The Concerns of Self-Medication of Bipolar II Disorder
The terms manic depressive disorder and bipolar disorder are essentially describing the same form of mental illness. Bipolar disorder is the term that is now applied to what would has been previously diagnosed as manic depression or manic depressive disorder. The terms describe the same disorder, but bipolar disorder is an upgraded term based on a more thorough understanding of the disorder.
Types of Bipolar Disorder
The American Psychiatric Association (APA) conceptualizes bipolar disorder into several different diagnostic categories based on the frequency or severity of the mania in the disorder. The release of the DSM-5, the diagnostic manual for APA, in 2013 also classified all of the bipolar-type disorders in a separate category from depression and other types of depression-like disorders: the bipolar and related disorders.
Bipolar disorder is categorized into two separate types of disorders that are differentiated by the type of manic-like behaviors presented by the person.
- Bipolar I occurs when the person presents with a formal manic episode. The person need not have any depression but must have at least one episode of mania. Many people with this disorder do experience depression, but having depression is not necessary to receive this diagnosis.
- Bipolar II is characterized by having at least one episode of hypomania that lasts at least four days and a major depressive episode that lasts at least two weeks.
The difference between hypomania and mania is based on the length of time the symptoms present themselves. The symptoms include:
- Grandiose behavior or inflated self-esteem
- Decreased sleeping (e.g., the person feels rested after a very short period of sleep [3 hours])
- Increased talkativeness or pressure to keep talking
- Racing thoughts (a flight of ideas)
- Extreme distractibility
- A decrease in goal-directed activities that can occur in numerous contexts, such as work, one’s sexual life, school, or relationships
- Excessive involvement in activities that can be potentially dangerous or painful (e.g., shopping sprees, foolish investments, or having multiple sexual partners)
The differentiation between mania and hypomania is that for mania to be diagnosed, the person must have at least three symptoms for at least one week, and the symptoms are present nearly every day most of the day; if irritability is the primary symptom, the person must have at least four symptoms. The symptoms in hypomania last four days or longer, but mania produces a marked change in the person’s functioning that requires treatment or hospitalization, whereas hypomania does not produce this type of drastic change in functioning. According to the DSM-5, about 5–15 percent of the individuals who are initially diagnosed with bipolar II disorder will eventually go on to be diagnosed with bipolar I disorder as their symptoms persist over time and in their intensity.
Sometimes, bipolar II disorder is characterized as a less severe form of bipolar I; however, this is not the case. People diagnosed with bipolar II disorder have a serious mental health disorder, and the depressive episodes that must occur in bipolar II disorder can be extremely debilitating. Thus, while the presence of hypomania does not necessarily impair the person’s functioning or require hospitalization, the depressive disorders may very well lead to significant complications.
There are research studies that suggest that bipolar disorder may be underdiagnosed because individuals typically do not seek treatment when they are in the manic or hypomanic phases, but may seek treatment when they are depressed. This may lead to misdiagnoses of major depressive disorder or some other related depressive disorder as opposed to recognizing the presence of bipolar disorder. Moreover, other diagnostic classifications in the DSM-5 may be mistaken in place of what is really bipolar disorder, such as personality disorders or attention deficit hyperactivity disorder.
Bipolar II and Substance Use Disorders
Research studies have traditionally indicated that having any mental health disorder increases the risk that a person will also develop a substance use disorder. Research has also suggested that the occurrence of substance use disorders is higher among individuals diagnosed with bipolar disorders than most of the other types of disorders in the DSM. The rate of co-occurring substance use disorders in individuals diagnosed with bipolar disorder ranges from about 20 percent to as high as nearly 60 percent in most of these studies.
Males tend to have higher rates of substance abuse than females, and this relationship appears to hold true for individuals who are also diagnosed with any type of bipolar disorder. It appears that the presence of mania increases the risk for substance abuse.
However, in a large meta-analytical study that combined the results of 56 studies, it was found that both those with bipolar I and bipolar II had about the same prevalence of substance use disorders. Meta-analytic studies combine the results of numerous studies that investigate similar issues, and these types of studies are believed to have more reliability and validity in their findings because they are able to utilize more information and more participants than studies that only use one sample of participants.
The research suggests that:
- Alcohol is by far the most common substance of abuse among individuals with bipolar II disorder.
- Cannabis products are the second most abused substance.
- Illicit drugs like heroin are the third most abused class of drugs.
- Stimulants and amphetamines are the fourth most abused drugs by this group.
The individuals who have co-occurring substance use disorders and bipolar disorders often had an earlier onset of their bipolar disorder; approximately 20.7 years for those with substance abuse compared to 24 years of age for those without it. Having a co-occurring diagnosis of bipolar disorder and substance use disorder also resulted in more hospitalizations than having bipolar disorder alone.
There have been numerous explanations to explain the relationship between bipolar disorder and a co-occurring substance use disorder. The self-medication hypothesis suggests that people abuse drugs and alcohol to relieve or self-treat the distress they are experiencing due to some mental health disorder or issue. This hypothesis often attempts to predict that the type of substance a person will abuse is based on how it will affect their psychological distress.
However, there are numerous problems with the self-medication hypothesis, including the notion that many of the individuals who abuse drugs and have a co-occurring mental health disorder are actually worsening their symptoms with the drugs they abuse. For example, alcohol actually worsens the symptoms of depression and, cannabis products and stimulants may worsen the symptoms of mania or hypomania. In addition, individuals with mania or hypomania often enjoy the associated feelings of grandiosity, increased energy, and rapid ideas, and they are not likely to seek treatment during these phases.
The self-medication hypothesis suggests that simply treating the person’s psychological distress will alleviate their substance abuse issue, and this approach has proved fruitless across numerous research studies and clinical trials. The treatment of an individual’s bipolar II disorder may result in a decrease in their substance abuse, but their substance use disorder will not remit in most cases unless it is directly treated.
The self-medication hypothesis might offer some insight into some of the episodic drug use that occurs in an individual with bipolar II disorder, and it may be relevant to impulsive use of drugs and/or alcohol. However, this hypothesis does not offer significant utility regarding the treatment of individuals with bipolar II disorder, nor does it sufficiently explain the relationship between the abuse of any substance and the diagnosis of bipolar II disorder.
Other research studies have viewed mental health disorders as overlapping disorders in the brain that involve one’s experience of reinforcement and reward, a loss of emotional and behavioral control, and problems with motivation. These studies suggest that individuals who have any type of mental health disorder have a shared vulnerability to developing other mental health disorders. This shared-vulnerability hypothesis includes an increased risk to develop problems with substance abuse, and it is far more useful in understanding the relationship between bipolar disorder and other mental health disorders.
Despite the many different hypotheses that attempt to explain the relationship for increased rates of substance abuse in people with bipolar II disorder, getting effective treatment for these people is crucial if their issues are to resolve in any manner.
Treatment of Bipolar II and Co-Occurring Substance Use Disorders
The use of medications (pharmacotherapy) is considered to be the first line approach in treating any form of bipolar disorder. Therapy can be used to address adjustment issues and to maintain medication compliance, but therapy alone to treat bipolar disorder has not provided sufficient results.
Medications used to treat bipolar disorder include lithium, mood stabilizers (typically anticonvulsant medications that have significant effects on treating mania or hypomania), and even antipsychotic medications for extreme cases. In some cases, severe depression can also be addressed with antidepressant medications and/or therapy.
Using the wrong medication could conceivably increase the risk of suicide for an individual with bipolar disorder II. According to the DSM-5, the risk of a suicide attempt is nearly identical in bipolar I and bipolar II disorder, and around one-third of these individuals will attempt suicide.
Substance abuse issues cannot be treated with medications alone. Instead, the research suggests that using an integrated approach that combines pharmacotherapy with therapy and other types of behavioral treatments (e.g., 12-Step group participation) is far more efficient in addressing the challenges that individuals with a diagnosis of bipolar II and a substance use disorder face. Both disorders should be addressed simultaneously.
Typically, the primary approach to treating bipolar disorder is the use of medications, and then, issues with adjustment, substance use, and other co-occurring issues are addressed with therapy and other behavioral interventions. However, when individuals need to be placed in medical detox (physician-assisted withdrawal management programs), they are treated with medications to help them get through the withdrawal period. Inpatient treatment would be the preferred method of choice initially.
Following the completion of the withdrawal management program and stabilization on medications for bipolar disorder and related issues, some type of outpatient treatment program could be instituted. The therapy sessions would focus on adjustment issues, changing negative behaviors, changing negative thoughts and beliefs, and relapse prevention. This means that the therapy portion of the intervention addresses both the issues of adjustment associated with the person’s bipolar disorder as well as their substance of abuse. Forms of Cognitive Behavioral Therapy would be preferable; however, there are numerous other types of therapy that would also be fruitful in addressing these issues.
The Need for Ongoing Care
Bipolar II disorder and substance use disorders are considered to be chronic, relapsing, psychological disorders. This means that the treatment for these disorders should be undertaken with both short-term goals and long-term goals in mind.
The majority of individuals with bipolar disorders will require long-term, even lifetime, maintenance on medications to control their symptoms. Likewise, the treatment of any substance use disorder is now considered to be a long-term endeavor. Thus, individuals with co-occurring bipolar II disorder and any substance use disorder should approach treatment as a lifestyle adjustment and be prepared for long-term participation in activities related to managing symptoms. Simply addressing the symptoms for the short-term and then neglecting treatment-related responsibilities will inevitably result in relapse of one or both conditions.