Alcohol and Bipolar

The Literature

Alcohol and bipolar is a topic about which there seems to be much confusion.  There is a little-understood known correlation between alcohol abuse and bipolar disorder [Regier et al. 1990, Kessler et al. 1996].  "These studies show that about 50% of individuals with bipolar disorder also manifest alcohol abuse or dependence and altogether about 75% have a substance use disorder. [Lydall et al. 2011]"

There are several things to note here.  First, this statement is about alcohol abuse and dependency which is the consumption of alcohol to the extent that it harms ones health and social obligations, the craving of alcohol, and the inability to limit its use.  This statement says nothing about moderate drinkers.  Second, this should not be taken to mean that alcohol abuse is causative of bipolar, since a correlation does not imply causation [correlation and causation].  For example asthma and socioeconomic status are correlated, but it is commonly thought that there are environmental factors which explain the trend [Almqvist et al. 2005].

The correlation between alcohol abuse and bipolar could have many explanations [Sonne and Brady 2002].  Alcohol abuse could cause bipolar, bipolar could cause alcohol abuse, or there could be a third factor such as genetics which is causing both.

The case for alcohol abuse causing bipolar is circumstantial and somewhat misleading.  The argument rests on studies done of substance abuse which includes cocaine abuse as well as alcohol abuse.  It should be clear that the mind-altering substances could produce results that are not generally applicable to alcohol abuse.  In other words, if the same study was done while considering only alcohol abuse, the correlation might disappear or be less strong. Additionally, the study authors themselves admit that "the effects of drugs of abuse, particularly with chronic use, can mimic nearly any psychiatric disorder."  At any rate, the results of these studies should be carefully considered since they show a correlation between a worse disease course and substance abuse [Sonne et al. 1994, Sonne and Brady 1999].    Again, all the caveats about drawing conclusions from correlations also apply to these studies. Additionally, it is known that treatment resistant forms of bipolar are more correlated with alcohol abuse, potentially providing a third explanation for disease-course correlation.  This suggests that the type of bipolar is predictive of both disease course and alcohol abuse, in turn suggesting that effective treatment of bipolar might alleviate both disease course and alcohol abuse.

The case for bipolar causing alcohol abuse is also circumstantial, but at least the studies are done for alcohol abuse and not substance abuse.  There are several studies indicating that alcohol abusers with bipolar recover better from alcoholism than other alcoholics [for discussion see Sonne and Brady 2002].  This leads to the additional explanation that "bipolar patients may use alcohol primarily as a means to medicate their affective symptoms, and if their bipolar symptoms are adequately treated, they are able to stop abusing alcohol."

The case for bipolar and alcohol abuse being influenced by a third factor is strong.  There was a recent study showing that there are underlying genetic factors that strongly correlates with alcoholism in people with bipolar [Lydall et al. 2011].  The wording may be awkward, but it is precise.  The study was performed on a group of individuals (n=1016), some with bipolar alcoholism (143) and some bipolar non-alcoholics (363), and some control nonbipolar non-alcoholics (510).  Then the genes known to be correlated with alcoholism were tested for correlation in the bipolar alcoholics vs. the controls and the bipolar non-alcoholics vs the controls.  They then looked for genes with a higher correlation in the bipolar alcoholics than in the bipolar non-alcoholics.  These are the genes that would predict risk for alcoholism for people with bipolar.  It turns out that they also found some of the alcoholism genes were also associated with bipolar in the bipolar non-alcoholics.  This indicates that those alcoholism genes are also risk factors for bipolar (independent of alcoholism).  The study authors reached the conclusion that "the relationship between bipolar and unipolar affective disorder and alcohol dependence is bidirectional (Sonne and Brady, 2002) and there is little room for doubt that the two disorders have reciprocal effects on each other."

The final topic that we know little about is the interaction between alcohol and medications for bipolar. Most psychotropic medications include a warning about alcohol consumption.  However, I have been unable to find a study which points to what bad effects or interactions might actually occur.  There is not a citation for this, but one doctor explained to me that the main concern is that the liver might be overworked since both alcohol and psychotropic medications both cause the liver to work hard.  The potential for harm to the liver seem to be a good reason to not drink large quantities of alcohol while on psychotropic medications.  While little is known about drug interactions of alcohol and psychotropic medications, there is something known about the effectiveness of treatment for different groups of substance abusers [Sonne and Brady. 2002].  It would seem that choice of medication should be tailored if one is a substance abuser.

In summary, we have many hypotheses about the known correlation between alcohol abuse and bipolar.  We have very few solid conclusions, at this point, and more research needs to be done.  Finally, all the existing conclusions are about alcohol abuse or alcoholism and are not about moderate drinking.  We know very little about how moderate drinking might interact with bipolar disorder, because studies on those topics have not been done.  We also do not know if there are drug interactions between alcohol and psychotropic medications.


My Choices

My statement of what I do should not be taken as a judgement of what other people should do.  There are many ways to deal with alcohol from alcoholism to abstinence.  I am not advocating for any particular choice for anyone else.  I am not advocating for illicit drug use, as this discussion is restricted to alcohol.  I am not advocating binge drinking, as there is a lot of strong evidence that binge drinking is dangerous.  My comments about what I do are limited to myself, and not a judgement of what other people should or should not do.

I choose to drink occasionally at home and in social settings.  By occasionally, I mean that most of my drinking falls in the moderate category and occasionally I abstain.  (Moderate drinking is defined as at most one drink per day for women and at most two drinks per day for men.)  I never drink and drive.  I do not appear to experience any alcohol cravings, and nobody has had reason to tell me that my drinking habits are harmful.  I understand that other people interact with alcohol differently than I do, and my choices regarding alcohol are not a judgement on what they should do.

I would like to see more studies done on the effect of moderate drinking for people with bipolar.  We know that in general populations, wine and beer have been shown to have benefits to the heart when consumed in moderation [Klatsky et al, 1997].  It seems to be unknown how frequently alcohol can be consumed before the risks of alcohol consumption out-weigh the health benefits.  On the subject of bipolar and alcohol, it is unknown at what consumption levels the health benefits out-weigh the elevated risk of developing alcoholism.