Understanding Bipolar Disorders & Co-Occurring Substance Abuse

Bipolar disorder is a serious, chronic illness that can significantly impair your ability to function normally in everyday life. Many people with bipolar disorder also have concurrent substance abuse issues which, in some cases, develop as a result of self-medicating mental health symptoms. When you have both a mental illness and a substance abuse problem, it is known as a co-occurring disorder (also called a dual diagnosis or comorbidity). Though both can be challenging to live with, there are integrated treatment options available for people with these disorders.

What Is Bipolar Disorder?Unhappy isolated woman at home

A serious mental illness characterized by unusual or severe changes in mood, energy level, and behavior, bipolar disorder has also been known as manic-depressive illness. People with bipolar disorder often experience distinct mood episodes during which they may display behavior that is markedly different from their normal personality; these episodes may last for 1 to 2 weeks or longer, in some cases.1

When bipolar disorder is severe, it can significantly interfere with your ability to maintain relationships, hold a job, or go to school, and you may need to be treated for it throughout your life to manage the symptoms. A 2011 analysis estimated that the projected lifetime risk of developing bipolar disorder is 2.4% in the world population.2

There are 4 basic types of bipolar disorder:1

  • Bipolar I: Characterized by manic episodes that last at least 7 days or by depressive episodes that often last at least 2 weeks. Mixed episodes (with both depressive and manic symptoms) are also possible.
  • Bipolar II: Characterized by a pattern of depressive episodes and hypomanic episodes, in which hypomanic episodes are less severe than full-scale manic episodes.
  • Cyclothymic Disorder (cyclothymia): Characterized by periods of hypomanic symptoms and periods of depressive symptoms that continue for at least 2 years in adults or 1 year in children and adolescents. Symptoms may be less severe than full manic and depressive episodes.
  • Other Specified and Unspecified Bipolar and Related Disorders: Characterized by bipolar indicators that do not fall precisely into the previous 3 categories.

Teen alone lamenting outsideShould manic episodes be present, people report feeling euphoric and extremely energized. Some say they feel extreme and unusual happiness, while others say they feel highly irritable. During a depressive episode, by contrast, people report feeling extremely fatigued, hopeless, or even suicidal.1

The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes in more detail some of the signs, symptoms, and behaviors associated with the manic and depressive episodes seen with certain types of bipolar disorders:3

  • Manic episode characteristics:
      • Feeling very high or elated.
      • Having a lot of energy.
      • Exhibiting increased levels of activity.
      • Feeling jumpy or wired.
      • Feeling over-confident in abilities, having inflated self-esteem or delusions of grandeur.
      • Feeling rested and awake after only a few hours of sleep.
      • Having racing thoughts or trouble concentrating.
      • Talking really fast, often loudly and inappropriately.
      • Being agitated, irritable, or touchy.
      • Beginning multiple projects at once, but never finishing them.
      • Doing risky things, like spending a lot of money or having reckless sex.
  • Major depressive episode characteristics:
      • Feeling sad, empty, or hopeless.
      • Experiencing an extreme loss of interest or pleasure in daily life.
      • Experiencing significant weight loss, weight gain, or either a decrease or increase in appetite.
      • Sleeping too much or too little.
      • Feeling fatigue or having no energy.
      • Feelings of worthlessness or guilt.
      • Feeling slowed down.
      • Having trouble concentrating, thinking, or making decisions.
      • Thinking about death or suicide; planning for or attempting suicide.

There are several factors that may increase your risk of developing this disorder. Research suggests a strong genetic component for developing bipolar disorder, but the specific genes involved have not been conclusively identified. Genetics are, however, only one of several risk factors involved. Scientists know this because studies of identical twins have shown that when one twin is diagnosed with bipolar disorder, the second twin is sometimes spared.1

What Are the Signs of Substance Abuse?A person taking a drag of a cigarette

The DSM-5 uses the term substance use disorder to talk about the diagnosis of drug and alcohol dependence and addiction. Depending on how many of the diagnostic criteria you meet in a 12-month period, your substance use disorder is categorized as mild, moderate, or severe. One of these criteria is that your drug or alcohol use causes significant problems in your life, such as mental or emotional distress or difficulty meeting your responsibilities at work, home, or school.3

Other diagnostic criteria for substance use disorders include:3

  • Taking more of the substance than originally intended.
  • Having a desire to quit or having past unsuccessful attempts to do so.
  • Spending a great deal of time acquiring the substance, using it, and recovering from its effects.
  • Experiencing intense cravings and urges to use.
  • Continuing to use the substance even though you know it’s causing problems in your relationships.
  • Giving up on or reducing social activities that used to bring you pleasure.
  • Using a substance in risky or physically hazardous situations.
  • Continuing using when you know it’s making a separate mental or physical health issue worse.
  • Requiring larger doses over time to achieve the same effects.
  • Experiencing withdrawal symptoms when you stop or reduce your dose.

Addiction is relatively common in the United States. In 2015, approximately 20.8 million people, aged 12 or older, had a substance use disorder: 15.7 million people had an alcohol addiction and 7.7 million people had a drug abuse disorder.4

Why Do They Occur Together?

Mixing drugs and alcoholFor decades, national surveys have shown that substance abuse is more common among people with mental illnesses than among the general population. Likewise, the reverse is also true: people with substance abuse problems are more likely than other people to have a mental illness.5 In 2015, an estimated 8.1 million adults had both a mental illness and a substance use disorder, while 2.3 million adults had a severe mental illness coupled with a substance use disorder.4 These disorders may coexist for different reasons; for example, compulsive substance use behavior may arise as a result of repeated attempts to self-medicate distressing mental health symptoms with alcohol and drugs. However, these substances often end up exacerbating the mental illness rather than helping it.

Those with bipolar disorder may be even more likely to develop a co-occurring substance abuse problem than people with other types of mental illnesses, according to the National Epidemiologic Survey on Alcohol and Related Conditions. Research indicates that 22–59% of people with bipolar disorder develop a drug or alcohol problem during their lifetime.6

There are several theories as to why people with bipolar disorder are more prone to develop substance abuse problems. Some researchers have suggested it has to do with the overwhelming desire to self-medicate the symptoms of manic and depressive episodes. Others argue that bipolar disorder and addiction involve the same systems in the brain that regulate impulsivity, motivation, and the feeling of reward. Some researchers believe that bipolar disorder and addiction share the same environmental and genetic risk factors, which would place a person at a higher risk for developing both problems. It is also possible for a substance abuse problem to precede or lead to bipolar disorder.6

Regardless of the cause, it is evident that co-occurring bipolar disorder and substance abuse can complicate diagnosis and treatment. Overlapping features, such as putting yourself in hazardous situations (substance abuse) and acting impulsively (bipolar), can lead to dangerous consequences and can make relapse more likely.

Ways to Treat Both Disorders

Supportive peers in a circleResearch evidence suggests that the best way to treat co-occurring disorders is to address them simultaneously. The previous protocol was to treat one at a time, which may have involved separate counselors or even separate facilities. Today, many addiction treatment centers are beginning to specialize in integrated treatment for dual diagnoses.6 Though it can be complex, treatment works best when it is tailored to meet your individual needs, symptoms, preferences, and responses to treatment—most approaches involve a combination of medicine and behavioral therapy.

Examples of medications used to treat bipolar and substance abuse disorders include:6

  • Mood stabilizers: Lithium is one of the most common mood stabilizers used to treat the extreme mood swings associated with bipolar disorder; Depakote and other anti-convulsants may also be used.
  • Atypical antipsychotics: Second-generation antipsychotics, such as Seroquel, Zyprexa, or Latuda are often used as anti-manic agents.
  • Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Wellbutrin may be used to lessen the severity of depressive episodes, but are not approved as a stand-alone treatment for bipolar.
  • Detox medications: Depending on the substance abused, some common medications administered to minimize the risk of detox complications and otherwise lessen the discomfort of withdrawal symptoms include benzodiazepines, anti-convulsants, anti-nausea medicine, and opioid agonists (e.g., methadone or buprenorphine in cases of opioid dependence).

A few forms of behavioral therapy that have proven effective in dual diagnosis treatment include:6

  • Cognitive behavioral therapy (CBT): CBT is a type of talk therapy that helps you learn to identify negative thought patterns and harmful beliefs and behaviors. The goal is to recognize these destructive thoughts, counter them with positive ones, and develop healthy coping strategies.
  • Family focused therapy (FFT): FFT educates families about bipolar disorder so they can recognize the onset of a depressive or manic episode. FTT also teaches families how to communicate effectively and to develop coping strategies.
  • Integrated group therapy (IGT): Proponents of IGT believe that you should view your co-occurring disorders as a single disorder—bipolar substance abuse. They believe that substance use worsens bipolar disorder and that not taking bipolar medication will increase the risk of relapse.
  • The FIRESIDE approach: This is an integrated treatment approach—the components of which spell out its acronym:
    • Follow-up (aftercare is strongly emphasized).
    • Interrelationship of diagnoses (one disorder can’t be improved without treating the other).
    • Relapse prevention.
    • Education (using lectures, videos, and discussions to learn about bipolar disorder and substance abuse).
    • Stabilization of withdrawal and mood (with medications).
    • Individuation of program (flexible program tailored for you).
    • Diagnostic equivalence (both diagnoses emphasized equally).
    • Empowerment (encouraging individual responsibility).

Resources

If you or a loved one needs help for substance abuse or bipolar disorder, there are several hotlines available to you, as well as educational resources for both issues:

National Suicide Prevention Lifeline

Call: 1-800-273-TALK

En Español: 1-888-628-9454

Chat: Lifeline Crisis Chat Program

The National Suicide Prevention Lifeline is a network of local crisis centers across the U.S. This 24-hour hotline provides free and confidential support to people in crisis.

Crisis Text Line

Text: “hello” to 741741

The Crisis Text Line is a free and confidential health hotline that is available 24 hours a day. After texting HELLO to the hotline, you will get an automated text asking you about your crisis; you will then be connected with the appropriate help.

SAMHSA’s National Helpline

Call: 1-800-662-HELP

The Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Helpline is a free, confidential, 24-hour hotline for treatment referrals and information, not counseling or emotional support.

Bipolar Network News

The latest news on bipolar disorder treatments and research.

Depression and Bipolar Support Alliance

Education, advocacy, and peer support for people with depression or bipolar disorder, or for families of people with bipolar disorder.

National Alliance on Mental Illness

A good overview of bipolar disorder symptoms, causes, and treatments.

National Institute of Mental Health

Another good overview of bipolar disorder symptoms, causes, and treatments.

National Institute on Drug Abuse

An informative article about integrated group counseling for co-occurring bipolar and substance abuse disorders.

SAMHSA-HRSA Center for Integrated Health Solutions

Information about using integrated care models to treat co-occurring bipolar and substance abuse disorders.

Sources

  1. National Institute of Mental Health. (2016). Bipolar Disorder.
  2. Merikangas, K.R., Jin, R., He, J.P., Kessler, R.C., Lee, S., Sampson, N.A., et al. (2011). Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative. Archives of General Psychiatry68(3), 241­–251.
  3. American Psychiatric Association. (2015). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  4. Center for Behavioral Health Statistics and Quality. (2016). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health.
  5. National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses.
  6. Substance Abuse and Mental Health Services Administration. (2016). An Introduction to Bipolar Disorder and Co-Occurring Substance Use Disorders.

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