Bipolar Disorder and Substance Use

Bipolar disorder, also known as manic-depressive disorder, involves bouts of major depression and periods of mania or hypomania— euphoria, poor judgment and extreme risk-taking activity — in an often-debilitating cycle. It usually begins in late adolescence or early adulthood.


Teens and young adults with bipolar disorder will show signs of both depression (prolonged sadness, lack of interest in things they previously enjoyed, sleeping too much) and mania (periods of excitability or irritability, exaggerated self-confidence, even recklessness). For many, the onset of bipolar disorder is marked by a depressive episode; in others, it is a manic episode. How long and how often between depressive and manic episodes varies quite a bit, especially in younger people.

Being on the lookout for symptoms of mania is particularly important if someone already has depressive symptoms. Bipolar disorder with an unnoticed manic component can be misdiagnosed as major depressive disorder — but the medications used to treat depression can be dangerous for someone with bipolar disorder, making accurate diagnosis very important.

Signs of Mania in Bipolar Disorder:

  • Drastic personality changes
  • Excitability and irritability
  • Inflated self-confidence
  • Grandiose/delusional thinking
  • Recklessness
  • Decreased need for sleep
  • Increased talkativeness, racing thoughts and scattered attention
  • Psychotic episodes, or breaks from reality

Signs of Depression in Bipolar Disorder:

  • Loss of interest or pleasure in things once enjoyed
  • Marked weight loss or gain
  • Decreased or increased need for sleep
  • Lethargy or fatigue
  • Feelings of hopelessness, helplessness, worthlessness
  • Excessive or inappropriate guilt
  • Preoccupation with death, plans of suicide or an actual suicide attempt

Psychotic episodes in young people with bipolar — essentially breaks from reality — can occur during manic episodes and severe depressive episodes. During a manic episode, these can include delusional thinking, such as proclaiming, “I can fly!” Psychosis is often the first outward sign of bipolar disorder.

Bipolar Disorder Treatment

Medication is essential to the treatment of bipolar disorder, as is the involvement of the whole family.

The first-line medication used to treat bipolar disorder is often a mood stabilizer such as lithium and various anticonvulsants (anti-seizure medication), which are generally effective at treating manic symptoms and lowering the frequency and severity of both manic and depressive episodes. In children and adolescents, antipsychotic medications can be used as first line treatments for acute manic episodes. Other drugs may be prescribed to treat symptoms like psychosis (antipsychotics) or trouble sleeping (anti-anxiety medicine). Many people with bipolar disorder take more than one medication that requires monitoring by an experienced clinician.

Bipolar disorder is often treated with cognitive behavioral therapy (CBT) in addition to medications. CBT helps children and adolescents with the disorder understand what triggers their episodes, how their thoughts influence their feelings, and how to control and manage them. A specialized form of CBT called social rhythms therapy helps reduce symptoms by encouraging regular and predictable routines. Family therapy is often employed to engage parents and other family members in keeping track of symptoms and managing stress levels to prevent the onset of manic or depressive episodes.

Bipolar Disorder & Interaction With Substance Use

Nearly 60 percent of individuals with bipolar disorder have a co-occurring substance use disorder. Many adolescents and young adults receive a diagnosis of bipolar disorder after seeking help for substance use issues, since drugs can bring on the manic episodes that are the most visible sign of bipolar disorder.

The behavioral symptoms of bipolar disorder also often lead to substance use problems. Impulsivity is a defining symptom of bipolar disorder — not only during a manic episode, but also between episodes. Young people with bipolar disorder are thus more likely to experiment with drugs and alcohol always.

Finally, as with many disorders, drug and alcohol use complicate diagnosis and make treatment difficult. Medications used to manage bipolar disorder have side effects such as weight gain and sluggishness that young people dislike and often decline to take. In addition, during stable stages they may be convinced they don’t need help or prefer to self-medicate. Medication non-compliance is a common consequence of substance use in bipolar disorder, which causes increased frequency and severity of mood episodes.

Drugs commonly used by youth with bipolar disorder, like nicotine and alcohol, also present a real chemical barrier to treatment effectiveness. Nicotine competes with enzymes necessary to make medications work in the body, and the effects of alcohol on the liver also decreases the availability of these enzymes. These drugs literally change the way a person’s body responds to psychiatric medications, leading to a smaller or larger than expected effect. Parents and concerned adults can help explain the importance of medication adherence, and other substance interactions.