Not only do individuals with mood disorders have higher risks for episodic promiscuity, extramarital affairs, or a compulsion toward sexual encounters, they are also prone to alcohol or drug abuse as a way of self-treating the high anxiety during the down mood or augmenting the elation and energy during the hypomanic high. In fact, bipolar disorder is associated with the highest rate of substance abuse of any psychiatric illness, with almost two-thirds of men and women with Bipolar I and II meeting the diagnostic criteria for an addictive disorder. When people with bipolar disorder get depressed, they frequently try to drink or drug their undesired mood away, even if they are highly cognizant of their substance abuse problem.

        The correlation between drugs and alcohol and psychiatric illness has been debated for centuries. Scientists believe that depression is associated with a decreased activity of important brain neurotransmitters such as dopamine and serotonin; the opposite is true for hypomania. As discussed on page 36, antidepressants increase the availability of these neurotransmitters in the brain's synapses, but so can illicit drugs.

        In my practice, the comorbidity of Bipolar II and substance abuse is explosive, with alcohol the leading precipitator of depressive episodes in many of my patients who are genetically vulnerable for depression or bipolar disorder. In fact, approximately 15 percent of all adults who have a psychiatric illness in any given year also experience a co-occurring substance abuse disorder, which complicates treatment.

        Alcohol is a central nervous system depressant, which is why many people use it as a tranquilizer at the end of a hard day or as an assist for tense social situations. I have some patients who stop drinking when they are depressed, but it is more common that Bipolar II patients increase their alcohol intake during low moods. According to the National Institute of Mental Health Multisite Epidemiologic Catchment Area Study, people with bipolar disorder are five times more likely to develop alcohol misuse and dependence than the rest of the population. For women, Bipolar II is associated with a higher incidence of alcohol abuse than Bipolar I; the incidence is about equal for men.

        Sometimes, in someone genetically predisposed to bipolar disorder, alcoholism will begin before Bipolar II symptoms appear. At other times, the person will harbor Bipolar II depression and hypomania, and prefer to use alcohol as a means of self-treatment. When a patient presents with both alcoholism and Bipolar II disorder, we use the term dual-diagnosis.

        All psychoactive drugs have the potential of altering mood in those with Bipolar II. Cocaine and amphetamines are the leading substances that precipitate hypomanic episodes. Cocaine abuse is associated with a several-fold increase in the incidence of bipolar disorder; in fact, the rate of bipolar disorder in cocaine abusers may be higher than in any other category of substance abuse. Cocaine and amphetamines instantly flood the brain with dopamine, a key neurotransmitter that regulates mood, movement, attention, and learning. Some people with Bipolar II  use hallucinogens and marijuana to reduce or suppress the symptoms of hypomania, while others self-medicate to enhance their hypomanic symptoms.

        It is thought that the rate of overall substance abuse among those with Bipolar I and II disorder is as high as 60 percent; cocaine abuse is reportedly as high as 30 percent. Generally, men seem to have higher rates of comorbid alcohol abuse/dependence and cannabis abuse/dependence than women do. But Bipolar II patients who abuse alcohol or drugs usually have a worse outcome than Bipolar II patients who are not substance abusers. Similarly, those Bipolar II patients who have comorbid substance abuse problems are also 15 times more likely to commit suicide than those without dual-diagnosis.

        A history of first-degree relatives is important in understanding a person's propensity for alcoholism and substance abuse. Relatives of alcoholics often likewise suffer from alcoholism, as well as suicidal behavior, serious depression, or mood swings. For example, there were many media reports about Rhode Island Congressman Patrick Kennedy, son of Senator Edward (Ted) Kennedy, undergoing treatment for cocaine abuse in 1984 when he was a student at Phillips Academy. Although Patrick disclosed in 2000 that he has sought treatment for mental illness, he became more specific in 2004 by openly disclosing that he suffers from bipolar or manic depression.

        It would seem that alcoholism runs in the family. Patrick's brother, Edward Jr., has undergone alcohol treatment. Patrick and his siblings acknowledge that they have become legal guardians for their mother, Joan Kennedy, to help her receive continued treatment for her long-standing alcoholism. Joan was arrested three times for drunken driving in the 1980s and 1990s and has spoken publicly in the past about her disease and recovery. Of course, the media reports of Ted Kennedy's own alcohol problems have been ongoing for decades.

        In the US House of Representatives, Patrick Kennedy has made mental illness one of his key issues, sponsoring legislation that seeks to compel insurance companies to cover mental illness as they would any other health problem.

        Other public figures have openly discussed overcoming a coexisting substance abuse problem with bipolar disorder. Actor and bodybuilder Jean-Claude Van Damme, who has manic depression, started doing cocaine in 1993. He admitted that at one time, he had an $8,000-a-week habit of 4 to 5 grams of cocaine a day, before checking himself into a rehab program in Marina del Rey, California. Today he uses medication to treat his bipolar disorder instead of abusing recreational drugs. Actor and author Carrie Fisher is a staunch advocate and educator for bipolar disorder, with which she was diagnosed at age 24. Fisher contends that she did not accept this diagnosis until 4 years later, when an overdose of drugs almost killed her. She endured a major breakdown in the late 1990s, thought to be precipitated from an allergic reaction to a medication. In retrospect, her mental breakdown is consistent with bipolar disorder and may have happened anyway if not properly treated. Today she has written several books, including Postcards from the Edge and The Best Awful, which give further insight into life with manic depression. Actor Linda Hamilton lived with untreated bipolar disorder for 20 years before she was diagnosed in 1995. At age 20, Linda turned to cocaine and alcohol to boost her confidence and keep her inner demons at bay. After failed marriages and years of depression, Linda now takes prescribed medication to stabilize her mood swings.

        As so many people have experienced, not only does substance abuse erode the personality, it increases the chance of broken relationships, failed marriages, job loss, and even suicide. In particular, cocaine produces acute panic and anxiety and can lead to a full-blown psychosis complete with hallucinations. Once a person becomes a chronic user, the only treatment that seems to work is Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) and complete abstinence. Phasing out slowly, just cutting down, or substituting one drug for another (called cross-addiction) simply does not work.

        For patients who use cocaine, I usually recommend an inpatient hospital program to increase their chances of succeeding in rebuilding a drug-free life. This program requires time in a treatment center, with group and individual counseling, peer group meetings, and Cocaine Anonymous meetings, along with NA and AA.

        For individuals who are addicted to alcohol, I recommend AA, which has been proven the most effective method worldwide to treat severe alcoholism. When I first begin treating bipolar patients with alcoholism, in addition to prescribing mood-stabilizing medication, I insist that they go to AA on a daily basis in the beginning. They also must choose a mentor outside of AA whom they trust and then meet with that person daily for the first few weeks or, in some cases, much longer. While the medications and the adjunctive psychotherapy take over, I insist on meeting the spouse or any other first-degree relative to strengthen the overall educational-support system. If the person is too sick from depression, mania, or an attempted suicide in combination with the alcoholism, then the patient should be hospitalized in a dual-diagnosis ward where treatment and withdrawal can be managed alongside the bipolar medications.

        To identify potential problems with substance abuse, I discuss questions similar to the following with my Bipolar II patients. (If you answer "yes" to 5 or more of these 19 questions, you most likely have a problem with substance abuse.)

1. Do you use alcohol or recreational drugs daily? 
2. Do you ever drink or use drugs during the morning hours? 
3. Do you drink or use drugs while at work? 
4. Do you miss work because of drinking or using drugs? How often? 
5. Do you have problems controlling your urge to drink or use recreational drugs? 
6. Do you use income intended to pay household bills to purchase alcohol or drugs? 
7. Have you missed paying your mortgage because of your need to buy alcohol or drugs? 
8. Have you lost your home because of this addiction? 
9. Have you lost your job because of this addiction? 
10. Has your spouse left you because of drinking or using drugs? 
11. Do you turn to alcohol or drugs when you are feeling depressed or let down? 
12. Do your friends know that you use alcohol or drugs or are you secretive? 
13. Has this addiction shattered relationships with family members and friends? 
14. Has the drinking or drug addiction injured your physical health? 
15. Have you ever had an accident (automobile or other) because of the substance abuse? 
16. Do you experience blackouts because of substance abuse? 
17. Have you had times where you don't remember how you arrived home the next morning? 
18. Do you use alcohol to come down off a stimulant high (cocaine)? 
19. Do you find yourself using drugs more frequently during periods of high and low mood swings?