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The Dilemma of Substance-Induced Mood Elevation

Should one proceed with post-mania treatment and/or prophylactic measures?

There are numerous prescribed drugs and non-prescription substances that can activate the onset of mood elevation symptoms quite like what is observed with episodes of bipolar hypomania or mania. For most who experience Substance-induced Mood Elevation (SME), the question of how to proceed following their elevation is infused with ambiguity and uncertainty.

The onset of bipolar symptoms typically occurs somewhere between mid-adolescence and the mid-20s. Initial symptom presentations often entail depression, but occasionally episodes of strong mood elevation (hypomania or mania) and/or strong energized irritability will occur without having been preceded by one or more episodes of depression.

Once the symptom pattern of bipolar mood disturbance is sufficiently clear, and it has been determined that mood disturbances are not indicative of other diagnoses, then the bipolar diagnosis is usually rendered. When symptoms are more subtle, it typically takes longer for an accurate diagnosis to be reached. Conversely, when symptoms of mood elevation reach a high level of intensity (mania) and when there are no better alternate explanations for the symptoms, then the bipolar diagnosis can be established more rapidly.

Diagnostically, a more challenging situation is one in which there is an initial episode of mood elevation concurrent with or following the use of a medication or drug that has a strong activating effect upon mood. Examples would be substances such as antidepressants, psychostimulants, steroids, or non-prescription substances (cocaine, meth, ecstasy, LSD, etc.).

It is well established that different substances can activate strong mood elevation. In fact, SME symptoms can often look identical to that which we see in bipolar hypomania or mania. What is less clear is whether SME represents a single event that will not likely recur in the absence of similar substances or whether the substance-induced elevation reveals an underlying predisposition toward bipolar illness. Furthermore, many instances of SME occur without an already establish "symptom pattern of bipolar mood disturbance". Essentially the first SME-related mood spike may be the only evidence one has with regard to the possible presence of bipolarity.

Metaphorically, think of unexpressed bipolar potential as being like dry tinder without sufficient heat. It exists as unexpressed potential, but conditions have not yet precipitated its activation. Once the drug or medication “heat” is introduced, the genetic potential becomes activated and we see bipolar symptoms that may continue to reappear intermittently through the individual’s life.

So how do we tell the difference between a non-bipolar SME and an SME that heralds the onset of bipolar illness? This is an important distinction as it has long-range implications regarding prognosis, lifestyle, and follow-up treatment choices.

Unfortunately, current psychiatric diagnostic practices have not progressed to the point where the bipolar diagnosis is established through bloodwork, genetic testing, or neuroimaging. It is therefore difficult to assign bipolar risk based on biologic markers. So how does one proceed after a substance-induced mood elevation? Does the individual do nothing? Go on with life and take a wait-and-see attitude? Or does the individual go forward with heightened caution as if he or she is possibly now living with bipolar disorder?

Why caution? The rationale is clearly reflected in the data pertaining to bipolar symptom relapse following an initial episode of mania. In a 2015 literature review article from the Journal of Clinical Psychiatry, the authors looked at 8 different studies which examined rates of relapse following initial manic episodes. They Identified post-initial manic episode relapse rates of 25.7 percent within 6 months, 41.0 percent by 1 year, and 59.7 percent by 4 years. Essentially, by year 4 following an initial manic episode approximately 60 percent of people will experience a relapse of manic symptoms.

An additional important element to consider regarding SME is whether the individual has a family history of mood disorders. Where there is clear evidence of one or more family members with bipolarity, recurrent major depression, or other biologically based major psychiatric disorders, then statistically speaking, odds are stronger that substance-induced mania may be indicative of underlying bipolar disorder. The same is also true if clear patterns of mood instability have been present for an individual prior to a substance-induced elevation.

When I observe episodes of SME in individuals with higher-risk backgrounds, then I typically advise that people obtain psychiatric consultation and consider taking medication as prophylaxis against future mood destabilization. I certainly don’t mean forever, but at least for a year or two following the initial strong mood spike to ensure that any bipolar “heat” remains relatively cool and controlled.

But we are still left with the large group of individuals without bipolar family history who have experienced an initial incident of SME. How careful do these folks need to be?

In an ideal world, individuals would proceed with a lot of caution. They would absolutely make sure they avoided using the same substance that activated their first hypomanic or manic episode (or substances in the same drug class). They might even obtain psychiatric consultation to learn what medication options they should consider if they have any recurrence of strong mood elevation. They would also consider implementing multiple lifestyle choices that optimize ongoing mood stability (minimizing substance use, implementing a consistent sleep-wake schedule, exercising regularly, increasing social support, establishing healthy daily routines, etc.).

But realistically speaking, people don’t want the bipolar diagnosis. This is especially true for the young adult population. They don’t want to strongly consider the possibility that bipolarity may be part of their future. They don’t want the stigma, the long-term use of medications, nor the lifestyle modifications that are recommended for living well with bipolarity.

The truth is, many don’t proceed with strong caution following an initial substance-induced mood elevation because they maintain a degree of denial. If they are among the population living with bipolar genetic predisposition, then they typically find out the hard way. The recurrence and gradual worsening of symptoms gradually become the motivation that leads people to get help.

Over the course of my career working with the young adult population, I’ve seen variations of SME play out many times. But these incidents of mood elevation are not just the purview of late adolescence or early adulthood. They can occur at any point in the lifecycle when the lit match of stimulating medication is brought to the dry kindling of unexpressed bipolar disorder. In most of these instances I advise that people proceed with substantive caution as opposed to disregard.

Yes, there are times when mood and energy become strongly elevated following the use of a psychoactive substance and nothing further comes of it. All instances of SME are not indicative of bipolarity. I nonetheless return to my cautionary message as well as to the data on bipolar relapse following initial manic episodes. Once bipolar neurochemistry becomes ignited, it can be exceedingly difficult to return to long-term, well-controlled mid-range mood.