Bipolar disorder and addiction: Why they occur together and how to treat both

Photo by Christian Erfurt on Unsplash

Bipolar disorder and addiction occur together so often that researchers describe the combination as close to the norm. In treatment settings, around four in ten people with bipolar disorder also have a problem with alcohol. Many others use cannabis or other drugs.

The two conditions feed each other. Mood episodes can drive substance use. In turn, substance use is linked with more frequent mood episodes and more difficulty sticking to treatment. Treating only one of the two rarely brings lasting stability.

This article covers how common the combination is and why the two conditions are so closely linked. The article also explains:

• Which substances are most often involved
• Why diagnosis is complicated
• What integrated treatment involves
• How families can support someone living with both conditions

What is bipolar disorder?

Bipolar disorder is a mental health condition marked by episodes of extreme mood that differ sharply from a person’s usual self. The episodes last days to weeks, with periods of more stable mood in between. Episodes take two forms:

• Mania or hypomania: Unusually high energy, little need for sleep, and racing thoughts, often with impulsive or risky behaviour. Hypomania is a milder form of mania.
• Depression: Low mood, exhaustion, and hopelessness, and in some cases thoughts of suicide.

Bipolar I disorder involves at least one episode of full mania. Bipolar II involves hypomania and depression. Both types carry a raised risk of substance use problems.

How common is addiction in people with bipolar disorder?

A systematic review and meta-analysis pooled studies of people with bipolar disorder in hospital and community settings. The review found these rates of substance use disorders:

• Alcohol use disorder: 42%
• Cannabis use disorder: 20%
• Other illicit drug use disorders: 17%

Men with bipolar disorder had a higher lifetime risk of substance use disorders than women. People with both conditions also tended to develop bipolar symptoms younger and were admitted to hospital slightly more often. Rates were similar for bipolar I and II.

Why bipolar disorder and addiction are so closely linked

Bipolar disorder and substance use influence each other in both directions. Different mechanisms come into play at different stages of the mood cycle.

Substance use during mania

Mania brings impulsivity, risk-taking, and a sense that nothing can go wrong. During a manic or hypomanic episode, people may drink heavily or use drugs they’d normally avoid. The episode itself weakens the judgement that might otherwise hold them back.

Self-medicating depression and other symptoms

During depressive episodes, alcohol and drugs can offer temporary relief from despair or exhaustion. Some people also use alcohol or sedatives to come down from a high or to get to sleep. The relief doesn’t last, and dependence can develop along the way.

How substances destabilise mood

Substance use makes bipolar disorder harder to control. A review of research on bipolar disorder and substance use found that people with both conditions tend to have:

• More frequent and longer-lasting mood episodes
• More difficulty sticking to treatment, including medication
• A lower quality of life
• A higher risk of suicidal behaviour

Sleep is one route by which substances do harm. Alcohol, stimulants, and withdrawal all disrupt sleep. Psychiatric researchers have shown that losing sleep can tip people with bipolar disorder into mania. Mania then reduces sleep further, which can keep an episode going.

Substance use and withdrawal can also mimic psychiatric symptoms, as our article on dual diagnosis explains. For that reason, treating both conditions together works better than treating either in isolation.

Which substances are most common with bipolar disorder?

Alcohol and cannabis are the substances people with bipolar disorder misuse most often, according to the same review. Cocaine comes next, followed by opioids. Alcohol leads by a wide margin, affecting around four in ten people with bipolar disorder in treatment settings.

Our articles on alcohol abuse and cocaine addiction cover the wider risks of each substance.

Why diagnosis is complicated

Substance use can hide bipolar disorder, mimic it, or make it look worse than it is. Intoxication, withdrawal, and the after-effects of heavy use can all cause mood swings and agitation that resemble a bipolar episode. A clinician has to work out which symptoms belong to the mood disorder and which to the substances.

Clarifying the diagnosis often means watching how mood behaves once a person has stopped using and withdrawal has passed. Family members can provide useful history. For example, they may know whether mood episodes occurred before substance use began, or during periods without substances.

An accurate diagnosis guides which medicines a psychiatrist chooses and how treatment is planned.

Treatment for bipolar disorder and addiction

Effective treatment addresses bipolar disorder and addiction together, in a single coordinated plan. Unstable mood is a powerful trigger for relapse, and continued substance use undermines medication and therapy for bipolar disorder.

Detox and stabilisation

Treatment begins with stopping substance use safely, ideally in a setting where staff can also monitor mood. At Houghton House, patients spend their first three days in our medical detox unit. They see a doctor daily and receive round-the-clock nursing care.

Psychiatric care and medication

Bipolar disorder usually needs long-term treatment with a mood stabiliser or another medicine chosen by a psychiatrist. Houghton House is licensed as both a rehabilitation centre and a private psychiatric hospital. An in-house psychiatrist assesses every patient on admission and prescribes medication where needed. The psychiatrist then monitors and adjusts it with the rest of the clinical team.

Therapy

Medication stabilises mood, and therapy builds the skills to keep it stable without substances. Our rehab programme runs for 30 days, extendable to 42 when clinically necessary. The programme includes:

• Cognitive behavioural therapy (CBT), to challenge the thinking patterns behind both mood episodes and substance use
• Dialectical behaviour therapy (DBT), to build skills for managing intense emotions and impulses
• Psychoeducation, to help patients recognise early warning signs of a mood episode or a relapse
• Individual and group counselling, along with 12-step facilitation

Consistent sleep supports mood stability, and an inpatient programme provides a regular routine from the first day.

Aftercare and relapse planning

People with both conditions need a plan for two kinds of relapse: A return to substance use, and a new mood episode. Our aftercare programme continues therapy and accountability after discharge. Ongoing psychiatric follow-up keeps medication under review.

How families can help

Families often bear the brunt of both conditions, from the chaos of manic episodes to the worry of depressive ones. Early signs of a mood episode include sleeping much less than usual or withdrawing from people. Recognising those signs can help families act before a crisis.

Agree on a plan with your loved one while they’re well, so everyone knows what to do if warning signs appear. Our family support programme also runs weekly meetings for anyone affected by a loved one’s addiction.

If someone with bipolar disorder talks about suicide or is in danger, act immediately. Contact emergency services, or call the South African Depression and Anxiety Group (SADAG) suicide crisis helpline on 0800 567 567.

Medical aid cover for bipolar disorder and addiction treatment

Substance use disorders are prescribed minimum benefits (PMBs) in South Africa. All registered medical aids must therefore cover addiction treatment. Houghton House is also a licensed psychiatric hospital. Patients can claim for additional mental health services where a co-occurring condition qualifies under psychiatric PMBs.

Our admissions team checks your benefits and handles pre-authorisation for you. Visit our medical aid cover page, or contact our admissions team to find out what your scheme covers.

Frequently asked questions about bipolar disorder and addiction

Can drugs or alcohol cause bipolar disorder?

Substances can trigger symptoms that look like a bipolar episode, and they can worsen mood episodes in someone already vulnerable. A psychiatrist can assess whether symptoms reflect bipolar disorder or the effects of substances. The picture usually becomes clearer once a person has stopped the substance abuse.

Is it safe to drink alcohol if you have bipolar disorder?

Alcohol is the substance most often linked with bipolar disorder. Heavy drinking is associated with more frequent mood episodes and more difficulty sticking to treatment. If you have bipolar disorder and are concerned about your drinking, discuss it with your psychiatrist, especially if you take medication.

Can you go to rehab if you have bipolar disorder?

Yes. A centre that can treat both conditions together offers the best chance of lasting recovery. At Houghton House, patients with bipolar disorder receive psychiatric care and addiction treatment in the same admission.

Where can I get help for bipolar disorder and addiction in South Africa?

Houghton House in Johannesburg treats addiction alongside co-occurring mental health conditions, including bipolar disorder. Call our admissions team on +27 11 787 9142 for a free, no-obligation telephonic evaluation, or contact us online.

Sources

• Cerullo, M. A., & Strakowski, S. M. (2007). The prevalence and significance of substance use disorders in bipolar type I and II disorder. Substance Abuse Treatment, Prevention, and Policy, 2, Article 29. https://doi.org/10.1186/1747-597x-2-29 
• Hunt, G. E., Malhi, G. S., Cleary, M., Lai, H. M. X., & Sitharthan, T. (2016). Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990–2015: Systematic review and meta-analysis. Journal of Affective Disorders, 206, 331–349. https://doi.org/10.1016/j.jad.2016.07.011 
• Wehr, T. A., Sack, D. A., & Rosenthal, N. E. (1987). Sleep reduction as a final common pathway in the genesis of mania. The American Journal of Psychiatry, 144(2), 201–204. https://doi.org/10.1176/ajp.144.2.201