Bipolar disorder is a serious mood disorder characterized by abnormal changes in moods, activity, and energy levels that interfere with daily life.
According to the National Institute on Mental Health (NIMH), it was estimated that 2.8 percent of the American adult population suffered from bipolar disorder in the past year, based on surveys from 2001-2003.
To be diagnosed with bipolar I disorder, a person must have experienced at least one manic episode. To be diagnosed with bipolar II disorder, a person must have experienced at least one hypomanic episode and at least one major depressive episode, and they must not have had any manic episodes.
Mania involves having an expansive, elevated, or irritable mood and increased energy or activity. Both must be abnormal and persistent. It must occur in a distinct period that lasts for at least a week and must be present for the majority of the day almost every day. Mania can also be diagnosed for episodes that are briefer if they are severe enough to require hospitalization. If hospitalization is not required, the episode must also significantly hinder functioning or involve psychosis. A subset of specific symptoms must also be present during the episode for mania to be diagnosable. Lastly, the episode must not be caused by drugs or another medical condition or intervention.
Hypomania is similar to mania, but it only has to last for 4 days to be diagnosable. It cannot require hospitalization, significantly hinder functioning, nor involve psychosis. The episode must be a clear change in functioning, and this change in functioning as well as change in mood must be able to be observed by others.
A major depressive episode involves having a depressed mood and/or a loss of pleasure or interest. A subset of specific symptoms must be present during a span of 2 weeks. There must be a change in functioning, and the episode must cause significant distress or significantly impair functioning. The episode must not be caused by drugs or another medical condition or intervention, and it must not be an appropriate response to a significant loss.
Alcohol and drugs can seem like a great way to relieve symptoms of bipolar disorder and may be used to cope with symptoms as a form as self-medication. For instance, marijuana or alcohol may be used to try to ease the irritability that can be present in a manic episode. An individual may use a stimulant drug, like cocaine or methamphetamine, to try to boost their energy during a depressive episode. Although using these or other drugs may seem like it helps in the short term, it is an unhealthy way to cope because it can cause more harm than good. In addition to the inherent dangers of misusing drugs, substance abuse can worsen bipolar disorder and make it harder to treat.
Bipolar Disorder, Drugs, and the Brain
Several elements can contribute to the development of bipolar disorder. Genetic factors play a role, and researchers have even identified some specific genes that are involved. Biochemical factors are also thought to be implicated. Changes in norepinephrine, epinephrine, and serotonin systems may contribute to both mania and depression. Glutamate levels may also be linked to bipolar disorder. Research also shows that disturbance of calcium regulation within cells might play a part in mania. Furthermore, imbalances of hormones and problems with the hypothalamic-pituitary-adrenal axis, which is involved in the stress response, may also be factors in bipolar disorder.
Additionally, neurophysiologic factors may also contribute. Bipolar disorder has been linked to decreased activation and reduction of gray matter in a brain network linked to emotional regulation, as well as to increased activation of regions that influence the experience of emotions and the production of emotional responses.
Drugs and alcohol also interact with brain chemistry and impact certain regions of the brain. Some are able to activate nerve cells because they are similar to natural neurotransmitters (chemical messengers). Others can prompt the cells to release excessive amounts of neurotransmitters or inhibit the cells from recycling neurotransmitters like they should. All of these effects can alter the normal communication of nerve cells.
- Some drugs excessively activate the reward circuit of the brain, driving the individual to repeatedly use the drug. Additionally, a circuit of the brain involved with anxiety and irritability can increase in sensitivity as drug use increases. When drug use is continued on a regular basis, nerve cells become accustomed to the drug exposure and will work normally only with drugs present, a phenomenon known as dependence. Withdrawal symptoms can develop if the individual stops using the drug. Drug use can also affect the prefrontal cortex, which plays a role in a person’s ability to think, problem solve, make decisions, plan, and control impulses. Some drugs also impact other areas of the brain, like the brain stem.
- Since both drug use and bipolar disorder are linked to brain changes, using drugs while battling the mental health disorder may have a greater impact. Research shows that adults who had bipolar disorder and alcohol use disorder had more abnormal functioning in the brain, less gray matter volume, and increased deficits in a neurotransmitter system in one part of the brain than adults who had bipolar disorder but no co-occurring substance use disorder.
Substance use may worsen bipolar disorder and make it harder to treat, and substance withdrawal may trigger bipolar symptoms.
Brain changes might also explain, or partially explain, why these disorders often co-occur. One article reports that the effects of addiction on a part of the brain involved in inhibition, the orbitofrontal cortex, may lead to a quicker onset of mania in those who abuse substances before their bipolar disorder develops. Additionally, bipolar disorder may be associated with orbitofrontal cortex deficits, and in those who develop bipolar disorder first, these deficits may make the compulsion to use drugs stronger.
Complications of Co-Occurring Bipolar Disorder and Addiction
People suffering from bipolar disorder often turn to drugs or alcohol. An article in the journal Current Psychiatry reports that about 60 percent of those diagnosed with bipolar I disorder also have suffered from a substance use disorder at some point in their lives. When multiple disorders, like a substance use disorder and bipolar disorder, occur in the same person, they are termed co-occurring disorders. Difficulties associated with co-occurring substance use disorder and bipolar disorder may include:
- Onset of mood symptoms earlier
- Worse clinical presentations
- Poorer outcomes
- More suicide attempts
- Increased rate of anxiety disorders
- Higher number of depressive episodes
- More frequent hospitalizations
- Higher rates of accidents
- Increased rates of rapid cycling
- Poorer treatment compliance
Both addiction and bipolar disorder can interfere with a person’s ability to perform day-to-day tasks and function normally in society. Homelessness, financial problems, work issues or unemployment, relationship difficulties, troubles with the law and legal entanglements, and suicide attempts are all possible complications of both bipolar disorder and addiction.
Doing drugs in childhood or adolescence, before the brain is fully developed, may have lasting consequences. It is associated with an increased risk of substance use disorders developing later and may also be linked to an increased risk for later development of other mental health disorders, according to the National Institute on Drug Abuse (NIDA). Also, having a mental illness as a child or adolescent can increase the risk of drug use later and substance use disorder development.
Co-Occurring Disorder Treatment Complications
Based on the 2017 National Survey on Drug Use and Health, it was estimated that over 18.7 million Americans ages 18 and up suffered from a substance use disorder in the past year and that over 8.5 million had both a substance use disorder and a mental illness in the past year. This means that about 45% of adults with a past-year substance use disorder also had a past-year mental illness. For individuals with co-occurring disorders, integrated treatment that addresses both mental illnesses and substance use disorders provides better results.
Suddenly stopping some substances, such as alcohol, can be life-threatening. As such, some individuals may need to detox in an inpatient medical detox facility. During inpatient medical detox, vital signs and mental health can be continually monitored. Medications may be used to help prevent dangerous complications and/or to provide a more comfortable experience. Individuals with bipolar disorder may also need medications to stabilize their mood.
Relapse rates for substance use disorders are high, between 40 and 60 percent, NIDA publishes, and may be even higher for people struggling with co-occurring disorders. As discussed earlier, individuals with co-occurring bipolar disorder and substance use disorder often have worse clinical presentations and outcomes than those with just bipolar disorder.
It is recommended that co-occurring bipolar disorder and substance use disorder be treated simultaneously in an integrated fashion by professionals. Although no treatment of choice for co-occurring bipolar disorder and substance use disorder has emerged, options include psychotherapy, medications used to treat substance use disorders, and/or medications used to treat bipolar disorder. By working together with treatment professionals, individuals with co-occurring bipolar disorder and substance use disorder can learn to manage their illnesses and live healthier, happier lives.