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By Melissa Tennen, HealthAtoZ writer
Within in a two-month period, Jacqueline Castine racked up $43,000 in credit card debt, became homeless, bankrupt and nearly suicidal. This was a woman who had a highly successful career in sales for a Fortune 500 company, did speaking engagements and even wrote a book.
Castine, 63, has bipolar disorder, a condition where she experiences extreme highs and extreme lows. During her career, she started to abuse alcohol to help deal with her undiagnosed illness. When she stopped drinking, the illness' suppressed symptoms sprang on her with a fierce intensity.
"I was no longer self-medicating, which had been a way to shut down my brain that was going full-time, all the time," she says. "I was always very high-energy and very high achieving. And then once that part of my life ended and I got over the alcohol addiction, it became a long, slow downhill spiral."
Castine is not unique. Bipolar disorder and substance abuse often go hand-in-hand at a higher rate than other forms of depression or any other mental illness. More than half with bipolar disorder, also known as manic depression, have had a lifelong substance abuse problem, according to the National Institute of Mental Health's Epidemiologic Catchment Area study. About one quarter percent of people with unipolar depression, or depression without mania, have a lifelong substance abuse problem. Compare those rates with the general population - about 6 percent.
"We really don't know why," says Myrna Weissman, Ph.D., professor of epidemiology in psychiatry at the College of Physicians and Surgeons and the School of Public Health at Columbia University and chief of clinical-genetic epidemiology at the New York State Psychiatric Institute. "It may be a way for possibly calming themselves because they are feeling so out of control. They also don't have good judgment when they are in a manic phase."
"Medicating" symptoms
The substance abuse could be "helping" with the depression, says David Dunner, M.D., director of the Center for Anxiety and Depression at the University of Washington.
"Bipolar disorder is a very painful disorder," he says. "Substance abuse is often used to alleviate the symptoms of the depression."
But self-medicating to relieve the bipolar symptoms brings a host of problems along with the tremendous mental, physical and financial cost of substance abuse itself.
"Substance abuse makes the illness more severe and the cycling more rapid, even cycling within a day," Dunner says. Typically, the change from mania to depression occurs over a series of weeks or even months.
Dunner says, "If they continue using drugs, it becomes impossible to treat them. You have to treat the substance abuse first."
This severity or the bipolar disorder itself is not reversible once the person stops abusing alcohol or drugs. The brain chemistry has changed permanently, with its landscapes of neurons shifting, forcing the person into new territories with their disorder.
"If left untreated, bipolar tends to get worse," says Frederick Goodwin, M.D., a professor of psychiatry and director of The Center for Neuroscience, Medical Progress and Society at George Washington University Medical Center in Washington, D.C. and a former director of the National Institute of Mental Health.
"This is not something that they can get over on their own," Goodwin says. "It's inevitable that another episode is going to occur if they don't get treatment. Once a person has gone through several episodes, the disorder starts to take on a life of its own."
Combined treatment rare
Only 19 percent of people who have a mental illness of any kind combined with substance dependence get treatment for both disorders and 29 percent do not receive any treatment for either problem, according to the Depression and Bipolar Support Alliance (DBSA).
Treatment of the disorders, if addressed in isolation, often fails. One disorder ends up begetting the other.
But families and friends may have trouble pinpointing the problem. People may be closet drinkers and can hide the drinking and keep the disorder suppressed for years. That's a tactic that can last for so long before that world crumbles.
Bipolar and many forms of substance abuse disorders are genetic, meaning people are born with a certain predisposition. With the right environmental trigger such as too much stress or a traumatic event, the disorders can be triggered.
A 2002 report from the Department of Health and Human Services said people with co-occurring disorders can and do recover with appropriate treatment and support services. However, the study found bureaucratic barriers and lack of funds interfere with getting treatment for both disorders in many cases.
Often a wrong diagnosis or treatment can worsen the disorder or cause people to forsake treatment.
"If the doctor assumes it's a unipolar depression, it would be treated with antidepressants, and by using antidepressants such as the selective serotonin reuptake inhibitors, you can make the mania worse. It can overshoot you into mania because there is no brake on it," Goodwin says, noting that people who are frustrated with their treatment failure may decide to go it alone. That's a dangerous thing considering the high rate of suicide among people with bipolar disorder.
That left doctors with little to help relieve the depression, although there are mood stabilizers such as lithium to temper the highs. New medications such as Lamictal®, an anticonvulsant, can help relieve the depressive symptoms.
 Children, teens and adults being treated with antidepressants, particularly anyone being treated for depression, should be watched closely for worsening of depression and for increased suicidal thinking or behavior. Close watching may be especially important early in treatment or when the dose is changed - either increased or decreased. Bring up your concerns immediately with a doctor.
"Bipolar disorder wrecks families, wrecks lives and wrecks work," Weissman says. "Education is one of the best protections for the patients and the families. Families must be aware of the symptoms of mania, which is the start of an episode. They need to discuss safeguards such as being in control of the bank accounts when an episode starts. There should be plans in place such as knowing how to reach the doctor."
Bipolar disorder, also known as manic depression, and substance abuse disorders are treatable illnesses. Bipolar is marked by extreme changes in mood, thought, energy and behavior. The disorder is not a character flaw or a sign of weakness. A person's mood alternates between mania (highs) and depression (lows). Bipolar disorder affects more than two million adult Americans.
Bipolar usually begins in late adolescence, often appearing as depression during teen years, although it can start in early childhood or later in life. A person with depression can develop the substance abuse problem as a young adult. An equal number of men and women develop this illness (men tend to begin with a manic episode, women with a depressive episode) and it is found among all ages, races, ethnic groups and social classes.
Traits of alcoholism
Alcoholism, also known as "alcohol dependence," includes four symptoms:
- Craving: A strong need, or compulsion, to drink.
- Loss of control: The inability to limit one's drinking on any given day.
- Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking.
- Tolerance: The need to drink greater amounts of alcohol in order to "get high."
The type of alcoholism generally associated with bipolar disorder is associated with an early age of onset before 25. Early onset alcoholics tend to drink to get high and often have addictions to illicit drugs as well. As far as we know, early onset is entirely genetic.
Alcoholism has little to do with will power. Alcoholics are in the grip of a powerful "craving," or uncontrollable need, for alcohol that overrides their ability to stop drinking. This need can be as strong as the need for food or water.
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External Sources
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Depression and Bipolar Support Alliance
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Alcoholics Anonymous
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Substance Abuse and Mental Health Services Administration
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This article was reviewed and updated June 2007.
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