Bipolar Disorder & Substance Abuse

By Team RehabAid

Last Updated March 22, 2024

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If you’ve ever met someone who swings between periods of excessive energy and excitement and periods of deep despair, they may be suffering from bipolar disorder. Previously known as “manic depression,” bipolar disorder is a serious psychiatric mood disorder that is known for its severe highs and lows. Individuals with this condition can experience intense periods of mania where they feel energized and on top of the world, followed by a severe crash into depression which leaves them feeling miserable and hopeless.

According to the National Institute of Mental Health, an estimated 2.8% of American adults receive a bipolar disorder diagnosis annually. Due to the intense and uncomfortable up and down moods associated with bipolar disorder, it is no surprise that this condition often leads to substance abuse. Conversely, substance abuse can also cause bipolar disorder and its symptoms, which is why this co-occurring condition is so complex. However, despite the prevalence of these two concurrent issues, there is hope for recovery.

In this article, we outline what bipolar disorder is, how it relates to substance abuse, and what types of treatments are available.

What Is Bipolar Disorder?

Bipolar disorder is a mental health condition characterized by intense shifts in mood, behavior, and energy levels. These shifts result in what is known as “manic” and “depressive” states where a person goes from feeling highly energized and confident before crashing into deep states of sadness and despair. These intense shifts in mood and behavior can make it difficult for individuals to carry out their day-to-day lives, especially if they frequently cycle between manic and depressive states. Bipolar disorder also comes in a variety of different forms as we outline below.

Bipolar I

Bipolar I is the most severe form of this disorder and is found in approximately 1% of the U.S. population. It is defined by extremes of mania and depression, with each state lasting anywhere from 7 days to 2 weeks. Individuals with Bipolar I can also have symptoms that are so severe that they require immediate hospital care. According to the National Institute of Mental Health, episodes of combined depression and mania (known as “mixed features”) are also possible with Bipolar I.

Bipolar II

This form of bipolar is milder than Bipolar I and is defined by less severe fluctuations between depression and mania. In some cases, depressive episodes may last longer and then alternate with periods of hypomania, which is a milder form of mania. What differentiates Bipolar II from Bipolar I is that the manic periods are less severe; however, individuals can still suffer from functional impairment.

Cyclothymia

Cyclothymia is characterized by milder depressive episodes and less intense manic episodes. Periods of depression are generally not as long or as intense as they are in Bipolar I and II.

Bipolar With Mixed Features

This version of bipolar disorder is characterized by depressive and manic episodes occurring at the same time. For example, an individual may simultaneously experience a combination of heightened energy and alertness, as well as feelings of worthlessness and despair.

Rapid Cycling Bipolar

Rapid cycling is when an individual rapidly goes through multiple, alternating periods of mania and depression for a period of 12 months. Individuals with other forms of bipolar disorder may experience these phases, which are often characterized by more extreme depression and mania.

Types of Bipolar Episodes

Along with the different forms of bipolar disorder, there are also varying types of episodes that an individual can cycle between.

Manic Episodes

As described above, manic episodes are characterized by excessive energy, confidence, alertness, excitability, and impulsivity. People in this state may appear chatty, friendly, overly energetic, and creative. They are also prone to engaging in poor judgment and making reckless decisions, such as going on big spending sprees. In extreme cases, manic episodes can last for a week or longer, and sometimes require hospitalization. While euphoria and elation can occur during this period, they can also be accompanied by aggression and irritability.

Hypomanic Episodes

Hypomania is a less severe form of mania. The main difference between these two states is that the period of mania is shorter and less intense in hypomania. Rather than a week of ongoing mania, for example, a person may only experience this state for 3 or 4 days. Individuals going through a hypomanic episode are also more likely to be able to carry out daily tasks without losing touch with reality.

Major Depressive or Bipolar Depressive Episodes

These episodes are typified by an intensely low mood and a disinterest in personal and social activities. Depressive states in bipolar disorder differ from regular depression in that individuals are more likely to feel irritability, guilt, unpredictable mood swings, and feelings of restlessness. Individuals may also speak slowly, sleep a lot, and gain weight during this period. To meet the clinical definition of a depressive episode, individuals must experience this state for at least two weeks.

Signs of Bipolar Disorder

The signs of bipolar disorder vary depending on what state the individual is in. Below are some of the most common signs of bipolar disorder:

Manic Episode Symptoms

• Hyperactivity
• High levels of energy and enthusiasm
• Inflated sense of self-confidence
• Decreased need for sleep
• Extreme talkativeness
• Racing thoughts
• Poor judgment
• Angry outbursts
• Short attention span
• Risky behavior
• Preoccupation with a specific goal
• Spending sprees

Major Depressive Episode Symptoms

• Feeling depressed or hopeless most of the day
• Having a sense of worthlessness
• Weight loss or gain
• Fatigue
• Foggy thinking
• Self-destructive behavior
• Slow speech
• Restlessness
• Insomnia or feeling the need to oversleep
• Loss of interest or pleasure in activities
• Excessive feelings of guilt
• Lack of concentration
• Thoughts of death or suicide

Underlying Risk Factors

There is no definitive cause of bipolar disorder, but there are risk factors that can contribute to it. These include:

Trauma

Individuals who have witnessed or experienced a traumatic event are at a higher risk of developing mental health conditions, such as bipolar disorder.

Brain Structure

Some studies indicate that the brain structure of individuals with bipolar disorder may differ from persons without the condition. However, research is ongoing and clinical diagnoses are made by evaluating physical and psychological symptoms, not by using brain imaging.

Genetics

While there is no single gene determining a condition like bipolar disorder, some research suggests that there may be genetic links. Also, people who have siblings or family members with bipolar disorder seem to be at higher risk of developing it themselves.

Family History

Individuals that grow up in dysfunctional families with unpredictable, extreme, or violent behavior can be more prone to developing bipolar disorder.

Substance Use Withdrawal

Drug misuse or weaning the body off medications or street drugs can cause bipolar disorder due to the way it alters brain chemistry.

Co-Occurring Mental Health Issues

Other psychiatric conditions also occur with bipolar disorder, such as anxiety, depression, psychosis, and attention-deficit disorder (ADHD), and eating disorders.

Bipolar Disorder & Substance Abuse Stats

According to the Journal of Psychiatry, up to 70% of individuals with bipolar disorder also struggle with substance abuse issues — which is much higher than the general population.

Other stats include:

• Globally, 46 million people have bipolar disorder (2018 Our World in Data).
• The 2017 National Alliance on Mental Illness shows that the average age of onset for bipolar disorder is 25.
• lcohol is the most abused substance by individuals with bipolar disorder.
• ndividuals with mania are 14 times more likely to have a drug abuse disorder and 6 times more likely to suffer from alcohol abuse.
• In one study, 60% of patients with bipolar I disorder also had a lifetime diagnosis of substance abuse disorder.
• In a national study presented by the American Journal of Managed Care, over half of the individuals with bipolar disorder had experienced drug or alcohol addiction in their lifetime.
• Approximately 46% of that same group had abused alcohol or were addicted to alcohol.
• Roughly 41% of that group had abused drugs or were addicted to drugs.

How Does Bipolar Disorder Lead to Substance Abuse?

Substance abuse and bipolar disorders are common co-occurring conditions. The two are intimately connected for several reasons that we outline below.

Self-Medicating Behavior

People who struggle with mental health conditions such as bipolar disorder often resort to self-medicating by using substances to cope. Whether it’s alcohol, prescription medications, or street drugs, individuals who are desperate to escape the intense symptoms of mania and depression will often turn to substances for relief. The problem with using substances is that they also tend to exacerbate a person’s bipolar symptoms, sometimes worsening them when the drugs wear off.

Another self-medicating behavior involves inverse effects. Substances like stimulants or even alcohol can enhance the effects of a manic period and extend it. As mania is a pleasurable state for people with bipolar disorder, they can sometimes end up abusing substances to maintain those feelings for as long as possible.

Biochemical Imbalances

Neurological factors also play a role in substance abuse and bipolar disorder. The reason is that neurotransmitters such as dopamine, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) are thought to be connected to depression and addiction. These chemicals are responsible for regulating mood and various bodily and mental functions. If an individual with bipolar disorder has an imbalance in these neurotransmitters, it is thought that they are more prone to addictive behaviors.

Substance Use & Addiction Withdrawal

Due to the way that drugs change the biochemistry of the brain, substance use can initiate bipolar disorder. This is known as substance-induced bipolar disorder, which is a result of the effects of drugs on key neurotransmitters. Stimulants, especially, can cause agitation, restlessness, irritability, and obsessive or irrational fears. Conversely, stopping long-term stimulant use can cause bipolar symptoms as part of the withdrawal period, creating bigger highs and lows. This can lead someone to return to their previous drug or alcohol use.

How Does Substance Abuse Affect Bipolar Disorder?

Another factor when it comes to bipolar disorder and substance abuse is how they affect each other. Here, we’ll explore some of the substances that are most commonly abused by individuals with bipolar disorder and describe what their effects are.

Alcohol & Bipolar Disorder

Amongst people with bipolar disorder, alcohol is the most typically abused substance. Some estimates suggest that 43% of people with bipolar disorder have had some form of alcohol abuse disorder at some time in their lives. If you’re struggling with bipolar disorder and are finding it difficult to cope with the symptoms, it can be tempting to turn to alcohol. However, the problem with alcohol is that it can exacerbate depressive symptoms, as well as manic ones. Therefore, alcohol can inflame both sides of bipolar disorder, making it a dangerous substance to abuse.

While drinking on occasion isn’t a bad thing, using it as a crutch can lead to more problems. If you find yourself in a cycle of drinking to cope with bipolar disorder, you could also end up with extended, and often more extreme cycles of mania and depression.

Stimulants & Bipolar Disorder

Stimulants are not normally prescribed for individuals with bipolar disorder because of the risk of augmenting manic symptoms. In general, stimulants excite the entire nervous system, resulting in increased heart rate, blood pressure, temperature, etc. This excitation stimulates the production of hormones and chemicals such as adrenaline, which can cause a person to feel more manic than before.

However, some people with bipolar disorder still find ways to acquire stimulants, whether it’s prescription medications such as Adderall, Desoxyn, and Dexedrine, or illicit ones like cocaine, speed, and crystal meth. The reason stimulant abuse is so dangerous is that it can directly create, and worsen, bipolar disorder; this is often referred to as “amphetamine-induced bipolar disorder.”

Opioids & Bipolar Disorder

Opioids, from Oxycontin to heroin, are another substance that is commonly abused by people with bipolar disorder. What complicates opioid use is that these drugs have also been known to both minimize and exacerbate bipolar symptoms. For example, opioids can sometimes provide temporary relief from depressive symptoms while also prolonging mania in some instances. However, over time, opioid use can cause dwindling euphoria due to a change in brain chemistry, making the person more sensitive to pain and depressive symptoms. Opioids are also highly addictive, which is why they are not often prescribed as a remedy for bipolar disorder.

Cannabis & Bipolar Disorder

Cannabis (marijuana) is a more complicated substance because it can act as both a depressant and a stimulant. While these effects may offset some of the uncomfortable symptoms of bipolar disorder, studies have shown that cannabis use can worsen mania, leading to more rapid cycling, and a general worsening of the condition overall. Other studies have revealed that some individuals develop psychotic symptoms after cannabis use.

While cannabis can provide temporary relief, high levels of THC in the body are linked to negative side effects such as anxiety, paranoia, increased heart rate, and hallucinations, so this substance is best avoided.

Bipolar Disorder & Substance Abuse Treatment Options

The good news is that despite the high rates of substance abuse and co-occurring conditions like bipolar disorder, treatment is available. While these conditions can be treated separately, they are best managed simultaneously, using multiple levels of care that begin with detox and continue through to inpatient/residential, outpatient, and aftercare programs.

If you need to seek help, many of these programs are found in rehab facilities or drug treatment centers across the country.

Dual Diagnosis

Centers that offer dual diagnosis treatment are also recommended as they are set up to diagnose and treat concurrent mental health conditions and substance abuse. This kind of treatment is especially useful for people who have underlying issues such as bipolar disorder, anxiety, and depression. Dual diagnosis programs allow clinicians to safely address these conditions while an individual withdraws from alcohol or drugs.

Key Therapies

Other key treatments to be aware of when it comes to anxiety and substance abuse are:

Cognitive-Behavioral Therapy (CBT)

One of the most effective therapies for bipolar disorder and substance abuse is cognitive-behavioral therapy (CBT). CBT helps individuals change negative cycles of thought and behavior into more positive ones and this has shown to be especially effective for addiction and mental health conditions. Clients receiving CBT for addiction often learn how to recognize “automatic thoughts” and dysfunctional thinking patterns, how to understand the behavior and motivation of others, and how to develop a greater sense of self-understanding and confidence.

CBT also helps clients find solutions to triggers that might encourage drug use. CBT is known to be effective and long-lasting, as clients can continue utilizing these strategies once their therapy sessions have ended.

Dialectical-Behavior Therapy (DBT)

Dialectical-behavior therapy is a type of cognitive-behavioral therapy that focuses on mindfulness, how to live in the moment, cope with stress, and improve relationships. DBT also helps clients better regulate their moods and learn how to develop healthy coping skills. This kind of therapy is useful for people who have co-occurring conditions, especially those who have anxiety, depression, or bipolar symptoms. DBT is also effective for PTSD and for people who exhibit self-destructive behaviors.

Eye Movement Desensitization and Reprocessing (EMDR)

Since a history of trauma and abuse can lead to or exacerbate bipolar disorder, treatments such as EMDR that focus on trauma are also effective. Consisting of 8 phases, EMDR is led by a therapist who guides an individual through a series of rapid eye movements to help redirect negative or traumatic memories. This redirection helps the person form new connections or associations so that the memory is less emotionally distressing over time. This therapy is therefore useful for individuals with mood disorders, as it helps them overcome the emotional suffering associated with traumatic events.

Motivational Interviewing (MI)

Motivational Interviewing (MI) is a type of collaborative therapy between a therapist and the client. During these sessions, the client and therapist work together to define sources of motivation and achieve self-defined goals. MI is known for its positive, client-centered approach and has shown to be effective in treating addiction and mood disorders. For example, a study published in Perspectives in Psychiatry Care showed that, after receiving MI therapy, individuals with bipolar disorder demonstrated an increase in consistently taking their medication, as well as experiencing a motivation to change.

Solution-Focused Therapy (SFT)

Like MI, solution-focused therapy helps individuals with addictions and mental illnesses achieve specific goals. Rather than standard “talk therapy,” which goes into the causes and history of one’s issues, SFT focuses on goals and measurable outcomes.

Medications

While there are no set medications for treating comorbid bipolar disorder and substance abuse, there are a few that have shown some promise during therapy.

Mood Stabilizers

Perhaps the most well-known mood stabilizer for bipolar disorder is lithium. This drug is most effective at preventing or reducing the severity of manic episodes, and is sometimes prescribed with other medications.

Anticonvulsant Drugs

Anticonvulsant or anti-seizure drugs such as Depakote, Lamictal, and Topamax are also sometimes prescribed for individuals with bipolar disorder. These medications help prevent mood instability and can reduce the frequency and severity of depressive episodes.

Antipsychotic Medications

These medications are often prescribed to treat the effects of bipolar disorder, such as delusional thought patterns and erratic moods that accompany manic phases. Common antipsychotics include Seroquel, Risperdal, and Zyprexa.

Other Medications

Along with psychiatric medications, other drugs such as hormone stabilizers, depressants (e.g., benzodiazepines), and blood pressure medications that slow down the nervous systems are also sometimes given to individuals with bipolar disorder.

Alternative or Holistic Therapies

Holistic therapies are also effective at treating addiction and mood disorders. The purpose of holistic therapies is to treat the whole person and not just the symptoms. These can be incredibly beneficial for providing calmness, spiritual support, emotional expression, improving physical health, and teaching valuable skills. Some of the popular holistic therapies include:

• Relaxation techniques
• Nutritional therapy
• Animal-assisted therapy (e.g., emotional support dogs)
• Massage
• Adventure therapy (e.g., hiking or rock climbing)
• Mindfulness and meditation
• Art therapy, Music therapy
• Yoga, Tai-Chi
• Equine-assisted (horse) therapy

Long-Term Recovery

Alongside these treatments, there are other ways to enhance your recovery by making personal lifestyle adjustments like the ones below:

Exercise

Vigorous activity can stimulate your endorphins, which can help with anxiety, depression, and low mood. Examples include low- and high-intensity exercises such as walking, running, swimming, cycling, or yoga.

Meditation

This can help calm anxious or racing thoughts and improve cognitive function, which is useful when recovering from bipolar disorder and addiction.

Eating Well

The right diet can help repair damage incurred following sustained drug use and lead to improved immunity, cognitive function, and energy.

Avoiding Triggers

Learning to avoid triggers like certain people, situations, or circumstances can help prevent a desire to take drugs.

New Hobbies

While cravings can be difficult to manage, hobbies such as sports, art, music, or crafts can be useful distractions.

Resources

If you or a loved one are struggling with bipolar disorder and substance abuse or addiction, you are not alone. Treatment and support are readily available. Contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment.

You can also find a list of treatment centers near you on our website to help get you on the path to recovery.

Key Sources

Bittar, J. (2021). Alcohol and Bipolar Disorder. Alcohol Rehab Guide. https://www.alcoholrehabguide.org/resources/dual-diagnosis/alcohol-and-bipolar-disorder

Bujara, S. (2018). Comorbid Bipolar Disorder and Substance Abuse: A Challenge to Diagnose and Treat. Psychiatry Advisor. https://www.psychiatryadvisor.com/home/bipolar-disorder-advisor/comorbid-bipolar-disorder-and-substance-abuse-a-challenge-to-diagnose-and-treat

Editorial Staff. (2021). Bipolar disorder and alcoholism: Are they related? National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Editorial Staff. (2021). Bipolar Disorder and Addiction. Dual Diagnosis.org. https://dualdiagnosis.org/bipolar-disorder-and-addiction

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.S., Keith, S.J., Judd, L.L, Goodwin, F.K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 264(19), 2511-8. https://pubmed.ncbi.nlm.nih.gov/2232018/

Smith, M., Segal, J. (2020). Bipolar Disorder Signs and Symptoms. Help Guide.org. https://www.helpguide.org/articles/bipolar-disorder/bipolar-disorder-signs-and-symptoms.htm

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