Complex connections among bipolar disorder, substance use and suicide

More than a decade ago, Mark Ilgen, Ph.D., a Clinical Psychologist and Health Services Researcher at Michigan Medicine, set out to understand which psychiatric conditions have the strongest associations with suicide risk.

“In men, the condition with the strongest association was bipolar disorder, and in women, it was having a substance use disorder,” Ilgen said.

The risk of suicide associated with conditions such as substance use disorder is considerably high, but it becomes magnified for people living with both.

“Approximately 1 in 5 had opioids in their system at the time of death by suicide, and a very similar proportion of people had alcohol in their system at a level consistent with intoxication at the time of suicide death,” Ilgen explained, referencing data from the 2022 National Violent Death Reporting System that examined all suicides in the United States.

This data emphasizes the relationship between substance use and suicidality.

As associate director for adult research at the University of Michigan Addiction Center, Ilgen explains that substance use also impacts emotions, almost mirroring the mood instability people can experience with bipolar disorder.

With chronic or heavy substance use, emotional cycling can develop, as well as sleep problems.

Bipolar disorder’s magnified risks

Sarah Sperry, Ph.D., director of the Emotion and Temporal Dynamics Lab and associate director of the Heinz C. Prechter Bipolar Research Program, has presented on the links between bipolar disorder, substance use and suicide risk.

“In bipolar disorder, close to 40% will have a suicide attempt over their lifetime. Death by suicide is close to 20% Sperry told the audience.

These numbers dwarf those seen in the general population.

Understanding the relationship bipolar disorder has with substance use has been a focus area for Sperry and her lab’s research.

“Individuals with bipolar disorder are at significantly higher risk of having a co-occurring substance use disorder … the rates of alcohol use disorder, cannabis use disorder, and other substance use disorders are remarkably higher than the general population,” she shared.

To dig deeper, Sperry and her lab utilized data from participants in the Prechter Longitudinal Study of Bipolar Disorder, one of the country’s largest longitudinal cohorts.

The research team found, “When people had more intense or frequent cannabis use than typical for themselves, that predicted higher levels of suicidal ideation over the next six months,” said Sperry.

The research also showed that people with bipolar disorder who had increases in impairment related to alcohol use experienced more suicidal thoughts over the next six months.

Prevention and care: What works?

Ilgen and Sperry emphasize that effective treatments exist for mood and substance use disorders.

Psychotherapies such as cognitive behavioral therapy, dialectical behavior therapy and a new brief intervention called crisis line facilitation offer hope for prevention and crisis support.

Ilgen described the crisis line facilitation intervention as a single session involving initial support and processing of a suicidal crisis, such as practicing calling 988 or other crisis supports.

Ilgen completed a trial of this intervention and found that those who received the crisis line facilitation intervention had a lower risk of suicidal behaviors for a year afterward.

Harm-reduction and abstinence-based approaches both have a role, depending on an individual’s readiness and circumstances.

Even small reductions in use can promote better mood stabilization and treatment effectiveness.

“Integrated treatment, addressing both substance use and mood symptoms together, is essential,” Sperry said.

Recovery, community and lived experience

Lillie Birnie, a University of Michigan master’s student in social work, brought the power of lived experience.

Diagnosed with bipolar I disorder and now in long term addiction recovery, Birnie shared her journey through severe depression, substance use and suicidality.

“Bipolar, addiction, and suicidality are experienced together. Those with experiences with any of these diagnoses have the capacity to heal and move forward into their life with hope and purpose,” she said.

Birnie shares her story and lived experience to break down stigma and improve care for others.

As an undergraduate at U-M, Birnie served as a peer facilitator for the Wolverine Support Network and a peer advocate with the College Recovery Program.

Beyond her peer support work, she credited these campus support networks with giving her community, connection, and courage to ask for help.

“The importance of community is what has stood out to me most in my recovery and mental health journey.”

Birnie also worked in Sperry’s lab as an undergraduate research assistant.

Her research examined the impact of alcohol and substance intensity and frequency on mood, mood variability, and functioning in individuals with bipolar disorder.

The primary finding was an association between cannabis use and manic symptoms: when a person increased their cannabis use above their norm, there was an increase in hypomanic symptoms, and this was seen on the population level.

Advocates like Birnie play a critical role in helping us learn and understand more about mental health.

In 2025, she received the Eisenberg Family Depression Center George Orley Student Mental Health Advocate Award.

She’s now pursuing a career in social work, which she credits to the insights she gained through her lived experience and her roles with the Wolverine Support Network, College Recovery Program, and Emotion and Temporal Dynamics Lab.

“Every part of my story, every moment of fear, hopelessness, and uncertainty throughout my life have contributed now to a sense of purpose and meaning that I never could have imagined having.”

Stigma falls, support builds

The Mind Matters webinar series is one step in connecting science, advocacy, and lived experience.

The panelists stressed the need to address stigma, encourage realistic expectations, and foster community support.

Birnie emphasized the power of creating these conversations: “I have bipolar disorder, I have a substance use disorder, I have a history of suicidality, and I'm not ashamed of them today. I know that I am who I am today because of what I have gone through. I will be who I am next week, and next year because of what I will go through.”

Papers cited:

“Psychiatric Diagnoses and Risk of Suicide in Veterans,” Archives of General Psychiatry. DOI: 10.1001/archgenpsychiatry.2010.129

“Surveillance for Violent Deaths - National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022,” Morbidity and mortality weekly report. Surveillance summaries. DOI: 10.15585/mmwr.ss7405a1

“Alcohol and substance use differentially impact suicidal ideation in a longitudinal cohort of bipolar disorder,” Psychiatry Research. DOI: 10.1016/j.psychres.2025.116357

“Encouraging the use of the Veterans Crisis Line among high-risk Veterans: A randomized trial of a Crisis Line Facilitation intervention,” Journal of psychiatric research. DOI: 10.1016/j.jpsychires.2022.07.047

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