Bipolar Disorder and Addiction

Understanding Bipolar Disorder

Bipolar disorder, formerly known as manic depression, is a mental health disorder that involves shifts in a person’s mood, energy, activity levels, and concentration. These shifts can make it difficult for an individual with bipolar disorder to carry out day-to-day tasks.²

Only a doctor or qualified mental health professional can diagnose someone with bipolar disorder.³ Healthcare professionals use criteria established by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) taking into account an individual’s symptoms, lifetime history, experiences, and family history to guide the diagnosis.^2,3

There are three types of bipolar disorder—including bipolar I, bipolar II, and cyclothymic disorder—that are typically diagnosed.²

Signs and Symptoms of Bipolar Disorder

The symptoms associated with each of the three bipolar disorders may vary from person to person—though each bipolar disorder involves clear changes in mood, energy, and activity levels.² The differences in the types of bipolar disorder involve the intensity and duration of the moods.⁴

Bipolar I: Individuals with bipolar I disorder have a history of at least 1 manic episode that lasts for 7 days or more, or is so severe that hospitalization is necessary.^2,4 The DSM-5 defines a manic episode as a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy that lasts for 7 days or more, or is so severe that hospitalization is necessary.

Manic episodes involve at least 3 of the following (4 if the mood is only irritable):³

• An inflated self-esteem or grandiosity
• A decreased need for sleep, or feeling rested after just a few hours of shut-eye
• Being more talkative than usual or talking very quickly
• Having a flight of ideas or racing thoughts
• Being easily distracted or drawn to unimportant or irrelevant external stimuli
• Exhibiting an increase in a goal-directed activity—either socially, at work or school, or sexually—or experiencing psychomotor agitation, such as purposeless, non-goal-directed activity

An individual with bipolar I may have been preceded by or followed by hypomanic or major depressive episodes A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy that lasts 4 days in a row and is present most of the day, nearly every day.^3,4 To qualify as a hypomanic episode, the individual exhibits at least 3 of the above manic episode symptoms (4 if the mood is only irritable), which is associated with an unequivocal change in functioning that is apparent to others, but the episode is not severe enough to cause marked impairment in social or occupational functioning or warrants hospitalization, and is not attributable to the physiological effects of a substance (whether taken as medication or recreationally).³

A major depressive episode involves 5 of the following (and at least 1 of the first 2) in a 2-week period:³

• A depressed mood for most of the day, nearly every day
• A marked loss of interest or pleasure in most or all previously enjoyed activities most of the day, nearly every day
• A significant loss of weight (more than 5% of body weight) when not dieting or weight gain or marked changes in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation, such as restlessness, or psychomotor retardation, such as slowed speech or movement, that occurs almost daily
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• An inability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death or suicide or planning or attempting suicide

Bipolar II: Bipolar II disorder means the individual has not experienced a manic episode but meets the criteria for a hypomanic episode and has a current or past major depressive episode.³ Bipolar II was once thought to be less severe than bipolar I disorder, but this is no longer the case because of the instability of mood experienced by individuals with bipolar II disorder, which is typically accompanied by serious impairment in work and social functioning.³

Cyclothymic disorder: Cyclothymic disorder involves periods of hypomanic and depressive symptoms that do not meet the criteria for hypomanic or major depressive episodes.^2,3 To be diagnosed with cyclothymic disorder, individuals need to have symptoms for at least 2 years, have hypomanic symptoms and depressive symptoms for at least half the time, and not be without symptoms for more than 2 months at a time.³

Co-Occurring Bipolar Disorder and Addiction

Many individuals with a bipolar disorder also have other mental health disorders and conditions, such as anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and substance use disorders (SUDs).² In fact, individuals with bipolar I have a 65% prevalence rate of lifetime SUD and a 54% prevalence rate of lifetime alcohol use disorder.⁵ Approximately 37% of individuals diagnosed with bipolar II have a SUD.³ Substance-related disorders may also be present in individuals with cyclothymic disorder.

The American Society of Addiction Medicine (ASAM) defines a substance use disorder—the clinical term for addiction—as a treatable, chronic medical disease involving complex interactions among an individual’s brain circuits, genetics, environment, and life experiences. Individuals diagnosed with a drug or alcohol addiction compulsively engage in substance use despite the harmful consequences.⁶

When someone meets the diagnostic criteria for bipolar disorder and substance use disorder, they are diagnosed with co-occurring disorders.⁷ Co-occurring bipolar and substance use disorders are associated with increased symptom severity, poorer treatment outcomes, and greater suicide risk.⁵

Causes of Co-Occurring Bipolar Disorder and Addiction

The relationship between addiction and other mental health disorders is multifaceted, with evidence suggesting a bidirectional relationship between bipolar disorder and substance use disorders—meaning the presence of one disorder may influence or worsen the other disorder—however, the exact ways in which the conditions impact each other is complex and variable.⁵ Research indicates three possible pathways that might explain why SUDs and other mental health disorders occur together. These include:⁷

1. Common risk factors. Common risk factors for both bipolar disorder and substance use disorder is one possible explanation for why these disorders commonly co-occur. Risk factors that may increase the likelihood of developing bipolar disorder can include:^7,8

• Having a first-degree relative with the disorder.
• Having a family history of other mental health disorders, such as anxiety disorders and ADHD.
• Experiencing trauma—especially during childhood.
• Substance misuse.

Some of these same risk factors, such as family history of the disorder and exposure to trauma, appear in the list of risk factors for substance use disorder, which also include:⁹

• Being exposed to drug and alcohol misuse in the home environment as a child.
• Having poor social skills, struggling in school, and experiencing peer pressure during adolescence.
• Beginning substance use early.
• Having a mental illness.
• Using substances in a manner—typically by smoking or injecting—that causes an immediate and intense high that fades quickly and leads to repeat use.

2. Mental health disorders can contribute to substance use and SUDs. Studies indicate that some individuals may use substances as a way of alleviating the symptoms related to their mental  illness. A narrative review of epidemiological literature found that 23.9% of people with bipolar II self-medicated with alcohol and 18.9% with drugs. Similarly, the same review found that 41% of people with bipolar I self-medicated with alcohol and/or drugs.¹⁰ Although self-medicating with substances may temporarily mask certain symptoms, continued substance use can become a maladaptive coping mechanism. Evidence suggests that the persistent use of drugs or alcohol in this manner can worsen the symptoms of bipolar disorder and increase the likelihood of developing a drug or alcohol dependence or addiction.^10,11

3. Substance use and SUDs can contribute to the development of other mental health disorders.
The changes that occur in the brain as the result of chronic substance use may increase the likelihood that an individual develops a mental health disorder.⁷

Treating Bipolar Disorder and Addiction

Co-occurring disorders, such as bipolar disorder and addiction, complicates diagnosis and treatment. Treatment facilities that integrate their screening and treatment processes to include both substance use and mental health disorders are able to diagnose when co–occurring disorders occur and subsequent treatment can lead to reduced or discontinued substance use, psychiatric symptom improvement, increased chances of better treatment outcomes, improved quality of life, and decreased hospitalization.¹²

Integrated treatment involves addressing both substance use and bipolar disorder simultaneously. This approach, which is today the standard of care for co-occurring disorders, has proven to be more effective than standalone treatment that addresses each condition separately.¹³

In an integrated treatment plan, an individual’s doctors, counselors, therapists, case managers, and community service providers work together as a team to create an individualized treatment plan that’s consistent and works toward the same goals in treating the co-occurring bipolar and substance use disorders.¹³

Treatment for co-occurring disorders may take place in different settings and may include:

Medical detox. Medically managed detoxification can help someone safely and comfortably undergo withdrawal from a substance and deal with associated symptoms under medical supervision.¹⁴

Inpatient treatment. Inpatient care involves living onsite for the duration of treatment and receiving 24/7 care and supervision.¹⁴ Individuals participate in various therapies and can fully focus on their recovery without outside distractions. Inpatient treatment can be beneficial for individuals with severe mental illnesses, like bipolar disorder and co-occurring addiction.⁵

Outpatient treatment. Outpatient treatment includes different levels of care—each involving different levels of intensity and time required in treatment. Depending on the severity of the disorders and the outside support one has, someone with bipolar disorder and co-occurring addiction may benefit from a partial hospitalization program (PHP) or intensive outpatient program (IOP), both of which provide a level of care similar to inpatient programs but allow the individual to live and sleep at home or in a sober living environment.⁵

The right setting for you or your loved one is determined during a comprehensive evaluation that involves various screening methods and takes into account all of your needs.⁵

Treatment for co-occurring bipolar disorder and addiction may include a combination of medications to manage bipolar symptoms and addiction (depending on the substance) and evidence-based behavioral therapy interventions, which may include:^5,7,11,13

• Cognitive–behavioral therapy (CBT). Behavioral therapy, such as CBT, is the foundation of treatment for co-occurring disorders and a key component to sustained recovery. Studies suggest that the use of CBT and relapse prevention strategies—which involve elements of individualized interpersonal therapy, psychoeducation, mutual-help group involvement (such as Alcoholics Anonymous), and group therapy sessions—may help reduce hospitalizations, increase abstinence, improve medication adherence, and reduce addiction severity.
• Integrated group therapy (IGT). IGT encourages individuals to view co-occurring bipolar and addiction as one distinct disorder or “bipolar substance abuse.”
• Motivational approaches. Motivational techniques can help individuals develop internal motivation to change harmful behaviors and reduce ambivalence toward treatment.
• Contingency management (CM). CM provides positive reinforcement when people achieve target goals, such as abstinence.

Getting Help for Co-Occurring Disorders

If you or someone you care about is struggling, American Addiction Centers (AAC), a leading provider of co-occurring disorder treatment in the U.S., can help. With treatment centers located across the nation, you can get the integrated treatment you need to live a healthy and productive life. Call our free, confidential helpline to speak to a knowledgeable admissions navigator about your treatment options, get the answers to questions you have, verify your insurance and begin your path to recovery.