Substance Use

Key Messages

What to know about substance use:

  • Substance use rates are high in bipolar disorder
  • The combination of bipolar disorder and substance use can lead to greatly reduced health and quality of life
  • Substance use and bipolar disorder mood symptoms are closely connected

Alcohol

People with bipolar disorder are more likely than those without bipolar disorder to drink too much alcohol. One systematic review found alcohol use disorder affects more than one in three people with bipolar disorder, affecting more than one in five women and two in five men1. This is especially worrisome, as research has shown that the combination of bipolar disorder and substance use can lead to greatly reduced quality of life and a poor expectation of future health2. Substance use and mood symptoms are closely connected: substance use can cause mood symptoms and mood symptoms can cause substance use. For example, the symptoms of hypomania and mania, such as impulsivity (doing things without thinking) and disinhibition (doing things you would normally stop yourself from doing, like making poor financial decisions, or having unprotected sex), often increase the chance of substance use. Similarly, people with symptoms of depression may seek comfort by using alcohol or other substances to try to feel better or avoid painful emotions. Increased substance use in patients with bipolar disorder is associated with increased risk of suicide3,4.

A glass of beer being filled from the tap.

Cigarettes

People with bipolar disorder are two to three times more likely to smoke cigarettes5; about 30-70% of people with bipolar disorder smoke6. As with other substance use, smoking and bipolar disorder probably have a two-way connection (each affects the other) as well as sharing common risk factors (for example, environmental and genetic factors). Overall, the literature in this area suggests that tobacco withdrawal early in quitting may be associated with mood instability (higher risk for mania, short-term depression), that smoking is linked more illness severity, higher rates of relapse and increased hospitaliations in people with bipolar disorder7.

Cannabis

The science on the relationship between bipolar disorder and cannabis use is still evolving. One review (which identified just six relevant research studies) suggests that cannabis use may make manic symptoms worse, or increase risk of experiencing manic symptoms9. Approximately one quarter of people with bipolar disorder are estimated to use cannabis10. Specific to cannabis use in people with bipolar disorder we recommended looking at the evidence from the National Academies of Sciences, Engineering, and Medicine review11. Previously these guidelines have stated that it is best to avoid cannabis if you have a risk for, or family history of mental illness. This new version is updated to be specific, primarily, to psychosis. This is because this is one area where there is general consensus that there is a clear and robust relationship between use and onset of psychosis. However, there continues to be fierce debate about the direction and nature of this relationship (i.e. whether it is correlation or causal). A weak association between cannabis use disorder and suicidal attempts in people with bipolar disorder has been reported12. Again, however, the quality of current research in this area is currently insufficient to determine whether this is a correlational or causal relationship (meaning it’s not clear if cannabis use disorder actually influences suicide attempts, or if another factor causes both cannabis use disorder and suicide attempts)

Psychedelics

An interesting resurgence of research into the therapeutic use of psychedelics (for example, psilocybin or “magic mushrooms”, ayahuasca) in people with mental health challenges is occurring. There is little published evidence yet on the safety and effectiveness of psychedelic therapies for people with bipolar disorder specifically13, but clinical trial data is expected to be produced in the near future.

Luminescent yellow mushrooms with pinpricks of light floating around them.

How you can take action

There hasn’t been a lot of research on the best way to treat someone who is dealing both with bipolar disorder and substance use problems (this is called dual diagnosis, which means having two conditions at the same time). A few research studies have been done with mood stabilizing medications and it looks like the bipolar disorder medications usually given work well even when substance use problems are present14,15. There is some evidence which associates medications used to treat bipolar disorder with lower levels of substance use; however, it is unclear whether they do so by directly reducing substance use or by stabilizing mood symptoms which may contribute to substance use.  There have been a few studies of psychological treatment (for example, cognitive behavioural therapy) for dual diagnosis individuals and these have shown improvements in depressed mood and possibly substance use16,17,18.

A circle of people in a support group. In the foreground, one woman, a middle-aged Latina woman smiles encouragingly at a dark-haired woman faced away from the camera. Other members are out of focus in the background, shown from the shoulders down.

Fortunately, many communities have programs for those dealing with substance use problems, including drug and alcohol counselors, detoxification facilities, residential treatment centers and support groups like Alcoholics Anonymous. It seems likely that individuals with bipolar disorder would benefit from these programs as much as those without bipolar disorder.

However, most people with bipolar disorder for whom substance use makes it more difficult to manage mood symptoms do not have a substance use disorder. So these cases can be categorized differently, as “high risk” substance use. That is, the person can be using alcohol or other substances in a way that will have negative effects over the long-term and certainly might make manic/hypomanic or depressive symptoms worse, but this person does not have a diagnosable substance use disorder. It is estimated that 15% of the general population use alcohol at a risky level – and that percentage is likely to be higher in people with bipolar disorder. The positive news here is that research shows that individuals falling in this risky drinking category can successfully use self-management strategies, especially if they have some support.

For help quitting smoking, there are a range of useful medications and behavioural treatments (for example, Cognitive Behavioural Therapy) available. However, at present, there hasn’t been high quality research looking at the safety and usefulness of these treatments in people with bipolar disorder. Therefore, it’s important to keep in mind the unknown risks and benefits of these treatments when deciding with your health care provider whether or not to include them in your wellness plan.

Take Action

How to take action: 

  • Assess and monitor your substance misuse
  • Seek evidence-based help/treatment for substance use problems
  • Explore self-help strategies for cutting down/stopping substance use

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References

  1. Di Florio A, Craddock N, van den Bree M. Alcohol misuse in bipolar disorder. A systematic review and meta-analysis of comorbidity rates. European Psychiatry. 2014 Mar;29(3):117–24.
  2. Salloum I.M., & Thase M.E. (2000). Impact of substance abuse on the course and treatment of bipolar disorder. Bipolar Disorders, 2: 269–280.
  3. Carrà G, Bartoli F, Crocamo C, Brady KT, Clerici M. Attempted suicide in people with co-occurring bipolar and substance use disorders: Systematic review and meta-analysis. Journal of Affective Disorders. 2014 Oct;167:125–35.
  4. Cardoso B.M., Sant’Anna M.K., Dias V.V., et al. (2008). The impact of co-morbid alcohol use disorder in bipolar patients. Alcohol, 42, 451–457.
  5. Thomson, D., Berk, M., Dodd, S., Rapado-Castro, M., Quirk, S. E., Ellegaard, P. K., . . . Dean, O. M. (2015). Tobacco use in bipolar disorder. Clinical Psychopharmacology and Neuroscience, 13(1), 1-11. doi: 10.9758/cpn.2015.13.1.1
  6. Heffner J.L., Strawn J.R., DelBello M.P., Strakowski S.M., & Anthenelli R.M. (2011). The Co-occurrence of Cigarette Smoking and Bipolar Disorder: Phenomenology and Treatment Considerations. Bipolar Disorders, 13(0): 439–453.
  7. Thomson, D., Berk, M., Dodd, S., Rapado-Castro, M., Quirk, S. E., Ellegaard, P. K., . . . Dean, O. M. (2015). Tobacco use in bipolar disorder. Clinical Psychopharmacology and Neuroscience, 13(1), 1-11. doi: 10.9758/cpn.2015.13.1.1
  8. McCandless F., & Sladen C. (2003). Sexual health and women with bipolar disorder. Journal of Advanced Nursing, 44: 42-48.
  9. Gibbs, M., Winsper, C., Marwaha, S., Gilbert, E., Broome, M., & Singh, S. P. (2015). Cannabis use and mania symptoms: a systematic review and meta-analysis. Journal of affective disorders, 171, 39-47.
  10. Pinto, J. V., Medeiros, L. S., Santana da Rosa, G., Santana de Oliveira, C. E., Crippa, J. A. de S., Passos, I. C., & Kauer-Sant’Anna, M. (2019). The prevalence and clinical correlates of cannabis use and cannabis use disorder among patients with bipolar disorder: A systematic review with meta-analysis and meta-regression. Neuroscience and Biobehavioral Reviews, 101, 78–84. https://doi.org/10.1016/j.neubiorev.2019.04.004
  11. National Academies of Sciences, E. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. https://doi.org/10.17226/24625 
  12. Bartoli, F., Crocamo, C., & Carrà, G. (2019). Cannabis use disorder and suicide attempts in bipolar disorder: A meta-analysis. Neuroscience and Biobehavioral Reviews, 103, 14–20. https://doi.org/10.1016/j.neubiorev.2019.05.017
  13. Today, P. (2020, May 11). Bipolar and Psychedelics: An Investigation into the Potential and Risks. Psychedelics Today. https://psychedelicstoday.com/2020/05/11/bipolar-and-psychedelics/ 
  14. Vornik L.A., & Brown E.S. (2006). Management of comorbid  bipolar disorder and substance abuse. Journal of Clinical Psychiatry, 67 (suppl 7), 24-30.
  15. Salloum IM, Brown ES. Management of comorbid bipolar disorder and substance use disorders. The American Journal of Drug and Alcohol Abuse. 2017 Jul 4;43(4):366–76.
  16. Weiss RD, Griffin ML, Jaffee WB, Bender RE, Graff FS, Gallop RJ, Fitzmaurice GM: A “community-friendly” version of integrated group therapy for patients with bipolar disorder and substance dependence: a randomized controlled trial. Drug Alcohol Depend 2009; 104:212–219
  17. Weiss R.D. (2004) Treating patients with bipolar disorder and substance dependence: lessons learned. Journal of Substance Abuse Treatment, 27: 307-312.
  18. Schmitz J.M., Averill P.M., Sayre S.L., et al. (2002). Cognitive-behavioral treatment of bipolar disorder and substance abuse: A preliminary randomized study. Addiction Disorders Treatment, 1: 17-24.