Alcohol Or Bipolar: What's The Real Diagnosis?

Bipolar disorder and alcohol use disorder (AUD) often co-occur, with an estimated 60% of people with bipolar disorder also having alcohol dependence. This makes it difficult to differentiate between the two conditions. Heavy drinking does not necessarily mean someone is an alcoholic, but alcoholics often feel they cannot stop drinking and need to drink more and more to feel satisfied. Manic episodes are the main sign of bipolar disorder, and people with the condition may drink alcohol to try to manage their symptoms. However, alcohol can amplify mood shifts and interfere with medication. If you are concerned about yourself or a loved one, it is important to talk to a doctor about treatment options.

Bipolar disorder and alcoholism comorbidity

Bipolar disorder and alcoholism commonly co-occur at rates higher than expected. Bipolar disorder, often called manic depression, is a mood disorder characterised by extreme fluctuations in mood from euphoria to severe depression, interspersed with periods of a normal mood. Bipolar I disorder is the most severe type of bipolar disorder, followed by bipolar II disorder, which is less severe. Unipolar depression is depression without manic episodes.

Several studies have reported an association between alcoholism and mood disorders. The National Institute of Mental Health's Epidemiologic Catchment Area (ECA) study (1990) revealed that 60.7 percent of people with bipolar I disorder had a lifetime diagnosis of a substance use disorder; 46.2 percent of those with bipolar I disorder had an alcohol use disorder, and 40.7 percent had a drug abuse or dependence diagnosis. Bipolar disorder was found to be more likely to occur with alcohol dependence than with alcohol abuse. The ECA study also found that mania (bipolar I disorder) and alcohol use disorders are 6.2 times more likely to occur together than would be expected by chance.

The National Comorbidity Survey (NCS) (1996) reported similar findings, with 48 percent of people with bipolar II disorder having a substance use disorder, 39.2 percent having an alcohol use disorder, and 21 percent having a drug abuse or dependence diagnosis.

The relationship between bipolar disorder and alcoholism remains poorly understood, although some evidence suggests a genetic link. This comorbidity has implications for diagnosis and treatment, as alcohol use may worsen the clinical course of bipolar disorder, making it harder to treat. There has been little research on the appropriate treatment for comorbid patients. However, some studies have evaluated the effects of valproate, lithium, and naltrexone, as well as psychosocial interventions, in treating alcoholic bipolar patients.

Self-medication and risk factors

Self-medication is a common phenomenon among individuals with mood disorders. Alcohol and drug use to relieve affective symptoms is prevalent in this demographic, but it is associated with a higher risk of psychiatric comorbidity. Self-medication can lead to higher odds of comorbid anxiety and personality disorders.

Bipolar disorder and alcohol use problems often co-occur, leading to the belief that alcohol is used as a form of self-medication to alleviate bipolar symptoms such as mania, depression, anxiety, and sleep disturbances. However, recent research suggests a more intricate relationship between the two. A study by the University of Michigan found that even temporary increases in alcohol consumption can lead to long-lasting changes in bipolar symptoms, but not the other way around. This indicates that alcohol may not be a simple form of self-medication for bipolar disorder.

The complex interaction between bipolar disorder and alcohol use is an active area of research, with studies aiming to identify the psychological and neurophysiological factors contributing to alcohol use and symptom changes in bipolar individuals. The current key message for people with bipolar disorder regarding alcohol use is to maintain consistency. Clinicians advise patients to keep their alcohol consumption low and stable and avoid binge drinking. This is similar to the advice given for sleep schedules, medication schedules, and eating patterns.

The risk factors associated with self-medicating bipolar disorder with alcohol are significant. The self-medication hypothesis has been explored in various studies, indicating that individuals with mood disorders, anxiety disorders, and substance-abuse disorders often turn to alcohol or drugs for relief. This can lead to a higher mental illness burden and substantial psychiatric comorbidity. Older Americans with mood disorders are also at risk of self-medication with alcohol, as are adolescents, where behavioural and health problems can influence alcohol and drug use.

Treatment and recovery

Bipolar disorder and alcohol use disorder (AUD) can co-occur more often than expected by chance, and this comorbidity has implications for diagnosis and treatment. Integrated treatment, also known as dual diagnosis treatment, is important for recovery from both disorders. This involves treating both disorders simultaneously.

Pharmacotherapy is one method used to treat both disorders. Mood stabilizers such as lithium and valproate can be used to manage bipolar symptoms, while medication can also alleviate alcohol withdrawal symptoms and reduce drinking in people with AUD. Atypical antipsychotics such as quetiapine can also be used to manage bipolar symptoms.

Psychoeducation can help individuals understand each disorder and how they interact. Self-help or mutual-help groups, such as Alcoholics Anonymous (AA), Dual Recovery Anonymous, or SMART Recovery, can provide valuable support and guidance. Integrated Group Therapy (IGT), based on cognitive-behavioural therapy (CBT) principles, can help individuals address the thoughts and behaviours contributing to both disorders.

SAMHSA's National Helpline offers a free, confidential referral service for individuals and families facing mental health and substance use disorders. They provide referrals to local treatment facilities, support groups, and community-based organizations.

While there is limited research on treating patients with comorbid bipolar disorder and AUD, some studies have evaluated the effects of valproate, lithium, and naltrexone, as well as psychosocial interventions. Further research is needed to optimize treatment for these patients.

Alcohol's effect on bipolar medication

Alcohol use is common among people with bipolar disorder, who may use it as a form of self-medication to induce sleep, calm anxiety, or boost their mood. However, alcohol is not a simple form of self-medication for bipolar disorder. Alcohol consumption can interfere with bipolar medication, including mood stabilizers, antipsychotics, and antidepressants, reducing their effectiveness or increasing adverse side effects. This interference can further complicate bipolar symptom management.

For instance, alcohol consumption in the context of rapid cycling, which involves four or more episodes of mania, hypomania, or depression within a year, can heighten emotional volatility and push the individual into more frequent or severe episodes. Alcohol use can also mask bipolar symptoms rather than treat them, further complicating the unpredictable cycle of mood changes.

Additionally, alcohol misuse can harm overall health, impacting the liver, heart, and brain. For those with bipolar disorder, compromised physical health can further destabilize mental health, leading to a more complicated treatment course and a heightened risk of severe mood episodes. Alcohol use can also impair judgment and self-awareness, causing individuals to miss the early warning signs of a manic or depressive episode and leading them to forgo healthy coping strategies or medication adherence in favor of alcohol use.

Therefore, it is crucial to treat bipolar disorder and alcohol misuse simultaneously for sustainable recovery. A comprehensive, integrated treatment approach may involve mood stabilizers, antipsychotics, medication for alcohol use disorder, cognitive-behavioral therapy (CBT), and dialectical behavior therapy (DBT). Keeping alcohol use low and stable, and avoiding bingeing, is also important for managing bipolar disorder.

Alcohol's effect on bipolar disorder

Alcohol use disorder (AUD) is a condition in which drinking causes distress or harm. People with bipolar disorder are at a heightened risk of AUD, with about 42% to 56% of individuals with bipolar disorder having a history of AUD. Bipolar disorder is characterised by unusual shifts in mood, energy, activity levels, and concentration. These fluctuations can make it challenging to maintain routines, hold jobs, and sustain relationships.

Alcohol use is linked to worsening symptoms of bipolar disorder, including increased depression, mania, and work problems. Bipolar disorder has two subtypes: BD I, which involves at least one manic episode with severe mood disturbances, and BD II, which involves at least one hypomanic episode (elevated mood of lesser intensity than in BD I) and at least one major depressive episode. Participants with BD II were more likely to continue heavy drinking than those with BD I.

Drinking alcohol can interfere with bipolar medication, making it less effective or even harmful. As alcohol is a depressant, it can make depressive episodes worse and harder to manage. It can also cause individuals to act more impulsively or take more risks when feeling manic. For those with BD II, alcohol might hide or confuse the signs of hypomania, making it harder to manage. Chronic alcohol use can also affect liver function, which is crucial for breaking down bipolar medications.

The ideal approach to treating individuals with bipolar disorder and AUD is through integrated treatment. However, most treatments for bipolar disorder do not address alcohol use. Researchers have not identified a clear link between bipolar disorder and AUD, but some theories suggest that people with bipolar disorder use alcohol to manage their symptoms, especially during manic episodes. Others suggest that AUD may trigger bipolar disorder or that the two disorders share genetic risk factors.

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