Bipolar disorder is characterized by significant fluctuations in a person’s mood, which may occur for no apparent reason. It tends to persist and people affected by it have phases when they are very happy and active, and phases when they are feeling very sad and hopeless, with often normal moods in between. Some people with bipolar disorder like the “high” phase so much that they may take no action until their mood is so elevated that they are hypomanic or even manic. In the “down” phase the person feels pervasively sad and may slump into a severe depression and feel life is closing in around them. Bipolar disorder typically starts in a person’s late teen or early adult years.
Bipolar disorder consists of two major types. Bipolar disorder, type I is the classical and well-known disorder, which used to be called manic-depressive illness. Episodes of hypomania and depression tend to alternate, with each phase lasting for days or weeks. Bipolar disorder, type II, is characterized by shorter-lived episodes of abnormal mood (it is sometimes termed “rapid cycling”) and there is a predominance of depressive phases. Bipolar disorder, type I occurs in approximately 1% of the adult population. Bipolar disorder, type II is more common and estimates vary from 2-3% to up to 6% of the general population. Some people use the term bipolar disorder, type III to indicate a disorder where hypomanic episodes are precipitated by antidepressant medications. A form of bipolar disorder can also be induced by substance use. Sometimes it can be difficult to distinguish between bipolar disorder and certain forms of post-traumatic stress disorder and some authorities argue that there can be an overlap between these disorders.
Responding to bipolar disorder
Bipolar disorder is a significant illness and it is vital that it is identified early and treated effectively. Self-management is a key aspect of mastering the disorder and people with the disorder can manage and modify its phases much more effectively if they are actively involved in monitoring their mood (preferably with the help of family or close friends) and taking steps to contact their psychiatrist, general practitioner, or health professional if they (or their family/friends) sense a deviation in how they are feeling or acting from their usual self.
Many people have experienced bipolar disorder, and although it is a challenge to manage it over several years, there is effective treatment, which typically combines medication and psychological therapy. Well known historical figures, such as Winston Churchill, are thought to have had bipolar disorder and there are many others who have made major contributions to life, in particular to the creative arts, while managing their bipolar disorder.
Bipolar’s links with alcohol and drug use
Bipolar disorder is also strongly associated with alcohol and drug and other addictive disorders, such as gambling. The relationship can be a two-way one. Substance disorders can induce bipolar-type disorders, with phases of hypomania and depression resembling the classical condition. Some substances, because of their pharmacological effects, will induce mood changes with alternating elevations and declines in mood. The use of psychostimulants such as methamphetamine and cocaine characteristically produces successive episodes of alternating moods.
More commonly, the phases of bipolar disorder can lead to episodes of substantial substance use which may persist until the mood normalises, or may lead to such a repetitive pattern of use that dependence (addiction) is induced. The most frequent time for substance use to “take off” is when the person has a hypomanic (or manic) episode. As part of the over activity and bright over-euphoric mood, the person may indulge in alcohol and drug use to a far greater extent than they would normally do. The person can also lose judgement and do things they later regret. A person in the hypomanic phase can overspend, which may involve illicit substances or gambling excessively. Substance use tends to continue unchecked until the hypomanic phase is treated. Serious disturbance to the person’s health and well being, finances, and personal relationships can ensue. Sometimes these phases are accompanied by excessive gambling and sexual activity, or sometimes bursts of gambling can occur without substance use or the other features.
Somewhat less commonly, substance use may become problematic in the depressed phase of the bipolar illness. Here the motive tends to be “medicinal”: people try to boost their mood or numb their emotions. Various substances may be used in this phase. Depression may be temporarily relieved by a psychostimulant – however, the “down” phase when stimulant use is terminated is usually more severe in the presence of a bipolar disorder. Sometimes people drink alcohol excessively, take sedative drugs such as benzodiazepines or smoke cannabis in an effort to numb themselves and to avoid the worst of the depressive experience. Such so-called benefits are only temporary and the bipolar illness tends to be worsened when such substances are used in this way.
Early diagnosis and effective treatment are key to the management of bipolar disorder. A history of trauma should be elicited to see if this is a contributory factor or whether the illness conforms more to a complex form of post-traumatic stress disorder. Mood stabilizers, such as lithium, valproate, and some anti-psychotic drugs are central to treatment. Caution needs to be taken if antidepressants are being considered because they can precipitate hypomania or mania (bipolar disorder, type III).
The treatment for accompanying substance use depends on its relationship with the bipolar illness and also, importantly, on whether it has been so repetitive and persistent that dependence has developed. In the earlier phases of bipolar disorder with superadded substance use, the focus should be on effective management of the bipolar disorder, and substance use will generally respond to this as the hypomanic and depressive phases come under better control.
When dependence has developed, the substance disorder has to be treated in its own right so that parallel and integrated treatment of the two disorders is undertaken. Mostly, appropriate treatment for the substance dependence can be provided using the same combination of medications, therapies, and involvement with self-help fellowships that apply when substance disorders occur without any psychiatric comorbidities.
The value of a treatment program
The combination of bipolar disorder and a substance disorder is a challenging one, both for the person affected, for their close family and friends, and for health professionals. One of the advantages of a period of inpatient treatment is that the relationship between the bipolar disorder and the substance disorder can be thoroughly examined, and a conclusion drawn as to whether the substance disorder is symptomatic of the bipolar condition or has developed into a disorder in its own right. Furthermore, integrated treatment and therapy can be more effectively marshalled when the patient has a period of in-hospital treatment. One of the great rewards for mental health and substance use professionals is to see a patient who was disabled by this combination address their dual disorders, gain increased confidence in monitoring themselves and their treatment, and re-establishing themselves in productive employment and life beyond that.
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