range of behavior, it may indicate a diagnosis of bipolar disorder.
The Occurrence of Substance Abuse with Bipolar Disorder
Psychiatric Times publishes that individuals suffering from bipolar disorder may battle a substance abuse disorder (SUD) at rates higher than the general public and at the highest rates of any other major psychiatric disorder. In fact, an individual suffering from bipolar mania is between eight and nine times more likely than the general population to also battle a drug or alcohol dependence at some point in their lifetime.
Addiction is a disease that impacts regions of the brain involved in mood regulation, decision-making, willpower, and motivation. When an individual abuses substances long-term, pathways in the brain are altered, and a dependency to drugs or alcohol may be formed. Dopamine, norepinephrine, and serotonin, neurotransmitters that help to transmit feelings of pleasure in the brain, are elevated by substance abuse, and over time, the brain may depend on their presence in order to function normally. Individuals may lose control over their substance abuse and engage in compulsive and drug-seeking behaviors continuously, which may indicate addiction.
Bipolar disorder may increase the chances that someone who is abusing substances will develop an addiction to drugs or alcohol, and substance abuse can increase the negative symptoms of bipolar disorder. More than 20 million American adults over the age of 11 are considered to have a substance abuse or dependency, the 2013 NSDUH reported, and bipolar disorder may complicate treatment. The reverse is also true; addiction can interfere with bipolar treatment methods.
Bipolar I Disorder
Bipolar I is recognizable by episodes of mania, and Mayo Clinic publishes that a diagnosis of bipolar I requires at least one manic episode that lasts at least a week, a possible psychotic break from reality, and potentially mandates hospitalization before the seven days are up. Depressive episodes and hypomania may also be present in bipolar I disorder. Manic episodes can be severe, and impairment may be significant and definitely recognizable as outside the range of normal behaviors. Manic symptoms may include:
- Bursts of energy
- Less need for sleep
- Grandiose or self-elevating moods
- Easily distracted
- Outgoing behaviors
- Taking on new projects or heightened goal-directed behaviors
- Engaging in high-risk behaviors
Someone in a manic state may spend money recklessly, make dangerous investments, engage in risky sexual behaviors, be overly aggressive, and abuse substances at high rates. Manic episodes may be severe enough to cause hallucinations, delusions, or other psychotic symptoms, and they may cause issues at school, work, and with personal relationships. Hypomanic episodes are indicated by elevated moods and less severe manic symptoms.
Mixed states are also potentially signs of bipolar disorder. This means that during a manic or hypomanic episode, at least three depressive symptoms occur during many of the days, Psych Central publishes.
Bipolar II Disorder
NIMH publishes that bipolar II is characterized by depressive episodes lasting for at least two weeks and hypomanic episodes, although hypomania does not develop into full-blown mania. Depressive symptoms include:
- Overwhelming feelings of sadness and hopelessness
- Trouble feeling pleasure
- Lack of interest in activities that may have been enjoyed previously
- Fatigue and drowsiness
- Trouble making decisions
- Memory issues
- Difficulties concentrating
- Inappropriate feelings of guilt or shame
- Feelings of worthlessness
- Suicidal thoughts or attempts and recurrent thoughts of death
- Loss of energy
- Marked change in appetite and sleep patterns
A major depressive episode may significantly impair an individual suffering from bipolar II disorder. It is a noticeable deviation from a person’s normal behavior and thought patterns.
Other Forms of Bipolar Disorder
Considered not as severe as bipolar I and bipolar II disorders, cyclothymic disorder is nevertheless still distressful and can cause impairment in parts of a person’s life. Depressive and/or hypomanic episodes may not be as intense or full-blown, however symptoms are consistent for a period of at least two years, are present more than half the time, and do not disappear for more than two months at a time, according to Mayo Clinic.
When someone experiences at least four manic, depressive, mixed features, or hypomanic episodes in a one-year time span, NIMH states that it is considered a severe form of bipolar disorder called rapid-cycling bipolar disorder. Sometimes bipolar symptoms are significant enough for a friend or family member to recognize them as extreme and outside of the range of normal behavior, but they do not meet specific bipolar disorder criteria. They are therefore not diagnosable as one of the main types of bipolar disorder and are instead considered to be “unspecified.”
Spotting Addiction and Bipolar Disorder
The prefrontal cortex and the amygdala are parts of the brain that help to regulate emotions, control impulses, cope with stress, and make good decisions. Brain imaging technology may show a dysfunction or lack of development in some of these areas of an individual suffering from bipolar disorder, NIMH publishes. Bipolar disorder is often considered a developmental disorder since about half of the time symptoms begin by the age of 25, NIMH further reports. In adolescents, these regions of the brain are still developing, which may account for why many teens engage in risky behaviors, make poor decisions, and may not cope well with stress. Mood swings and poor impulse control may be common as well as experimentation with drugs or alcohol. When these mood swings seem extreme and mania or depression is prolonged for days or weeks, it may be a symptom of bipolar disorder.
Someone battling bipolar disorder may be more likely to develop a dependence on drugs or alcohol, as these substances interact with some of the same regions of the brain affected by the disorder, the journal Addiction Science & Clinical Practice reports. When substance abuse seems to take over a person’s life and interferes in everyday functioning, it may be a sign of addiction. Some of the signs that an individual may be suffering from co-occurring bipolar disorder and addiction may include:
- Lack of regard for consequences and poor impulse control
- Substance abuse in risky situations
- The need to take more substances each time to feel same effects (tolerance has developed)
- Violent or aggressive behaviors
- Self-harming and suicidal thoughts or actions
- Even more extreme bouts of mania, hypomania, or depression
- Loss of interest in things previously enjoyed
- Social and personal withdrawal
- Hostility, anger, and irritability
- Trouble regulating substance abuse and spending inordinate amounts of time using drugs or alcohol, recovering from their use, and figuring out how to obtain them
- Difficulties sleeping or sleeping a lot
- Weight loss or gain
- Inability to fulfill school, family, or occupational obligations consistently
- Trouble with law enforcement or involvement with the criminal justice system
- Financial troubles from excessive spending during manic episode or money spent on supporting substance abuse habits
- Knowledge that substance abuse poses social, physical, and/or emotional risks and perpetuating abuse regardless
- Trouble staying focused or concentrating
- Potential psychotic symptoms, like paranoia, hallucinations, or delusions
Substance abuse is likely to increase the rapid cycling between mania, depression, or hypomania in someone who is suffering from bipolar disorder. Mood swings may occur more frequently, and manic, hypomanic, or depressive episodes may be more intense due to the influence of drugs or alcohol, JAMA (Journal of the American Medical Association) publishes. It is important to note that addiction can also create bipolar symptoms, such as significant mood swings, changes in eating and sleeping patterns, and engaging in dangerous behaviors. Alcohol and drugs may lower inhibitions, elevate moods, and impair the part of the brain that puts the brakes on individuals trying things that may be risky or harmful. These symptoms may be a side effect of intoxication and withdrawal, and not actually be bipolar disorder. It may be necessary to help an individual maintain a period of abstinence in order to determine if bipolar symptoms are caused by substance abuse or by the mental disorder itself.
If bipolar disorder or addiction is suspected, medical and mental health professionals can determine the best course of action and develop a safe detox plan. All of the potential side effects of drug and alcohol abuse may be heightened by bipolar disorder and vice versa.
There are several factors that may be involved with the onset of both bipolar disorder and addiction, and many of these factors are the same for both issues. For instance, overlapping brain regions may be underdeveloped, smaller, or less functional in someone battling bipolar disorder, and the same parts of the brain may also predispose someone to substance dependence if substance abuse is perpetuated. Abusing substances at a young age before these regions of the brain are fully developed can increase the risks for addiction as well. NSDUH reported that 15.4 percent of American adults aged 18 and older with an alcohol abuse or dependency issue in 2013 began abusing alcohol before the age of 14, while only 3.8 percent of adults had an alcohol dependence or abuse problem when they waited until 18 to have their first drink.
The reward system in the brain that uses chemical messengers to relay feelings of pleasure and helps to keep emotions in check may also be dysfunctional in an individual battling bipolar disorder, and substance abuse may also damage this same circuitry, therefore leading to addiction and compulsive drug or alcohol abuse. The journal Frontiers in Psychiatry reports that certain brain functions, circuitry, and even shared genetic factors may be related to why bipolar disorder and addiction so often co-occur. Family history is an important diagnostic tool as both bipolar disorder and addiction may have roots in genetics.
Just as personal physiology and individual genetics may be an underlying cause for bipolar disorder and addiction, environmental factors may also be involved.
Chronic stress and childhood trauma may reshape brain structure and connectivity, actually damaging parts of the brain or brain functionality and potentially opening the door to mental illness and the development of a mood disorder, Psychology Today publishes. Around 80 percent of individuals suffering from bipolar disorder are believed to have experienced at least one life event that was deemed stressful, and half report childhood trauma, Psychiatric Times reports.
Similarly, the journal Brain Research highlights that stress may also play a role in the onset of addiction. Bipolar symptoms may be intense and individuals may turn to substance abuse in order to attempt to regulate or minimize the highs or lows. Alcohol, for example, is a depressant that may temporarily seem to decrease mania. Psychiatric Times reports that 46 percent of individuals suffering from bipolar I disorder experience an alcohol use disorder in their lifetime and 39.2 percent of those battling bipolar II disorder may as well. Bipolar disorder may be a root cause, and the symptoms may be a trigger for substance abuse. Chronic substance abuse may then become addiction.
Risks Associated with Long-Term Addiction and Bipolar Disorder
Both bipolar disorder and addiction are serious illnesses that may have serious and potentially life-threatening consequences when left untreated. When they occur together in the same person at the same time, risk factors are compounded, and negative emotional, physical, and interpersonal side effects may be increased.
Substance abuse may appear to be useful in self-medicating bipolar symptoms; however, such abuse brings serious risks. Stimulant drugs like cocaine or methamphetamine can boost depressive moods, while opioids or alcohol may regulate mania; however, the side effects of these mind-altering substances can be exponential and serve to actually increase bipolar mania and depressive symptoms in the long run.
Addiction to drugs or alcohol can make bipolar disorder worse and interferes with possible treatment plans or medications. The risk for overdose is high when drugs or alcohol are mixed and may result in toxic drug interactions. Alcohol or drug abuse may also trigger a bipolar manic or depressive psychotic break that may be more intense due to the effects of the psychoactive substance and may require immediate hospitalization.
Self-harm and suicide are very real side effects of bipolar disorder,
and the risks for a successful suicide attempt may increase when coupled with co-occurring addiction. About one out of five people suffering from bipolar disorder may commit suicide, the Depression and Bipolar Support Alliance (DBSA) reports.
Violent behavior is also a side effect of bipolar disorder, as between 9.4 and nearly 50 percent of individuals suffering from the disorder also have a history of violence, according to Psychiatric Times; this violence may be related to poor impulse control, agitation, irritability, and possibly co-occurring disorders. Drugs and alcohol may decrease inhibitions, raise feelings of indestructibility, and reduce the fear of consequences, all of which may be heightened by bipolar disorder symptoms. Individuals suffering from bipolar disorder are also more likely to commit both nonviolent and violent crimes than the general population, and substance abuse likely increases this likelihood, as reported by the journal Social Psychiatry and Psychiatric Epidemiology.
Sustained and untreated bipolar disorder and prolonged substance abuse due to addiction or dependence can also increase the risks for many physical illnesses, including heart disease, thyroid issues, respiratory infections, kidney and liver disease, diabetes, obesity, migraines, gastrointestinal problems, blood pressure issues, brain infections, skin legions, infectious and blood-borne diseases, and other health complications. Premature mortality and a higher risk for cardiovascular disease may be health concerns for long-term and untreated bipolar disorder, the journal Frontiers in Psychiatry reports.
Tips for Helping a Loved One Enter Treatment
Addiction and bipolar disorder are treatable, and many of the dire side effects may be minimized or avoided with comprehensive care. Individuals can lead healthy and happy lives with a comprehensive treatment plan, especially when the disorders are caught and managed early on. NIMH reports that individuals in a depressive state or episode may be more inclined to seek treatment than those in a hypomanic or manic state.
If an individual is suffering from a drug overdose, is suicidal or violent, or may be experiencing psychosis, crisis intervention services and immediate professional help may be required. Otherwise, a planned intervention, developed with the help of a mental health or medical professional, may be beneficial. The goal of an intervention is to help get a loved one into a treatment program, hopefully by motivating that person to voluntarily seek help. Some things to consider may include:
- Find a time to have the conversation about substance abuse and/or mental illness treatment when the individual is least agitated, stressed, or intoxicated.
- If there is a history of violence or self-harming behaviors, seek the help of a professional.
- Keep the tone nonconfrontational and calm.
- Use “I” statements and show specific examples of how a person’s substance abuse and/or mental illness has personally affected each member of the family or support system.
- Research potential treatment programs and understand how treatment and recovery work and what to expect.
- Set clear personal boundaries and realistic expectations.
- Show support and faith in the individual.
- Do not be afraid to ask for help from a professional.
Finding the Right Treatment Program
Treatment for bipolar disorder often includes the use of medications to help stabilize moods. When substance abuse and addiction co-occur, it is important for treatment providers to be aware of what substances may be regularly abused and how they may negatively interact with prescribed medications. Integrated treatment models may be optimal, wherein medical, mental health, and substance abuse treatment professionals all work together to develop and implement a comprehensive treatment plan. A drug screen to uncover what substances may be in a person’s system, as well as a complete evaluation on an individual’s mental and medical state, and research into personal and family histories, are all important initial steps.
Crisis intervention methods, including medical and mental health stabilization or hospitalization, may be necessary initially. Through detox, the person is stabilized as drugs and alcohol leave the body. Medical detox involves managing drug cravings and withdrawal symptoms while monitoring the individual around the clock in a safe and secure environment.
Treatment providers may agree on a care plan that incorporates both pharmacological and behavioral aspects. One of the most common mood-stabilizing drugs, which also may reduce substance abuse as much as 75 percent of the time in individuals suffering from co-occurring bipolar disorder, is lithium, Psych Central publishes. Lithium was one of the first FDA-approved mood-stabilizing medications. Today, other drugs that were not initially considered to be mood stabilizers, but instead functioned as anticonvulsants, may be just as effective. These drugs include Lamictal (lamotrigine), Depakote (valproic acid), Topomax (topiramate), Neurontin (gabapentin), and Trileptal (oxcarbazepine), as published by NIMH. Again, treatment providers may need to take into account substance abuse patterns before prescribing these medications.
Therapy methods for the treatment of co-occurring bipolar disorder and addiction may be provided in an outpatient or residential setting, depending on the severity of the disorders and level of dependency on drugs or alcohol. 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 as well as a natural balance between body and mind. 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.
Cognitive Behavioral Therapy (CBT) is a behavioral approach that uses both group and individual sessions to help individuals recognize how their thoughts influence their actions and how to modify negative thought patterns to positively bring change to behavior. Skills training and stress management are also taught. Family therapy and programs that focus on the family unit may be beneficial as well.
The National Institute on Drug Abuse (NIDA) highlights a study that shows promise for integrated group therapy in reducing substance abuse and relapse in individuals battling bipolar disorder. This model is a CBT-based intervention focused on relapse prevention. Individuals were less likely to abuse alcohol or drugs while participating in the study and up to three months after the therapy, per NIDA.
Peer support and 12-Step programs may also be beneficial in preventing relapse. Individuals who need to take maintenance medications, such as mood stabilizers, may need to find a 12-Step group that is supportive of taking necessary medications during recovery.
Addiction may occur much more frequently among those with bipolar disorder than in the general public. This may be due to genetic issues, affected brain regions, or environmental factors. Both disorders can interfere with the treatment of each disorder and increase potential emotional, social, and physical side effects. Extreme mood swings that may involve high “highs” or mania; low “lows” during a depressive episode; hypomanic states; or mixed bipolar features may characterize the different subtypes of bipolar disorder.
Substance abuse may be used as a tool to self-regulate symptoms, although drugs and alcohol only make matters worse in the end, increasing all risks and symptoms, and substance abuse may end up developing into addiction. Integrated treatment models that use both therapy and medications may be beneficial during treatment and recovery from co-occurring disorders. Early intervention can reduce self-harm, as well as harm to others. Medical and mental health professionals can help families and individuals choose the right course of action, depending on specific personal needs and circumstances.