I was chatting with a colleague about how some patients with the manic or hypomanic symptoms of bipolar disorder often seem to sabotage their own treatment by going off their medications. This begged the question: Is mania addictive? My conclusion: Quite possibly….How could this be true? Is it possible that there is a substance secreted in the brain during hypomania/mania that could be addictive?
In an excellent comprehensive review in Nature magazine, Stork and Renshaw reviewed most of the scientific findings in bipolar disorder research and correlated them all with the newer, mitochondrial, theory of bipolar disorder. One of their suggestions is that the brain overproduces monoamines (serotonin, noradrenaline, and dopamine) in an attempt to correct a pH imbalance that is observed in bipolar patients who are between the depressive and manic/hypomanic phases of their illnesses. Most patients with bipolar disorder will agree that they experience all of the feelings associated with the monoamines when they are in hypomanic/manic states: increased energy, increased focus and motivation, lack of anxiety, elevated mood, psychotic phenomena, and a global sense of purpose (reward). [Other patients experience another form of mania called irritable mania in which serotonin seems to be decreased during the manic episode.]
In my subspecialty of addiction, we know that the most potent reinforcer of behavior is dopamine. In particular, any substance or behavior that can increase the production of dopamine in the brain substantially enough can lead to addictive behavior. Now if what the researchers are suggesting is correct, then bipolar patients experience a large increase in dopamine during their hypomanic/manic states. And if that is so, then it is quite possible that they are activating the addiction centers in their brains.
So in short, yes, it is definitely possible that bipolar patients have an experience similar to addiction. Perhaps it is a withdrawal from this elevated state that compels our patients to go off of their medications. If that is the case, then how can we help them?
Here is some outside-of-the-box thinking: Offer our bipolar patients a medication that’s known for reducing craving. Naltrexone is a medication that is gaining popularity in the addiction field. Originally designed to treat patients in heroin overdose, this little pill is showing effectiveness in alcohol addiction and pathological gambling too. Could it help? To show effectiveness, we would need a study looking at patients who take medication for hypomania/mania and whether naltrexone increases the length of time that they stay on their medication. I’m not currently set up to carry out such a research study but perhaps we can get the word out. A lot of patients stand to benefit from this information.