The standard advice about drinking when you have bipolar is to avoid alcohol altogether. Is moderate drinking ever a good idea? Some things to ponder.
You walk into a social gathering and see that most of the guests have a drink in hand. So you grab a beer, too—maybe to calm your nerves before you mingle, maybe to join the festive atmosphere, maybe even to get a buzz going.
That common scenario gets more complicated when you have bipolar disorder.
“We tend to look at alcohol as a beverage, but it is a drug,” says Beth Letterman, a substance abuse counselor in North Carolina. “Alcohol can cause someone to be elated or depressed. If they are down, they will go lower. If they are high, they’ll go higher.”
When it comes to alcohol use, Letterman draws from both professional and personal experience: She spent her younger years drinking heavily, all the while living with undiagnosed bipolar disorder.
The party line (no pun intended) when it comes to drinking and bipolar is pretty simple: Don’t. But many individuals who have bipolar are looking for a middle ground. They may not want to feel left out when everyone else is having a drink or two, or they may enjoy a relaxing glass of wine at the end of a long week.
Is it ever OK to imbibe if you have bipolar? On a case-by-case basis, there may be some give in the blanket prohibition—but there is persuasive evidence for being a teetotaler.
“The biggest problem alcohol use poses for people with bipolar is how it interacts with moods,” says Henry R. Kranzler, MD, a professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia.
It is tempting to drink to mute feelings of anxiety and depression—otherwise known as self-medicating— but that backfires in the long run. Alcohol actually acts as a mood depressant and its use over time can worsen bipolar depression.
Drinking makes most people feel more social and less inhibited because alcohol impairs regions of the brain that help us self-monitor, Kranzler explains. But that loose and easy feeling only lasts an hour or two after the last drink. Then blood alcohol level drops, leaving you “sluggish,” he adds.
Liquor can temporarily slow the disorganized, racing thoughts that accompany mania, says Anita Everett, MD, chief medical officer of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).
However, the lowered inhibition that comes with drinking also greases the way for risk-taking behaviors that accompany elevated mood, such as overspending, excessive arguing, unsafe driving, sexual indiscretions, and acting on grandiose ideas.
“Because alcohol often acts to change the normal checks and balances in decision-making, it is easier for a person under the influence to take risks and act in ways that they would not normally act,” Everett notes.
Drinking may also tip the balance when it comes to taking your own life: “Persons who might normally have suicidal thinking but would not act on [it] are much more likely to while under the influence,” she says.
Letterman, a former naval officer who practices at Marine Corps Base Camp Lejeune, started sneaking drinks in high school and intensified her consumption in college. She says heavy alcohol use, coupled with mood shifts, fueled promiscuity.
“I’d put myself in danger—go to a bar and drink all night and go home with someone I didn’t know,” the 55-year-old recalls.
At age 25, Letterman was the married mother of a newborn baby girl. That enormous new responsibility gave her the strength to stop drinking. But stability eluded Letterman until her late 30s, when she was able to identify and address her underlying condition.
“When I was diagnosed with bipolar II, I finally comprehended the word serenity,” she says.
Another argument for abstinence: Studies have shown that people with bipolar disorder have a 60 percent chance of developing a drinking problem at some point in their lives.
Given the prevalent overlap of alcohol or drug use problems and behavioral health conditions like bipolar, the U.S. National Institute of Mental Health recommends that anyone seeking help for one issue be evaluated for the other. Addressing only one half of the “dual diagnoses” equation tends to be less effective than tackling both simultaneously.
Researchers are trying to puzzle out why having bipolar disorder significantly raises the risk of alcohol use disorders. It doesn’t mean that bipolar causes alcoholism, or vice versa, says Kranzler.
“There’s a lot we don’t know,” he says. “We presume alcohol alters the neurotransmitter levels and their metabolism and production, but what’s actually going on is not entirely clear.
Pre-existing impulse control deficits could play a role. A study published in the September 2013 edition of the journal Psychopathology compared 47 participants who had bipolar disorder and an alcohol disorder with 66 individuals with bipolar disorder alone and 90 without either diagnosis. The dual diagnosis group scored significantly higher on impulsivity measures than the other two groups.
Scientists also are studying inherited traits that bipolar and alcoholism share. For example, the genetic traits that appear to affect the brain chemistry linked to bipolar disorder may also be involved in how the brain responds to alcohol and other drugs, putting certain individuals at higher risk of both developing bipolar illness and becoming substance abusers.
Henry B. has a family history of alcoholism on both sides of the family. At 12 he began raiding his dad’s unlocked liquor cabinet. By the time he was in his 30s, he’d come home from work and drink until he passed out.
“I spent all my money for bills on alcohol,” says Henry, who is now 43.
He kept drinking after getting a bipolar diagnosis in 1999, although he knew it was undermining the effectiveness of his prescribed medications. He also recalls that with a few of the different meds he tried, drinking would lead to bouts of rage.
Some mood stabilizers negatively interact with alcohol while others do not, says Kranzler. Often, drinking means your meds can’t do their job properly—or it may amplify side effects.
“Alcohol increases the metabolism and makes some drugs lose their effectiveness,” Kranzler explains. “It can also cause dizziness and drowsiness because both alcohol and mood stabilizers have those effects.”
After attending an outpatient rehabilitation program, Henry remained sober for three years before relapsing in 2011. He attributes his lapse partly to the fact that his late wife was still using alcohol, “but also because I missed drinking.”
Henry has since relocated from Maine to California to restart his life as a widower.
“I’ve not been drinking much at all since moving. I’ve kind of lost the desire to do so,” he says.
He admits to worrying about slipping back into heavier drinking, but adds, “I try not to fixate on it—I don’t want to set myself up for failure. “
A family or personal history of alcohol dependence would certainly loom large in weighing whether to drink or not. Other factors: Why you drink, how much you drink, when you tend to drink, and how easily you can quit drinking when you choose.
Using alcohol to numb emotional unease or stress is a maladaptive coping mechanism—something that doesn’t actually improve your situation. The same is true for using alcohol as a sleep aid.
“You may fall asleep [more] easily but then wake up in the night and be unable to fall back to sleep,” Everett says.
Everett isn’t opposed to drinking in moderation for all people with bipolar disorder—as long as it can be done safely.
“You need to be honest with yourself. Is it really [one drink] once or twice a week? Ask your ‘pit crew’ and if they don’t feel there are any problems, it’s probably okay,” she says, referring to the people who provide you with support.
Bill B.’s attitudes toward alcohol have been shaped by the 20 years he spent in the U.S. Army—“the military culture is a drinking culture,” he says—and by his upbringing, where a glass of wine with dinner was the norm.
The retired lieutenant colonel, who has bipolar I, works as a peer support provider at a Veterans Administration inpatient detoxification unit. Even so, “abstention doesn’t work for me,” the 56-year-old says.
He says his alcohol consumption ranges from “almost no drinking to drinking more than I should. Then I have to bring it back. I can’t let drinking control my life.”
He knows that drinking greatly influences his behavior and emotions, so he tries to monitor his mood state.
“If I’m aware that I’m becoming depressive or manic, my internal control says ‘hold off.’ ”
Unfortunately, not everyone is able to recognize when their drinking reaches the danger zone. For one thing, says Everett, dependency typically creeps up on you slowly, over a long period of time. For another, a poor sense of how you’re really functioning can be an aspect of bipolar.
“It’s very hard for the person to see that the drinking can make [the bipolar] worse,” she adds. “There’s a sense of denial. That’s why we recommend family help when things are not right.”
Like many clinicians, Kranzler advises zero tolerance as the best practice for those with bipolar. If that’s not what you’re doing, he recommends keeping your health care team in the loop.
“A very low level of alcohol would probably not be problematic, but it really depends on the individual. You should first discuss it with your prescriber.”
Natalie M.’s psychiatrist and therapist have both cautioned her to avoid drinking, but she’s not there yet.
“I used alcohol so much in the past as a coping mechanism, it was hard to eliminate it from my life completely,” says the 29-year old, who works in a hotel and attends college in Victoria, British Columbia.
These days, she’s says it’s “mostly it’s the social aspect” that has her downing cans of hard cider. On occasion, though, she misses hypomania and “a light buzz from drinking can sometimes fill that void.”
Natalie was diagnosed with bipolar at age 25. This past winter, she achieved enduring stability for the first time since her teens. As part of her management plan, she pays close attention to any signs of emerging illness.
“If I’m slightly depressed or manic I don’t go anywhere near drinking,” she says. “It makes me more depressed. I’ve learned my lesson and know where my limits are.”
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Signs of problem drinking
The medical definition of an alcohol use disorder is problem drinking that becomes severe. Diagnostic criteria include:
Drinking more or longer than intended
Couldn’t cut down or stop drinking when desired
Spending a lot of time drinking or recovering from the aftereffects
Strong urge to drink
Drinking has interfered with job, school or family responsibilities
Continued to drink even though it causes trouble with family or friends
Cut back on other activities you enjoyed in order to drink
Getting into risky situations while drinking (such as driving, using machinery, or having unsafe sex)
Continued to drink even though it was making you feel depressed or anxious, or after a memory blackout
Needing to drink more to get the same effect
Experiencing withdrawal symptoms such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating
The more of these symptoms you have, the more urgent the need for intervention.
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