Bipolar disorder is a mental health condition marked by episodes of mania or hypomania that alternate with episodes of depression. It affects an estimated 2.8 percent of U.S. adults in a given year, according to the National Institute of Mental Health, and it has one of the highest rates of co-occurring substance use disorder of any psychiatric condition. Peer-reviewed research in the American Psychiatric Association’s clinical literature puts the lifetime rate of co-occurring substance use disorder at 42 to 60 percent for people with bipolar disorder, with alcohol and cannabis the substances most often involved. Families across New Hampshire who are navigating this pattern often say the same thing: no one warned them the two conditions would show up together.
Why Bipolar Disorder and Substance Use Show Up Together So Often
The connection is not a coincidence, and it is not a matter of willpower or character. During manic or hypomanic episodes, impulsivity and impaired judgment raise the odds of risky substance use, sometimes as an extension of the elevated mood itself. During depressive episodes, alcohol or other substances are often used as an attempt at self-medication, a way to blunt symptoms that feel unbearable without any other tools to manage them.
There is also a shared biological vulnerability. Both bipolar disorder and substance use disorders involve dysregulation in the brain’s reward and stress response systems, which means having one condition measurably increases the biological likelihood of developing the other, independent of any conscious choice involved. None of this excuses harmful behavior that may occur during an episode, but it does explain why simply telling someone to stop using rarely works when an underlying mood disorder is driving part of the pattern.
The Problem With Treating Only One Condition
This is where a lot of well-meaning treatment attempts go wrong. Treating a substance use disorder without addressing bipolar disorder, or stabilizing a mood disorder without addressing substance use, tends to produce the same outcome: relapse in one area destabilizes the other.
A person who gets sober but whose bipolar disorder remains untreated is still vulnerable to manic episodes that can trigger impulsive relapse, or depressive episodes that reintroduce the urge to self-medicate. A person whose mood is stabilized with medication but who continues drinking or using is working against the very treatment meant to help them, since alcohol and many other substances interact directly with mood-stabilizing medications and can undo their effectiveness. Substance use can also mask or mimic mood symptoms, making it genuinely difficult for a clinician to get an accurate read on what is bipolar disorder and what is a substance-induced mood shift, unless both are being assessed and treated by the same coordinated team at the same time.
Integrated treatment, meaning both conditions addressed simultaneously by clinicians trained in each, is the approach recommended in the psychiatric literature on this comorbidity. It is the model used at Heartfelt Recovery Centers, a Joint Commission accredited outpatient provider in Hudson, NH, serving Southern New Hampshire and Northern Massachusetts.
What Integrated Treatment Actually Looks Like
A comprehensive assessment at intake screens for both conditions rather than assuming one is the primary issue and the other a side effect. From there, treatment typically combines several elements working together rather than in sequence.
Medication management, coordinated with a psychiatric provider, addresses mood stabilization directly, since certain mood stabilizers and antipsychotic medications have a meaningful evidence base for treating bipolar disorder even when substance use is also present. Cognitive Behavioral Therapy and Dialectical Behavior Therapy both have applications here: CBT helps identify and interrupt the thought patterns that precede both manic-driven risk-taking and depressive self-medication, while DBT’s skills in distress tolerance and emotional regulation directly target the impulsivity and mood instability that make relapse more likely.
Family involvement matters here more than in some other treatment contexts, because family members are often the first to notice the early warning signs of an emerging manic or depressive episode, sometimes before the person themselves recognizes what is happening. Teaching family members what those early signs look like, separate from ordinary mood swings, gives everyone a better chance of intervening before a full episode and its associated relapse risk take hold.
Heartfelt’s Partial Hospitalization and Intensive Outpatient Programs treat this integrated model as standard, not as an add-on, with flexible evening and weekend scheduling so treatment does not mean stepping away from work, school, or family responsibilities. Adults travel from Nashua, Manchester, and communities across Northern Massachusetts to our Joint Commission accredited facility in Hudson, where this kind of integrated care typically unfolds over months, not weeks.
What This Means If You Recognize This Pattern
If you or someone you love has cycled between periods of high energy, poor sleep, and risky decisions, followed by stretches of depression and heavier substance use, and every attempt at getting sober on its own has eventually broken down, that pattern is worth naming directly with a clinician rather than working around. It does not mean previous treatment attempts failed because of a lack of effort. It often means only one half of what was actually happening was being addressed.
A comprehensive dual diagnosis assessment is the starting point, and it exists specifically to sort out which symptoms belong to which condition, and which combination of treatment running at the same time gives the best chance at lasting stability. Our earlier articles on dual diagnosis versus co-occurring disorders and treating addiction and mental health together cover related ground, if either feels closer to what you are seeing.
Why Mood Stability Has to Come First, Not Last
The title of this article is not a throwaway phrase. In bipolar disorder specifically, mood instability is not just a symptom sitting alongside the substance use disorder, it is frequently the mechanism driving relapse. A person who has been sober for months can still be pulled back toward substance use during a manic episode’s impulsivity or a depressive episode’s despair, regardless of how much motivation or insight they had during a stable period. Relapse prevention planning that only addresses triggers related to substance use, without accounting for the mood cycling itself, is treating half the picture.
This is why clinicians who specialize in this comorbidity tend to prioritize mood stabilization early in treatment, not as a nice-to-have addition once sobriety is established, but as one of the load-bearing pillars holding sobriety up in the first place. A stable mood does not guarantee someone will not relapse. It does remove one of the most common and most severe triggers for relapse in this specific population, which is meaningfully different from most single-diagnosis addiction treatment.
Frequently Asked Questions
How common is substance use among people with bipolar disorder?
Peer-reviewed research estimates that between 42 and 60 percent of people with bipolar disorder will experience a co-occurring substance use disorder at some point in their lives, with alcohol and cannabis the most commonly involved substances. This is among the highest comorbidity rates of any psychiatric condition.
Can bipolar disorder be misdiagnosed because of substance use?
Yes. Substances can produce mood symptoms that closely resemble mania, hypomania, or depression, which is why an accurate diagnosis often requires observing mood patterns during periods of abstinence, or close coordination between addiction and psychiatric specialists who can distinguish substance-induced symptoms from the underlying disorder.
Should someone stop drinking or using drugs before starting bipolar treatment?
Not necessarily, and waiting for full abstinence before addressing bipolar symptoms often backfires. Integrated treatment that addresses both conditions at the same time, under coordinated clinical supervision, is the approach supported by current research rather than treating one condition as a prerequisite for treating the other.
Is medication for bipolar disorder safe to take alongside addiction treatment?
Mood-stabilizing and antipsychotic medications are a core part of integrated dual diagnosis treatment and are managed by a psychiatric provider who accounts for any substance use in the treatment plan. What is not safe is continuing to drink or use other substances that interact with these medications without your care team’s knowledge.
What should family members watch for?
Noticeable changes in sleep, energy, spending, or decision-making that last several days, paired with any increase in substance use, are worth raising directly with the person and, if needed, with a treatment provider. Family members are often positioned to notice these shifts earlier than the person experiencing them.
Does insurance cover integrated treatment for bipolar disorder and substance use?
Most major insurance plans cover outpatient dual diagnosis treatment, though coverage details vary by plan and level of care. A free, no-obligation insurance verification can confirm what is covered before treatment begins.
Start Integrated Treatment for Bipolar Disorder and Substance Use
If mood episodes and substance use have been feeding each other in a cycle that never quite breaks, treating them together, not one after the other, is the path most likely to hold. Heartfelt Recovery Centers offers Joint Commission accredited dual diagnosis assessment and treatment at our Hudson, New Hampshire location, serving families across Southern New Hampshire and Northern Massachusetts. Contact our team or verify your insurance to get started.
WRITTEN BY
Mitchell Cohen, LICSW, MLADC
Licensed Clinical Social Worker, Master Level Alcohol and Drug Counselor
Mitchell Cohen, LICSW, MLADC, is a licensed clinical social worker and Master Level Alcohol and Drug Counselor at Heartfelt Recovery Centers in Hudson, NH. With over 12 years of experience in outpatient addiction treatment, Mitchell specializes in family systems therapy, relapse prevention planning, and dual diagnosis treatment. He is trained in Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT) and holds advanced certifications in family intervention techniques and trauma-informed care.
MD Mitchell Grant Cohen
Dr. Mitchell G. Cohen is a board-certified Internal Medicine specialist with over 34 years of experience in patient-centered healthcare. A graduate of Hahnemann University School of Medicine, Dr. Cohen completed his internship at the University Health Center of Pittsburgh, where he gained invaluable hands-on experience. He is also a certified addiction specialist, holding membership with the American Society of Addiction Medicine (ASAM).
Currently based in Nashua, NH, Dr. Cohen is affiliated with Saint Joseph Hospital, where he provides comprehensive care focusing on both internal medicine and addiction treatment. His expertise includes prevention, diagnosis, and management of adult diseases, as well as specialized care for individuals facing substance use disorders.
Dr. Cohen is committed to fostering open communication, ensuring his patients are fully informed and empowered to make confident decisions about their health and treatment options.
