When Bipolar Patients Abuse Drugs – The Dual Diagnosis Dilemma

Most people familiar with public health issues are aware of the challenges posed by “dual diagnosis” patients — those with both a psychiatric diagnosis and a substance abuse diagnosis. But the special case of addicted bipolar disorder patients is particularly problematic. Writing in the August issue of Current Psychiatry, Bryan K. Tolliver lists the severe outcomes that plague the victims of bipolar disorder who are also substance abusers: “Poor treatment compliance, longer and more frequent mood episodes, more mixed episodes, more hospitalizations, more suicide attempts.”

In Bipolar Disorders, Cassidy and coworkers conclude that lifetime rates of substance abuse in test populations of bipolar patients can run as high as 48.5% for alcohol and 44% for drugs. In addition, a study published in Psychiatric Services, which sampled almost 3,000 veterans diagnosed with bipolar disorder, found more evidence for troubling correlations: “Patients diagnosed as having both an alcohol use disorder and polysubstance dependence and who also were separated from their spouse or partner had a 100% risk of psychiatric hospitalization [Italics added]; risk of psychiatric hospitalization decreased to 52% if the patients were not separated from their partner.”

Not a pretty picture.

What is the link between these two seemingly disparate conditions? Why do bipolar disorder patients abuse alcohol and other drugs at rates far higher than other populations of psychiatric patients, or the population at large? In his article, professor Tolliver, who is with the clinical neuroscience division at the Medical University of South Carolina, lists several theories, along with their limitations:

Drug abuse as self-medication for an existing bipolar disorder. This explanation is often invoked to explain the very high rates of cigarette smoking among schizophrenics. However, it fails to account for the fact that manic depressives often use stimulant drugs when they are manic, and sedating drugs when they are depressed, rather than the other way around.

Co-morbidity as the result of common genetic risk factors. A compelling hypothesis, but, according to Tolliver, specific evidence in the form of genetic linkage studies is lacking.

Drug abuse as a symptom of bipolar disorder. The problem with this explanation is simply that most bipolar disorder patients do not have drug problems. And, in those that do, there is a “poor correlation of onset.”

Drug abuse as a trigger for bipolar disorder. In this case, the counter-evidence is that “emergence of mania before substance use disorder is common.” However, when the onset of mania precedes the development of drug abuse, particularly during adolescence, it “may predict a more severe course of both illnesses,” writes Tolliver.

Misdiagnosis based on common symptoms and “poor diagnostic boundaries.” But in this case we find that a high rate of drug abuse is common in longitudinal studies of patients initially hospitalized for mania.

There are other diagnostic problems. For example, procedures for bipolar clinical studies and drug trials often mean that patients with drug problems are routinely excluded. Similarly, patients with serious mental illnesses are themselves excluded from randomized controlled trials in substance abuse treatment studies.

Another common problem is that “denial of illness is a critical symptom that may fluctuate with disease course in both disorders.”  Furthermore, there can be clinical confusion when bipolar disorder “is overdiagnosed in persons engaged in active substance abuse or experiencing withdrawal.”

There is no FDA-approved pharmaceutical treatment for co-occurring bipolar disorder and substance abuse.  To make matters worse, drug abuse in bipolar disorder patients, especially rapid cyclers, usually predicts that the patient will have a poor response to lithium, the most common treatment for bipolar disorder.

Limited drug studies have been done, but thus far, few compounds have emerged as heavyweight candidates. Depakote,  (divalproex sodium), which is another common treatment for the manic phase of bipolar disorder, decreased the number of heavy drinking days in dual diagnosis patients when combined with lithium. But in a different study, the group differences petered out after six months. (Lithium alone was associated with decreases in cannabis use.) Carbamazepine, an anti-convulsant with a mixed history when used for cocaine dependence, seemed to slow cocaine use in one study of bipolar disorder patients. And Seroquel (Quetiapine), a controversial drug used in the treatment of schizophrenia, lessened some symptoms of depression. Finally, Revia (naltrexone), in a 12-week study of alcoholic patients with diagnosed with bipolar disorder, led to modest decreases in the number of drinking days.

None of these results can be characterized as a breakthrough, to say the least.  Integrated group therapy, designed specifically for dual diagnosis patients, has shown promise, compared to standard group drug counseling. But the reality is that additional research on treatment avenues is urgently needed for this most challenging of dual diagnosis disorders.


Tolliver, BK (2010). Bipolar Disorder and Substance Abuse. Current Psychiatry, 9 (8).

Cassidy F, Ahearn EP, & Carroll BJ (2001). Substance abuse in bipolar disorder. Bipolar disorders, 3 (4), 181-8 PMID: 11552957

Hoblyn JC, Balt SL, Woodard SA, & Brooks JO 3rd (2009). Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatric services (Washington, D.C.), 60 (1), 50-5 PMID: 19114570

  • David Henwood

    I find this article interesting from the point that there seems to be some question as to why manic depressives tend to use stimulants when manic and depressants when depressed but I would argue that it is a quite logical reaction to their condition. When a person is experiencing a manic episode they are drawn into that manic state and it tends to be those observing them who are most concerned by what they are observing. The manic state is, at that point, their ‘natural state’ so they are drawn to drugs that fit that state or maintain that state. Likewise with a person in a depressed state being drawn into that depressed state and using drugs that provide a level of ‘comfort’ within that state. The logical response would be for a manic person to take a depressant to counteract the mania but for a person in that state the mania is the naturally logical comfort state.

    • AAA

      As a type 2 bipolar, in my personal experience it’s exactly the opposite to your argument that “The manic state is, at that point, their ‘natural state’ so they are drawn to drugs that fit that state or maintain that state”

      For example, when I’m in a hypomanic state, THC makes me crazy – very high energy and social anxiety, forced speech, confusion, hypersexuality, loss of appetite for many hours even with small amounts. I’ve learned to avoid it completely as it can make a hypomanic episode considerably worse, or even trigger an episode. However, when I’m feeling normal or depressed, THC is quite pleasant or relaxing.

      On the other side of the recreational spectrum, when I’m already in a hypomanic state, cocaine is actually very relaxing. I don’t know why, but that’s the way it is, and obviously it’s completely opposite to “normal” people. I’m not on any prescription drugs, and I’m not an addict or an alcoholic.

      If others are like me, then the self-medication explanation seems far more likely.

  • Bridget Roberts

    Misdiagnosis and the questionability of the evidence base for treatments highlight the importance of working with each person from a biopsychosocial standpoint. This includes working with, not on, the person, having the time to get the full story, marshalling the resources and political/social will to make the most of the repertoire of drugs and/or therapies. Yes, researchers with the right skills and preferences will keep up the search for the Holy Grail treatments but they are only addressing one of the questions facing people who are diagnosed with bipolar disorder and who use alcohol or other drugs.

  • sjhart

    I continue to find it disturbing, that within our community of practicing clinicians and researchers, there is black and white thinking that perpetuates complex situations into simple ones.
    The issue of “self-medicating” has been a long-standing part of our language that minimizes and disrepects the obstacles to competent evalutions, competent dual treatment, and language that explains the continued lethal problems of addictions and the role they play in stabilization.
    Without mental health care coverage, expensive deductibles, pre-existing conditions, stigma that runs deep within our culture and society, and the continued lack of education, overdose and suicide will likely continue to rise.
    For those who sit in offices rather than interviewing clients about the symptoms they suffer, and easier access to street drugs and alcohol, it will be that much more difficult to press for change. We must learn transdisciplinary treatment to advocate as we educate. I fear I will continue to bury our clients..because we don’t get it.
    SJ Hart,MEd,CADC
    Author “Lies In Silence”
    Dual Cliician 25 years
    National Public Educator
    Three generations with bipolar and co-occurring cconditions
    Bipolar since 2005
    “I do not know what lies ahead, but I refuse to be quiet to what Lies In Silence.” Press for Change.

    • jennifer Slate

      I could”t agree with Ms Sjhart more. Both my mother and my adult son were diagnosed with bipolar disorder. My mother after witnessing the accident and death of her two young brothers and brother in-law in a flood and being unable to save them. She had neither abused drugs or alcohol prior to this, however she did later on in life. She suffered for 30 years before she was diagnosed and her treatment back in the sixties was horrific. My son was a victim to a severe abusive psyshological episode when he went away to a job training core at the age of 19 he went into a catatonic state and kidney failure before we were notified he ended up being diagnosed as bipolar several weeks later. We went through years of failed treatment due to no insurance for him. He was treated by a fm prac dr who had little knowledge of the severity of sise effects of the drugs she prescribed and he suffered a massive heart attack. He self medicated from time to to time with street drugs and binge drinking when he heard voices. Now he has medicare and I took him to a genuine shrink who told me that bipolar patients don’t drink or do drugs that he is just an addict and doesen’t have any other problems. I
      He said he has too many other problems now and is going to die if he self medicates and you need to make him stop. I said are u kidding? What u r saying is that you’re not going to treat him now because so many doctors have messed him up, but now you are blaming him and holding me responsible at the same time. What college did you get your degree? He came to you for help, he has taken all the drugs you doctors handed out and it destroyed his heart and you are now treating him like a burden to society because you see everything so black and white. On top of everything else he has a severe learning disability and has been given drugs without knowing what they could or would do to him physically. This has been truly a nightmare for our family and its only going to get worse just look at our homeless population they are mostly mentally ill. Doctors woork like machines with no compassion they are didgusted with the very people they treat. They could care less what their backstory is . They run them in and out like cattle write a script and if it doesnt work it is the patients fault.

  • Don

    The message of ths story? Simple!
    “NORMAL” people don’t need or do drugs.
    That drug taking is an aberation, a “sickness”.
    That society MUST eradicate such antisocial behaviour.

    The truth is much more sinister.

    Society and so-called social norms themselves are an aberation. And very likey a psychosis. If normal society is responsible for the state of the world, it’s finances, it’s care for it’s members etc. than it can only be described as sick and probably insane.

    “There is no salvation in becoming adapted to a world which is crazy.” – Henry Miller

    Since this insane society insists on marginalizing and demonizing drug users, such lifestyles probably contain some useful and necessary elements for society’s regeneration.

    As a bipolar AND a drug user, I strong resent the implications that “NORMAL” people and their “NORMAL” values are something I should aspire too.

    I find the idea that “NORMAL” people hire armed thugs to oppress and persecute people who choose to use drugs sickening and terrifying. Yet in in the name of society, it is done every day.

    Why do YOU do this? Why do you want your “LEGAL” agents to destroy homes, families and lives? It’s you who are sick and disordered if you tacitly approve this and blind and stupid if you don’t realize it’s YOU doing it.

    Do not be confused. The war on drugs and drug users is un-winnable. You best consider truce while you can.

    People self-medicate because they prefer to. Most figure out what works and in most cases, the only real threat is from YOU! You and your thugs.

    The Pharma giants are behind the laws and social programming which maintains this disgusting status quo. They stand to lose multi-billons of dollars of revenue if self-medication is allowed to contiinue. And just like Obama bailed out the bankers and not the people, it’s Big Pharma who gets the say in the outcome.

    This time however, the scales are about to tip. Too many people have experienced the mind opening effects of major and minor psychedelics, and have seen the lies and corruption. Their values and perceptions are forever altered. Your insistance that they are sick and need fixing can only push them away.

    Your drug taking sons and daughters are looking for something you can’t give them. And apart from brainwashing them with shock treatments and group therapies, you will never make them want what you have. They know you are blind and lame. And while there are some real risks to some kinds of drugs and drug use, those risks pale against the risk of going back to sleep in society’s “la-la” land. That way is insanity.

    my decidely biased and non-social pont of view.


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  • My son was diagnosed with Bipolar disorder before age 16. His father had personality disorder. No one in the family has mental illness. He self-medicated with drugs and has been in and out of prison. I am a christian and do believe in miracles. Everytime he is arrested, I too, suffer. Being helpless and frustrated of finding a good cure/therapy brought sadness. I turn to God for comfort. The revolving door to prison is a constant threat when he is released. To have faith in God is to have peace. My days are filled with prayers for him to recover. Without God, I’d be lost forever.

  • Valentino

    I live cocaine it was legal in the 60-89’s but you have to be strong to take such substance and have money cause its for rich people and as far as the pharma drug dealers they just feeding us poison they want no one to cut there profits in drugs/narcotics because its the bIggest money maker

Dirk Hanson, MA

Dirk Hanson, MA, is a freelance science writer and the author of “The Chemical Carousel: What Science Tells Us About Beating Addiction.” He is also the author of ”The New Alchemists: Silicon Valley and the Microelectronics Revolution.” He has worked as a business and science reporter for numerous magazines and trade publications. He currently edits the Addiction Inbox blog, and is senior contributing editor for the addiction and recovery website, The Fix.

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