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Bipolar disorder is a debilitating mental illness characterized by extreme shifts in mood ranging from elevated highs to depressive lows. 

While genetics play a role, environmental factors are also known to influence risk and episode occurrence. One important external trigger is certain prescription and recreational drugs.

Many medications, both psychiatric and non-psychiatric, have been implicated in either inducing initial bipolar episodes or worsening existing symptoms. 

Additionally, substances of abuse can also precipitate mood shifts in predisposed individuals.

In this article, we examine the research on medications and substances most strongly tied to bipolar onset or exacerbation. But first, let’s explore what bipolar disorder is.

Understanding Bipolar Disorder

Bipolar disorder, also known as manic-depressive illness, is a mental health condition that causes extreme and fluctuating shifts in a person’s mood, energy levels, and functioning. 

Individuals with this disorder experience periods of elevated mood as well as depressive episodes, often with shifts happening over days to weeks at a time. 

Between mood episodes, most individuals with bipolar live functionally without symptoms.

However, some experience ongoing subthreshold depressive or irritable symptoms. 

There are three main types of mood episodes associated with bipolar disorder.

1. Depressive Episode

A depressive episode involves experiencing symptoms of depression, such as persistent feelings of sadness, hopelessness, loss of interest in activities, changes in appetite, sleep disturbances, and fatigue. 

During these periods, a person’s mood is characterized as feeling severely “down” most of the time for at least two weeks.

Depressive episodes can greatly impact one’s daily functioning and quality of life.

2. Manic Episode

In contrast to depressive episodes, a manic episode involves a distinct period of abnormally and persistently elevated mood. 

Symptoms may include inflated self-esteem, decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and excessive involvement in pleasurable activities without consideration for consequences. 

Manic episodes can last for weeks and result in severe impairment without treatment.

3. Hypomanic Episode

A hypomanic episode shares features with mania but involves mood changes and symptoms that are not as severe. 

Episodes include periods of abnormally elevated, expansive, or irritable mood lasting a minimum of four days.

Impairment is present, but not to the extent of a full manic episode. 

Hypomania can be difficult to recognize and may be perceived by others as high energy or enthusiasm rather than a bipolar disorder symptom.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes three main types of bipolar disorder: bipolar I, bipolar II, and cyclothymia. 

Bipolar I involves manic or mixed episodes while bipolar II involves hypomanic and depressive episodes. 

On the other hand, cyclothymia is marked by numerous periods of hypomanic and depressive symptoms lasting for extended periods but not meeting the criteria for full episodes.

Bipolar is a lifelong condition with no cure. However, treatments such as mood stabilizing medications, psychotherapy, supplements, and lifestyle changes help manage symptoms and allow individuals to lead productive lives. 

Left untreated, bipolar disorder can be severely disabling due to unpredictable mood shifts and increased risk for substance abuse or suicide. 

Common Triggers of Bipolar Disorder

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Bipolar disorder can be triggered by a myriad of factors, some of which include the following:

1. Stress:

Numerous studies suggest a significant correlation between stress and bipolar disorder. 

A meta-analysis found that individuals experiencing a relapse of bipolar disorder reported a higher incidence of stressful life events compared to those in more stable mood phases. 

Stress management strategies, therefore, play a crucial role in preventing and mitigating bipolar episodes.

2. Sleep Disturbances:

Sleep disruption is another well-established trigger for bipolar mood episodes. 

In a 2015 research study, one group of participants with bipolar disorder and insomnia underwent bipolar-specific cognitive behavioral therapy (CBT), while the other group just received educational materials with no intervention plan. 

The results were striking, with the CBT group experiencing only 3.3 days in a bipolar episode compared to 25.5 days for those receiving only educational materials. 

This underscores the critical role of maintaining healthy sleep habits in managing bipolar disorder.

3. Seasonal Changes:

Seasonal patterns can influence mood fluctuations in individuals with bipolar disorder. Around 20% of people with bipolar disorder exhibit mood changes corresponding to shifts in weather. 

Research indicates that women may experience manic episodes more frequently in summer and autumn, and depressive episodes in winter, while men are more prone to manic episodes in summer.

4. Life Events:

Significant life events, whether positive or negative, are also linked to the onset of bipolar episodes. 

Disruptions caused by major life changes can alter stress responses and routines, potentially triggering mood swings. 

Research shows that women with bipolar disorder also face an elevated risk of mood episodes during the postpartum period, emphasizing the impact of life events such as pregnancy. 

Other events, including job changes, the death of a loved one, or any substantial life alteration, can also influence the course of bipolar disorder.

Can Drugs Cause Bipolar Disorder?

While drugs alone do not cause bipolar disorder, they can play an important role in both triggering initial symptoms and worsening the long-term progression of the illness. 

Certain medications and recreational drugs have been shown to induce temporary bipolar-like symptoms or worsen existing conditions through impacts on brain function and neurotransmitter activity.

Research has also examined physical changes in areas of the brain related to mood and motivation for individuals experiencing drug-induced mood issues. 

Brain scans have highlighted alterations in regions regulating emotion and the brain’s reward system, revealing how substance use can substantially impact neural circuits underlying mood.

Drugs that disrupt the balance of neurotransmitters such as dopamine and serotonin in key brain circuits controlling emotion also disturb a person’s mood regulation ability.

These brain circuits may include the prefrontal cortex, involved in decision-making, and the mesolimbic pathway, linked to motivation and pleasure-seeking.

Disturbances in these neurotransmitters within these circuits can lead to substance-induced mood disturbances, highlighting the relationship between drug use and bipolar-like symptoms.

Which Drugs Can Trigger Bipolar Disorder?

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1. Medications

Certain medications have been identified as having the potential to induce bipolar symptoms, particularly in individuals with pre-existing bipolar affective disorder. 

Research shows that levodopa, corticosteroids, and anabolic-androgenic steroids are among the substances with a demonstrated tendency to cause manic episodes

Additionally, the class of antidepressants, including tricyclics and monoamine oxidase inhibitors, has been implicated in inducing mania in patients with underlying bipolar conditions. 

Other drugs, though with less scientifically secure evidence, are also considered capable of inducing mood episodes. 

This category includes dopaminergic anti-Parkinsonian drugs, thyroxine, iproniazid, isoniazid, sympathomimetic drugs, chloroquine, baclofen, alprazolam, captopril, amphetamine, and phencyclidine.

2. Recreational Substances

The relationship between commonly abused substances and bipolar disorder adds another layer of complexity to mental health considerations. 

Alcohol, in particular, has been suggested to interact with the same neurotransmitters affected by bipolar disorder, creating a reciprocal influence where each condition may trigger symptoms of the other. 

Heavy alcohol use has also been found to be associated with nearly half of all depressive episodes observed in the general public.

Commonly abused substances like cocaine and opioids, especially heroin, are also frequently linked to the triggering of mood episodes in individuals with bipolar disorder.

Additionally, research shows that hallucinogens such as LSD, PCP, and psychedelic mushrooms can also act as potential triggers for bipolar episodes. 

Individual Responses and Vulnerabilities

Individual responses to drugs that might trigger bipolar episodes vary widely due to a mix of genetic and environmental factors. 

While certain drugs are linked to bipolar disorder, each person’s susceptibility is unique. 

Genetic factors play a significant role; those with a family history of bipolar disorder may be more prone to experiencing mood disturbances and bipolar episodes. 

However, genetics, lifestyle choices, past traumas, and current stress levels also contribute to an individual’s vulnerability and heighten the risk of drug-induced bipolar episodes.

Additionally, the presence of other mental health conditions or physical illnesses adds further complexity. 

Comorbidities can either amplify or mitigate the effects of drugs on mood regulation, making it challenging to predict the precise outcome for any given individual.

Treatment Implications

The multifaceted nature of bipolar disorder, influenced by genetics, environmental factors, and substance use, necessitates a comprehensive approach to treatment, which may include:

1. Initial Intervention: Substance Cessation and Assessment

The primary step in treating drug-induced bipolar disorder involves the immediate cessation of illicit recreational drugs known to trigger manic or hypomanic symptoms. 

This aims to determine whether symptoms naturally subside once the effects of the substance have left the body. 

In cases where prescription medications are suspected, a prudent approach is to discontinue or reduce the dosage, if medically advisable based on the patient’s overall healthcare needs.

2. Medication-Based Treatment for Ongoing Symptoms

If symptoms persist post-substance cessation, additional medication-based treatments may be necessary to manage ongoing manic symptoms. 

Studies highlight the short-term use of mood stabilizers like lithium or specific antipsychotic medications for bringing mania under control

3. Psychotherapy as a Vital Component

Psychotherapy plays a vital role in the treatment plan, offering diverse benefits. 

Cognitive behavioral therapy (CBT) can be very helpful, as it aims to modify unhelpful thoughts and behaviors to exacerbate symptoms.

Family counseling is also done to educate loved ones on signs of worsening conditions, facilitating appropriate lifestyle support.

4. Continuous Monitoring and Support

Close monitoring of substance use remains integral to the treatment process, with outpatient support groups and regular drug screening helping sustain recovery efforts. 

For more severe cases, intensive outpatient or partial hospitalization programs may be necessary, offering daily therapy sessions and monitoring to address treatment-resistant conditions.

5. Dual Diagnosis Treatment for Comprehensive Care

Specialized dual diagnosis treatment is recommended for individuals facing both bipolar disorder and substance abuse. 

These programs incorporate detoxification, individual and group therapy sessions, life skills, and relapse prevention training to comprehensively address both disorders simultaneously

Conclusion

In summary, certain medications and recreational drugs have demonstrated a propensity to induce bipolar episodes in individuals with underlying bipolar disorder. 

Medications that directly affect brain neurotransmitters involved in mood regulation, such as antidepressants, corticosteroids, and dopaminergic drugs, appear to carry the highest risk. 

Commonly abused substances like alcohol, cocaine, opioids, and hallucinogens also correlate with higher rates of triggering manic or depressive cycles according to research. 

While the pathophysiological mechanisms are still under investigation, the evidence supports carefully considering medication and substance use in bipolar patients to avoid the potential induction of mood episodes. 

FAQ’s:

1. Can substance-induced bipolar symptoms be reversible?

In many cases, once the substance is eliminated from the system, bipolar-like symptoms may subside.
However, individual responses vary, and ongoing monitoring and appropriate interventions are essential for effective management.

2. How do family members and friends support individuals with bipolar disorder triggered by substances?

Family counseling and education play crucial roles in supporting individuals with bipolar disorder.
Understanding potential triggers, recognizing signs of worsening conditions, and providing lifestyle support can contribute to a supportive and nurturing environment for recovery.

3. Are there specific interventions for individuals with dual diagnoses of bipolar disorder and substance abuse?

Yes, specialized dual diagnosis treatments coordinate care for both disorders simultaneously. 
These comprehensive programs often include detoxification, individual and group therapy, life skills training, family therapy, and relapse prevention skills development to address the complexities of co-occurring conditions.

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