Substance/Medication-Induced Bipolar and Related Disorder

Primer

Substance/Medication-Induced Bipolar and Related Disorder is diagnosed when a substance (alcohol, illicit drugs, or prescribed medication) causes manic/hypomanic and/or depressive symptoms while an individual is using the substance or during a withdrawal syndrome associated with the substance.

Prognosis
  • In phencyclidine-induced mania, individuals may present first with delirium, which then progresses to a mixed or manic state.
  • In stimulant-induced mania, the symptoms typically emerge within minutes to an hour after ingestion. The episodes are brief and usually resolves within 48 hours.
  • In medication-induced hypomania/mania, corticosteroids, and some immunosuppressant medications are the common culprits. The hypomania/mania (or mixed or depressed state) usually begins several days after ingestion, and higher doses are more likely to produce bipolar symptoms.

DSM-5 Diagnostic Criteria

Criterion A

A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities.

Criterion B

There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

  1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
  2. The involved substance/medication is capable of producing the symptoms in Criterion A.
Criterion C

The disturbance is not better explained by a bipolar or related disorder that is not substance/medication-induced. Such evidence of an independent bipolar or related disorder could include the following:

  • The symptoms precede the onset of the substance/medication use
  • The symptoms persist for a substantial period of time (e.g. - about 1 month) after the cessation of acute withdrawal or severe intoxication
  • There is other evidence suggesting the existence of an independent non-substance/medication-induced bipolar and related disorder (e.g. - a history of recurrent non-substance/medication-related episodes).
Criterion D

The disturbance does not occur exclusively during the course of a delirium.

Criterion E

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers

Specifiers

Specify the substance:

Note: Tobacco, caffeine, inhalants, opioids, and cannabis are not listed as a substance that can cause a bipolar disorder in the DSM-5.

Onset Specifier

Specify if:

  • With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.
  • With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
Example: If cocaine intoxication was thought to have induced a manic episode, the diagnosis would be cocaine–induced bipolar and related disorder, with onset during intoxication.

Substances/Medications

Antidepressants

  • A key exception is if an episode of hypomania or mania occurs after antidepressant medication use or other treatments (e.g. - ECT) and persists beyond the physiological effects of the treatment.
  • This is considered an indicator of true bipolar disorder, and not substance/medication-induced bipolar and related disorder.
    • The appearance of 1 or 2 nonspecific symptoms of medication treatment, such as irritability, edginess, or agitation during antidepressant treatment (in the absence of a full manic or hypomanic syndrome) should not be taken to support a diagnosis of a bipolar disorder, however.

Investigations

  • Urine drug screens can be ordered if there is suspicion of a substance use contribution.

References

1) Nagano, H., Miura, T., & Ueda, T. (2019). Mania induced by isoniazid preventive therapy during steroid treatment for rheumatoid arthritis and organising pneumonia. BMJ Case Reports CP, 12(11), e231919.