Dual diagnosis, also referred to as co-occurring disorders, refers to the coexistence of both a substance use disorder, or addiction, and a mental health disorder, such as bipolar disorder. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that approximately 7.9 million adults had a dual diagnosis in 2014.1
Substance use disorders impact one’s psychological, interpersonal, and physical well-being. When left untreated, they can lead to fatal consequences, such as overdose.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), some of the signs and symptoms of a drug or alcohol addiction—or substance use disorder—include: 2
The bipolar disorders are a category of mental health issues characterized by both manic and depressive episodes. The DSM-5 indicates that both men and women experience bipolar disorder at similar rates, with the average onset occurring around age 18.2
There are several disorders that belong to the category of bipolar disorders. For example, there is bipolar I disorder, bipolar II disorder, cyclothymic disorder, and other specified and unspecified bipolar and related disorders that don’t match the first three categories.11 For this article, we will be focusing on bipolar I disorder.
To meet the criteria for having a bipolar disorder diagnosis, a person must have a history of the following:2
Dual diagnosis represents a common phenomenon, with research suggesting that nearly half of those with a substance use disorder also have a mental health disorder, and vice versa.3
Doctors believe that substance addictions and mental health disorders can actually feed into each other. For example, many people begin experimenting with drugs during adolescence when the first symptoms of mental illness, such as depression or anxiety, may emerge.3
Furthermore, environmental factors, such as trauma or chronic stress, are both associated with an increased risk for developing both substance use and mental health disorders.4
Some people with mental health disorders, such as bipolar, may self-medicate in an attempt to control adverse symptoms. Drugs and alcohol may provide a temporary relief to manage this discomfort, but will ultimately worsen the psychiatric symptoms.4 Research suggests that using cocaine may exacerbate symptoms associated with bipolar disorder and may also play a key role in the progression of this condition.4
With dual diagnosis, it is not always possible to tell if one of the disorders caused the other, even if one of them appeared first.
Because many symptoms of these disorders can overlap with one another, it can be challenging to properly assess and identify dual diagnoses. Anyone entering treatment for psychiatric support should be thoroughly screened for both substance use and mental health disorders, and anyone entering treatment for addiction should be evaluated for psychiatric symptoms. Doctors and mental health professionals will typically conduct a screening of a patient’s biopsychosocial history and evaluate the presence of their symptoms and their frequency, intensity, and duration.
For this reason, patients should undergo a comprehensive assessment to give treatment providers a more accurate diagnostic picture.5 An evaluation should include a thorough assessment of the following:5
However, ideally a period of abstinence is necessary for accurate diagnosing. This is because the effects of substance intoxication and/or withdrawal symptoms can look like the symptoms present in bipolar disorder (i.e. depressed mood, lack of energy, poor concentration).5,6 If the bipolar symptoms are still present 4 weeks following detoxification, then this more strongly indicates a co-occurring mental health condition.5
There are several different screening tools that may be used in order to obtain a proper diagnosis. These include:5
Reduced cognitive functioning will impact the evaluation process, as will many other general factors, such as cooperation, severity of bipolar symptoms, and motivation for change.
Withdrawal symptoms emerge when someone who is dependent on a substance abruptly discontinues or dramatically reduces use. Withdrawal symptoms can be both physical (such as body aches and pains and flu-like symptoms) and psychological (such as depression, severe cravings, hallucinations).7 In general, these symptoms can range from mildly uncomfortable to extremely painful and distressing. Depending on the substance or combination of substances used, withdrawal can even be life-threatening.7
The symptoms of bipolar disorder may influence the severity of the withdrawal syndrome and, conversely, withdrawal can impact bipolar symptoms as well. For example, withdrawal from stimulants, such as cocaine or methamphetamine, often includes symptoms, such as:7
Someone with a dual diagnosis involving bipolar disorder may experience a worsening of any depressive episodes present during the withdrawal period. Alternatively, the irritability associated with withdrawal could exacerbate a manic episode, or the other way around. Stimulant intoxication could also trigger a manic state in someone with bipolar disorder.7
Another example of a substance that can impact the course and severity of bipolar disorder is alcohol. Research indicates that alcohol withdrawal may actually trigger the symptoms of bipolar disorder.10
There is no clear one-way relationship when it comes to drug or alcohol withdrawal and bipolar disorder, but rather, co-occurring disorders are extremely complex and tend to impact each other in a bidirectional pattern.10
Furthermore, a sustained period of confirmed abstinence (at least 1-2 weeks) is typically sought before initiating treatment with mood stabilizers or other psychiatric medication appropriate for managing bipolar symptoms.7
Various factors, including heightened feelings of anxiety, depression, mania, substance cravings, and emotional discomfort can all complicate the withdrawal process. Therefore, medical professionals frequently recommend that patients seek dual diagnosis detox services to stay safe and supported during this difficult time. Specialized detox can provide patients with the initial stabilization and monitoring needed to address potential complications that can arise.
Detox treatment should integrate treatment elements to address both substance abuse and mental health issues, so that the treatment team can appropriately identify and address the unique needs present in both dual diagnoses.
Detox refers to a group of interventions intended to manage acute intoxication and withdrawal symptoms. During detox, the body clears itself of toxins associated with substance use. Detox procedure entails the evaluation of a patient’s substance use and mental health status, stabilization throughout intoxication and withdrawal, and appropriate referrals and entry into substance abuse treatment.7
While there are many different settings available for dual diagnosis detox, inpatient is a commonly utilized option. Medical inpatient detox provides 24/7 supervision, monitoring, and medical treatment. Patients have access to a comprehensive treatment team that includes medical and psychiatric professionals. This is especially important if complicated withdrawal symptoms arise during detox.7
Both bipolar and substance use disorders represent chronic, serious mental illnesses. When left untreated, there remains a high risk for impaired functioning and diminished quality of life. Appropriate treatment and support are essential for increasing one’s emotional and physical well-being.
Although detox often represents the first step towards recovery, it is not a substitute for longer-term dual diagnosis treatment. After completing detox, people are well advised to transition into ongoing treatment to learn the adaptive coping skills needed to manage drug cravings, triggers, and stressors.
The preferred model of treatment for those with a substance addiction and co-occurring bipolar disorder is integrated treatment. This means that the same staff members treat both conditions in the same location.5 An integrated dual diagnosis treatment program tailors the treatment plan to each individual patient and their unique treatment needs.
Some principles of integrated care for those struggling with substance abuse and bipolar disorder include:5
Rehab facilities provide patients with continuous support and monitoring throughout their care. These facilities employ a variety of clinical services, including individual and group therapies, medication management, drug education, and aftercare planning, to teach people how to manage negative feelings and triggers, manage problematic symptoms, and improve their overall life functioning. A rehab facility that specializes in dual diagnosis treatment understands fully addressing the needs of both bipolar disorder and addiction. They work to treat both disorders simultaneously, rather than only focusing on one of them at a time.
Even though bipolar disorder does not have a cure, recovery is possible. Typical treatment methods include:8,9
If you or a loved one is struggling with a dual diagnosis, it’s normal to feel scared, alone, or angry. With that said, help is available. Make a positive change today by reaching out to an appropriate dual diagnosis detox or rehab program.