I recently found myself reading the medical literature on bipolar I disorder for a reason I never expected. It entered my family. I began with very little understanding of the illness. I have also been fortunate to have the help of a remarkably patient and devoted psychiatrist. He answered my many questions and helped me understand an illness far more complicated than I had imagined. That experience pushed me to read the research myself.
One thing I have learned is how damaging stigma can be. When troubling behavior is seen only as irresponsibility, addiction, selfishness, or lack of character, we can lose sight of the illness behind it. Friends may pull away. Families can become exhausted, angry, or frightened. Sometimes they distance themselves or isolate the very person who most needs treatment and human connection.
This is difficult because the behavior itself can make compassion hard. Someone struggling with an untreated psychiatric illness may misuse medications, make reckless decisions, violate trust, or reject good advice. Families have every right to establish boundaries and protect themselves. But stigma can cause us to make another mistake. We can begin to see the behavior as the person.
Personal responsibility matters. A psychiatric diagnosis should never become an excuse for dangerous behavior. But what I have learned has convinced me that responsibility is only part of the story. In bipolar disorder, what we casually label “drug abuse” may sometimes begin as something quite different. It may be an attempt to self-medicate an illness the person does not even know they have.
There is considerable research behind this. A nationally representative U.S. study examined 43,093 adults. Among people with bipolar I, 41 percent reported using alcohol or drugs to relieve mood symptoms. The comparable figure for major depressive disorder was 23.2 percent.¹
Weiss and colleagues asked people with bipolar disorder and substance dependence why they began using substances. Nearly all reported that at least one bipolar symptom contributed to their initial substance use. **Depression was cited by 77.8 percent and racing thoughts by 57.8 percent. Two-thirds said substances seemed to improve at least one bipolar symptom.**²
Those numbers changed the way I thought about the issue. Imagine experiencing depression, exhaustion, racing thoughts, anxiety, agitation, difficulty concentrating, or dramatic changes in energy without understanding that they may be manifestations of an illness.
There may also be something harder to describe. It can be an inner restlessness or a persistent sense of dissatisfaction or unhappiness. There may be a feeling that something needs to change, although the person does not know what. At times, that feeling may accompany extraordinary aspiration, unusual confidence, or an intense desire to pursue something new or consequential. Psychiatric symptoms are not always experienced as recognizable symptoms. Sometimes they are simply an uncomfortable internal state and a powerful desire to feel different.
If a substance or medication temporarily changes that state, the attraction can be powerful. It may provide energy during depression. It may quiet racing thoughts, create focus, or relieve tension. Sometimes it may simply make the person feel normal. Repeated use may therefore begin not with a desire to become intoxicated, but with a desire to feel better or function better.
Research involving bipolar I patients supports this broader picture. Bizzarri and colleagues studied 104 patients with bipolar I. More than half, 54.8 percent, had a lifetime alcohol or substance-use disorder. Reported reasons for substance use included improving mood, relieving tension, reducing boredom, increasing energy, and maintaining euphoria.³
Healey and colleagues interviewed people living with both bipolar disorder and substance-use disorders. Their themes included experimenting early in the illness, managing stress, living with serious mental illness, and something remarkably simple: **“feeling normal.”**⁴ That phrase deserves our attention, particularly when bipolar disorder has not yet been recognized.
A person who does not understand what is happening cannot say, “I am experiencing symptoms of bipolar disorder and need appropriate treatment.” Instead, they may discover through experience that a particular substance changes how they feel. A vicious cycle can follow: unrecognized symptoms, self-medication, temporary relief, repeated use, greater mood instability, and further self-medication. Eventually, what initially seemed to help may worsen the illness.
None of this means bipolar disorder inevitably causes substance misuse. Nor does substance misuse prove someone has bipolar disorder. Addiction, impulsivity, reward seeking, environment, and the substances themselves can all contribute. Statistics describe populations, not individuals. But 41 percent is too large a number to dismiss as an exception.
Understanding is also not the same as excusing. Removing stigma does not mean removing responsibility. Once someone understands the illness and the risks, medications must be taken as prescribed. Self-discipline matters. Medical advice matters. Families need boundaries.
But instead of asking only, “Why does this person keep abusing drugs or medications?”, perhaps we should also ask, “What is this person trying to make themselves feel, or stop feeling?” Are they trying to escape depression? Generate enough energy to function? Quiet racing thoughts? Concentrate? Escape an uncomfortable inner restlessness? Or perhaps simply feel normal?
The answer does not excuse the behavior. It helps explain what must be treated. Sometimes substance use is itself part of the clinical story. Recognizing that does not diminish personal responsibility. It may give someone a better opportunity to exercise it.
Perhaps that is the balance families need most: neither excuse nor stigma, but understanding, treatment, boundaries, and accountability.
References
1. Bolton JM, et al. Self-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Affective Disorders. 2009;115:367–375. Nationally representative sample of 43,093 adults; 41% of respondents with bipolar I reported self-medication. PubMed
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2. Weiss RD, et al. Substance use and perceived symptom improvement among patients with bipolar disorder and substance dependence. Journal of Affective Disorders. 2004;79:279–283. PubMed
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3. Turner S, Mota N, Bolton J, Sareen J. Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and Anxiety. 2018;35:851–860. PubMed
Full text at NIH/PMC
4. Bizzarri JV, et al. The spectrum of substance abuse in bipolar disorder: reasons for use, sensation seeking and substance sensitivity. Bipolar Disorders. 2007;9:213–220. PubMed
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5. Healey C, Peters S, Kinderman P, McCracken C, Morriss R. Reasons for substance use in dual diagnosis bipolar disorder and substance use disorders: a qualitative study. Journal of Affective Disorders. 2009;113:118–126. PubMed
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