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Summary: Bipolar disorder (BD) and alcohol use disorder (AUD) can both have a powerful negative impact on quality of life. When both occur at the same time in the same person, the problems caused by bipolar disorder and alcohol use disorder can become substantially more complex.

Key Points:

  • Research shows a significant connection between BD and AUD.
  • About 7 million adults in the U.S. have bipolar disorder.
  • Studies suggest that 40%-70% of adults with bipolar disorder also have AUD.
  • Among the general public, 2% of adults had alcohol use disorder in the previous year.

New Research Explores the Connection Between Bipolar Disorder and Alcohol Use Disorder

Public health experts know people with bipolar disorder have an elevated risk of AUD, yet they don’t fully understand why. One theory is that alcohol misuse serves as a form of self-medication, allowing people to temporarily numb emotional distress.

Several recently published studies shed new light on the connection between bipolar disorder and alcohol use disorder, a.k.a. alcohol addiction, formerly known as alcoholism or alcohol abuse.

In addition to identifying areas of the brain that may contribute to this connection, these studies may help experts better understand the nature of the relationship itself. For example, do worsening symptoms of BD cause people to drink more, or does AUD lead to more severe bipolar symptoms?

The Scope of the Problem: Prevalence of Bipolar Disorder and Alcohol Use Disorder

The disordered use of alcohol and drugs is prevalent throughout the United States, but the problem is greatest for adults with mental health conditions:

  • Experts estimate about 25% of adults had some type of mental illness in the previous 12 months.
  • Among adults with a mental health disorder, 2% developed disordered use of alcohol or another drug.
  • Among the general population ages 12 and above, the rate of substance use disorder is 5%.

The impact of comorbid BD and AUD can be severe. A 2021 study in Frontiers in Psychiatry reported:

  • About 68% of people with bipolar disorder and alcohol use disorder attempt suicide at least once. Among those with bipolar disorder only, the rate of attempted suicide is about 35%.
  • Co-occurring AUD can cause more rapid and frequent cycling from depression to mania or hypomania among people with bipolar disorder.
  • Criminal behavior is twice as common among people with both disorders than among those with bipolar disorder only.
  • Co-occurring AUD increases the likelihood that women with bipolar disorder will have anxiety or another mental health disorder.

As the authors of that study note:

“Alcohol use disorder and bipolarity significantly influence each other’s severity and prognosis with a more complicated course of both disorders.”

More Than Self-Medication?

In June 2024, JAMA Open Network published a study from the University of Michigan (UM) that explored the ways that comorbid alcohol use disorder and bipolar disorder influence each other. All participants were part of the Prechter Longitudinal Study of Bipolar Disorder (PLS-BD) for at least five years. They completed an array of assessments, including tests to measure alcohol use, depression, mania, anxiety, and overall functioning.

Here’s what the study showed:

  • A link between alcohol use, mood instability, and poor work function. This link remained consistent among participants with both types of bipolar disorder.
  • Alcohol use led to the onset of all three types of bipolar disorder symptoms: mania, hypomania, and depression.
  • Increases in mania, hypomania, and depression did not lead to similar increases in alcohol use, which casts doubt on the self-medication
  • Participants with bipolar II disorder scored higher on the Alcohol Use Disorders Identification Test (AUDIT), suggesting people in this group are more likely to have long-term problems with alcohol use.
  • Members of the bipolar II group also showed increased mania and hypomania, as well as greater impairments in workplace functioning after drinking than the members of the bipolar I group.

The UM researchers noted associations between certain medications and the impact of alcohol use:

  • Participants taking antipsychotics scored lower on the AUDIT assessment and showed reduced risk of depression after drinking.
  • For participants taking mood stabilizers, alcohol led to greater impairments in workplace functioning.
  • Participants taking benzodiazepines showed greater variability in depression symptoms and more manic and hypomanic symptoms.

The UM researchers noted the impact of alcohol use was consistently problematic, even among participants who didn’t meet the criteria for a diagnosis of AUD:

“Fluctuations in alcohol use were common in the sample and were associated with unstable mood and functional impairment at work, regardless of whether an individual had AUD. Thus, regular monitoring of alcohol use with the AUDIT or similar tools may be advisable in treating patients with [bipolar disorder].”

A UM news release about the study highlighted additional findings, such as:

  • Any amount of alcohol use could negatively impact bipolar disorder symptoms. Participants who didn’t engage in binge drinking, didn’t drink frequently, or didn’t drink to the point of impairment still experienced an uptick in symptoms after using alcohol.
  • The brains of people with bipolar disorder seem to be affected more strongly by alcohol, and take longer to recover from alcohol’s disruptive influence, than do the brains of healthy individuals.

Sarah H. Sperry, PhD, the lead author of the UM study, said the impact of alcohol on people with bipolar disorder may extend far beyond the drug’s immediate effects:

“The reasons behind our findings likely have more to do with what alcohol and social situations involving alcohol do to a person’s circadian rhythms and brain-based reward circuits, not just the action of the substance in the brain.”

Unique Neural Activity

The UM team documented the impact of alcohol use on symptoms and behaviors, then used those findings to theorize about the brains of people with bipolar disorder.

Pursuing a similar goal from a different perspective, a group from the Medical University of South Carolina (MUSC) used functional magnetic resonance imaging (fMRI) to explore how bipolar disorder and alcohol use disorder affect neural activity. JAMA Psychiatry published this study in August 2023.

Led by James J. Prisciandaro, PhD, the MUSC team focused on how brain reward circuitry responds to alcohol-related cues. Their study involved 112 adult participants with a mean age of 38.7 years. In addition to using fMRI to collect whole-brain data for each participant, the researchers employed several assessments to gauge levels of depression, mania, impulsivity, and related symptoms.

Results included:

  • Participants with bipolar disorder and AUD exhibited “abnormally low alcohol cue reactivity” when compared with the other groups.
  • Neural imaging indicated that the cue reactivity response involved a cluster of brain areas, including the right inferior frontal gyrus, which plays a role in inhibition and attention and the dorsal striatum, which controls voluntary movement and the forming of habits.
  • Participants with both conditions demonstrated greater impulsivity and more obsessive-compulsive alcohol cravings than those in the other groups.
  • Researchers theorized the combination of diminished cue reactivity, impaired impulse control, and obsessive-compulsive cravings could be risk factors for alcohol use disorder among people who have bipolar disorder.

In an article about the research, Dr. Prisciandaro noted:

“Not only is the reduced reward cue reactivity signal a potential biomarker … this observation could help focus research on new pharmaceutical interventions targeting impulsivity-related brain mechanisms in order to improve executive control and thus potentially lower the risk that people with [bipolar disorder] will develop AUD.”

Treating Bipolar Disorder and Co-Occurring AUD

Hopefully, continued research into the neurological basis of bipolar disorder and alcohol use disorder will lead to more targeted treatment options. However, people with these conditions don’t have to wait for future developments before they can benefit from professional care.

Today, effective treatment for bipolar disorder and co-occurring alcohol use disorder often involves a combination of medication and therapy. Personalization is essential, as treatment options that work well for some patients may have little to no positive effect on others.

Depending on a host of individual factors – including the presence of other co-occurring disorders – comprehensive treatment for bipolar disorder and co-occurring alcohol use disorder may include:

  • Medication such as antidepressants, mood stabilizers, and antipsychotics
  • Individual and group therapy sessions
  • Cognitive behavioral therapy (CBT)
  • Dialectical behavior therapy (DBT)
  • Acceptance and commitment therapy (ACT)
  • Motivational interviewing
  • Transcranial magnetic stimulation (TMS) therapy
  • Eye movement desensitization and reprocessing (EMDR) therapy
  • Genetic testing
  • Life skills and work skills education
  • Case management services

To learn more about treatment for bipolar disorder and co-occurring alcohol use disorder in Southern California, please visit our Contact page or call us today. We look forward to answering all your questions and helping you determine if Crownview Co-Occurring Institute is the ideal place for you or a loved one.