Bipolar Disorder

Overview

What Is It?

Bipolar disorder is characterized by intense episodes of elation or irritability and despair, with any combination of mood experiences in between, including periods of normal moods.

Bipolar disorder can be one of the most distinct and dramatic of mental illnesses. It is characterized by intense episodes of elation or irritability and despair, with any combination of mood experiences in between, including periods of normal moods. Mood changes are accompanied by changes in behavior, such as altered patterns of sleep and activity.

Traditionally, one percent of the population has been affected by bipolar disorder, but as the condition has expanded to include a spectrum of proposed bipolar conditions, this number has risen to an estimated 2.6 to 6.5 percent. According to the World Health Organization, bipolar disorder is the sixth leading cause of disability among people aged 15 to 44. It is less common than major depression, also called "unipolar" depression, or simply, "depression."

The classic form of bipolar disorder, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes, called hypomania, that alternate with depression; this form of the illness is called bipolar II disorder. In addition, there are two other forms of bipolar disorder: bipolar disorder not otherwise specified (BP-NOS) and cyclothymic disorder, or cyclothymia. BP-NOS is reserved for cases where people have symptoms of bipolar disorder that do not meet all the diagnostic criteria for bipolar I or II. Cyclothymia is a mild form of bipolar disorder where people have episodes of hypomania that shift back and forth with mild depression for at least two years. The symptoms of cyclothymia also do not fit into the diagnostic criteria for bipolar I or II.

Studies show that men and women are equally likely to develop bipolar disorder; however, there is some evidence that women may have more depressive and fewer manic episodes than men with the illness. Women seem to have "mixed states" (mania or hypomania occurring at the same time as depression) more often than men. Also, women are more likely to have the rapid cycling form of the disease, which is characterized by four or more episodes of depression, mania or hypomania a year, and may be more resistant to standard treatments. Women are also more likely to have bipolar II disorder.

The symptoms of bipolar disorder can be severe and debilitating. Bipolar disease is not curable. However, medication can help many people achieve remission of symptoms. Treatment and maintenance of this disorder is necessary throughout a person's life once bipolar disorder is diagnosed.

Like some other illnesses that require lifelong treatment, bipolar disorder poses unique medical challenges for women with the disorder who are pregnant or considering pregnancy. The notion that pregnancy itself is protective for women with bipolar disorder is not true. The risk of recurrence of either depression or mania during pregnancy and postpartum is high. A recurrence during the postpartum period often develops as postpartum psychosis. These risks are high for women who stop their mood-stabilizing medications and even higher for women who stop these medications abruptly.

So a woman with bipolar disorder who wants to become pregnant should discuss her treatment options with her health care team before conception, if possible, or as early in her pregnancy as possible. Concerns exist about the potential harmful effects mood-stabilizing medications used to treat bipolar disorder may have on the developing fetus and the nursing infant. However, these concerns need to be weighed against the potential serious risks that an episode of mania or depression may pose to the developing fetus, infant or mother.

Diagnosis

Bipolar disorder, also known as manic depression, generally strikes in late adolescence or early adulthood, most often between the ages of 15 and 30, and usually continues throughout a person's life. However, some people develop their first symptoms in childhood and others don't develop them until later in life.

Researchers theorize that there are a number of contributing factors for why and how someone develops bipolar disorder, including a genetic predisposition, environmental influences and brain chemistry.

According to the National Institute of Mental Health (NIMH), close relatives of people suffering from bipolar illness are four to six times more likely to develop bipolar disorder than the general population. It is important to note, however, that not everybody with a family history develops the illness. No one gene has been identified for the disorder, but it appears likely that many genes act together and in combination with other factors in the person or the person's environment to cause bipolar disorder.

Studies of identical twins who share the same genes show that a person who has an identical twin with bipolar disorder is more likely to develop the disorder than someone who has a sibling with the illness, indicating that genes are definitely involved. However, an individual who has a twin with bipolar disorder will not always develop the illness, indicating that genes and other factors both play a role.

Studies suggest that stress, difficulty at work or interpersonal relationships may trigger episodes in those with bipolar disorder, particularly if the stress causes loss of sleep. The theory is that stress and/or loss of sleep precipitates changes in brain chemistry in susceptible people.

Behaviors and moods common to bipolar disorder may initially be attributed to other medical problems, or other mental illnesses, which can delay an accurate diagnosis and appropriate treatment. For example, many people with bipolar disorder are misdiagnosed with major depression. In addition, alcohol and drug abuse and/or difficulties with work and school performance may be identified, but their underlying cause—bipolar disorder—may not be diagnosed. However, the disorder is not difficult to diagnose by a well-trained clinician.

Bipolar disorder is diagnosed based on an evaluation of symptoms, the course of the illness and family history. To be diagnosed with bipolar disorder, a person must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), published by the American Psychological Association. In addition to a psychiatric evaluation, a complete medical exam should be completed. A physical exam and blood tests can rule out medical conditions that can mimic or worsen bipolar disorder.

Physical tests, such as a blood test or brain scan, cannot conclusively identify the illness, although progress is being made in these areas. For example, brain-imaging studies using magnetic resonance imaging (MRI), positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) procedures allow researchers to take pictures of the brain to examine its structure and activity. These noninvasive techniques are beginning to help scientists learn what goes wrong in the brain to produce bipolar disorder as well as other mental illnesses.

Symptoms

The symptoms of bipolar disorder fall into several categories: depression, mania and mixed state type of episodes (in mixed episodes, symptoms of both depression and mania are present at the same time). In addition, people experiencing any of these types of mood episodes may experience psychosis, which is a serious inability to think and perceive clearly, or losing touch with reality. If you or a family member experiences any of these symptoms, you should discuss them with a health care professional and request a thorough evaluation, which should include a physical checkup and a family health history.

The symptoms of depression include:

• constant or persistent sadness
• loss of pleasure and interest in activities that were once fun, including sex
• significant change in appetite or weight (either increase or decrease)
• restlessness or agitation
• irritability or excessive crying
• change in sleep patterns, either oversleeping or insomnia
• lack of energy, feeling slowed down mentally and physically
• feelings of guilt, worthlessness, helplessness, hopelessness
• persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain
• difficulty thinking or concentrating
• recurring thoughts of death or suicide

The symptoms of mania include:

• persistent and abnormally elevated mood (euphoria)
• irritability
• overly inflated self-esteem or feelings of importance
• a decreased need for sleep
• increased talkativeness
• racing thoughts
• increased activity, including sexual activity
• distractibility
• increased energy and/or physical agitation
• excessive involvement in risky behaviors, such as spending money irresponsibly
• poor judgment
• inappropriate social behavior

Significant disruption in your sleep-wake cycle is an early warning sign of an impending episode. Controlling your sleep-wake cycle and maintaining a regular pattern is critical to avoid making the illness worse. Decreased and disrupted sleep occurs frequently for new mothers. It is important for women with bipolar disorder who are pregnant or considering pregnancy to talk with their health care providers about ways to reduce their sleep disruptions after giving birth.

Other symptoms of manic depression include psychosis, which involves hallucinations and delusions (falsely believing in something with conviction, despite proof or evidence to the contrary).

Mixed state episodes include symptoms of both depression and mania, often including agitation, trouble sleeping, change in appetite, psychosis and thoughts of suicide.

Symptoms of mania, depression or mixed state are episodic and typically recur. Episodes may become more frequent with age if the condition isn't properly treated. These episodes, especially early in the course of the illness, are separated by periods of wellness, when someone suffers few or no symptoms.

Women with bipolar syndrome are more likely to experience psychosis and manic episodes during pregnancy and after giving birth. This risk is higher for women who stop their mood-stabilizing medications and even higher for women who stop these medications abruptly.

The combinations and severity of symptoms vary from person to person. Some people have severe manic episodes in which they feel out of control, have tremendous difficulty functioning and severe psychosis. Other people have milder "hypomanic" episodes that include increased energy, euphoria and irritability. Some suffer completely incapacitating periods of depression and are unable to function within their normal daily routine. Hospitalization is necessary to treat severe episodes of mania or depression.

If you have bipolar disorder, you may have difficulty acknowledging your mood swings even if family and friends tell you about these behaviors.

During a manic episode, you might abuse alcohol, schedule too many events or meetings for one day, drive recklessly, go on a spending spree, make unwise or risky business decisions or be unusually promiscuous sexually. Untreated, the manic phase can last from days to months. As it fades, a period of normal mood and behavior may occur. Sometimes the depressive phase of the illness then sets in, but another manic episode could also follow.

When you're experiencing a depressed episode, you might lose complete interest in everything you used to enjoy, not be able to stop crying, feel completely hopeless and contemplate suicide. In some people, depression occurs immediately after a manic episode or within the next few months. But with others, there is a long interval before the next manic or depressive episode. The depressive phase has the same symptoms as major depression (also called "unipolar" depression).

People with bipolar disorder may have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that your health care professional closely monitor your thyroid levels. Additionally, if you're treated with lithium, that may cause low thyroid levels.

Treatment

If you have bipolar disorder, you will need lifelong treatment. Regular monitoring and consultation with a health care professional is necessary to establish which medication or combination of drugs works best.

Medications called "mood stabilizers" are most often prescribed to help control bipolar disorder, and several types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for an extended time to manage their illness, usually for years. Other medications are sometimes combined with mood stabilizers when necessary to treat powerful episodes of mania or depression that may break through despite the mood stabilizer. These additional medications may include: an antipsychotic for psychosis or mania; an antidepressant for depression; and/or a benzodiazepine for agitation.

For nearly 40 years, the mood stabilizer lithium has been one of the main treatments for people with bipolar disorder.

Lithium evens out moods so you don't feel as high or as low, but it's unclear exactly how the medication works in the brain. Lithium is not used just for manic attacks, but rather as an ongoing treatment to prevent all types of episodes. It can take up to three weeks to start reducing severe manic symptoms. It might take a few months of medication before the illness is under control.

When taken regularly, lithium can effectively control depression and mania and reduce the chances of recurrence. However, while it is effective treatment for many people, it doesn't work for everybody.

Regular blood tests are a must if you're taking lithium. The level of lithium in your blood can be measured with a blood test. This level is used by your doctor, along with your symptoms, to determine the appropriate dose of lithium for you. Too small a dose might not be effective and too large might produce unwanted side effects, including weight gain, tremors, excessive thirst and urination, drowsiness, weakness, nausea, vomiting and fatigue.

Salt intake also affects the amount of lithium in your body. A dramatic reduction in salt intake, excessive exercise and sweating, fever, vomiting or diarrhea may cause lithium to build up in your body to toxic levels. An overdose of lithium can cause confusion, delirium, seizures, coma and may result, although rarely, in death.

In addition to lithium, other mood stabilizers used in the treatment of bipolar disorder include anticonvulsants. They may be combined with lithium or with each other for maximum effect. Specific ones used for bipolar syndrome include:

• Anticonvulsants. Antiseizure medications (also called anticonvulsants) such as valproic acid (Depakene) and divalproex (Depakote) can have a mood-stabilizing effect in people with bipolar disorder. There is some evidence that valproic acid may result in hormonal changes in teenage girls and polycystic ovarian syndrome (PCOS) in women who began taking the medication before age 20. Young women should discuss this risk with their health care professionals, and those taking valproic acid should be monitored carefully for possible hormonal problems. The anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal) also have some effects as mood stabilizers, although they are not yet approved for bipolar disorder by the U.S. Food and Drug Administration (FDA). At this point, there is more evidence on the effectiveness of Tegretol than Trileptal. And the anticonvulsant lamotrigine (Lamictal) is FDA-approved for the long-term treatment of adults with bipolar disorder. It is specifically used to treat the depressive episodes involved with bipolar disorder.Some anticonvulsants can decrease the effectiveness of hormonal contraceptives, such as birth control pills. It is important to discuss your method of contraception with your health care provider to determine if there is an interaction.

Severely ill patients may require a combination treatment with mood stabilizers and other drugs, including:

• Antidepressant medications. Several classes of antidepressant medications are sometimes used to treat the depressive symptoms of bipolar disorder, including fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and bupropion (Wellbutrin). However, the use of antidepressants in people with bipolar disorder is controversial, since antidepressants may not be any more effective than mood stabilizers at treating depressive episodes in people with bipolar disorder and can trigger manic episodes. Make sure you tell your health care professional about any prior symptoms of hypomania or mania (episodes that include increased energy, euphoria and irritability) before beginning antidepressants. Side effects and effectiveness differ for each class of antidepressant, as well as for the individual brands.
• Antipsychotics. If you're experiencing psychotic or manic symptoms during an episode of bipolar disorder, health care practitioners will sometimes prescribe antipsychotic medicine alone or in combination with a traditional mood stabilizer to control symptoms. Olanzapine can also be used alone for the treatment of bipolar disorder. Examples of antipsychotics used include: olanzapine (Zyprexa), ziprasidone (Geodon), quetiapine (Seroquel), aripiprazole (Abilify) and risperidone (Risperdal), all FDA-approved for the treatment of bipolar disorder. In addition, antianxiety medications such as benzodiazepines may be used in some people with bipolar disorder with acute mania to help with sleep. There is a potential for abuse of or physical dependence on benzodiazepines. Therefore, these medications are often prescribed only for a limited time, such as during an acute episode.

Be patient. It may take up to three weeks of regular use of a new drug before your symptoms improve or subside. Stay in close communication with your health care professional and let him or her know if you don't feel like you are responding to treatment. In some cases, treatment plans need to be changed to effectively control symptoms.

Electroconvulsive therapy (ECT) is another treatment option for bipolar disorder and other types of major depression. It is usually only used to treat bipolar disorder when medication, psychosocial treatment or the combination of these treatments are ineffective or work too slowly to relieve severe symptoms such as psychosis or thoughts of suicide. ECT may also be considered when certain medical conditions, such as pregnancy, make the use of medication too risky.

Just prior to ECT treatment, you're given a muscle relaxant and sometimes general anesthesia. Electrodes are then attached to your scalp. An electric current causes a brief convulsion. Treatments usually last for 30 to 90 seconds. You won't remember the treatments and will probably awake slightly confused. You will most likely recover in five to 15 minutes and be able to go home the same day. Acute treatments usually occur three times per week for about a month. Maintenance treatments may be given after that at a reduced frequency.

ECT has been used for more than 70 years and has been refined since its early introduction as a treatment for depression. According to Mental Health America , ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals. Researchers don't understand exactly how it works to improve symptoms of depression and/or mania in some individuals, but the evidence is clear that it does work.

Although myths and negative perceptions continue to be perpetuated about ECT, it is a very effective treatment for many people with severe depressive, manic or mixed episodes who don't respond to or have bad effects from other treatments or can't take other treatments for some reason. Research has shown that patients who receive ECT followed by maintenance lithium therapy have better outcomes than patients who receive lithium alone. As with all other treatments, you should undergo a complete physical evaluation before beginning ECT therapy.

Side effects can include permanent memory loss and confusion. These side effects were more of a concern in the past, and modern ECT techniques have reduced them significantly. However, the benefits and risks of ECT should still be carefully weighed before an individual or his or her family and friends decide to go with the treatment.

Psychotherapy. As with all mental illnesses and other serious conditions, bipolar disorder can devastate a person's self-esteem and relationships, especially with spouses and family. Without treatment, people with the illness may jeopardize their finances, their careers, their families and their lives. Thus, in addition to treatment with medications, psychotherapy ("talk therapy") is also recommended for individuals with the disorder, as well as for their family members.

Bipolar Disorder and Pregnancy

Women with bipolar disorder who want to become pregnant need to consider several issues. Careful planning for pregnancy can help women with bipolar disease best manage their illness while avoiding risks to their babies. The goal is to maintain a stable mood during pregnancy and postpartum. It is extremely important to consider both the risks of the medications to the unborn baby, as well as the risks of untreated bipolar disorder to both the mother and unborn baby. These should be weighed carefully in a thorough discussion with your health care provider.

After discussing risks and benefits with your health care professional, if you prefer not to use medication during pregnancy, a trial off medications (following a gradual taper) prior to pregnancy, possibly only stopping medications after conception, might be an option. Most health care professionals suggest avoiding sudden changes in medication during pregnancy, which can increase the risk of relapse.

Overall, studies show that taking only one mood stabilizer during pregnancy poses less of a risk to the developing fetus than does taking multiple medications. Some anticonvulsants have been shown to be harmful to fetuses, possibly leading to birth defects. However, rates of problems vary widely based on the medication. Discuss possible medications and their risks with your health care professional and always weigh this against the risk of untreated bipolar disorder.

Some of these medications can be used while breastfeeding but all options should be discussed with your health care professional. Overall, if you are pregnant or planning to become pregnant and you have bipolar disorder, be sure to discuss safety of various treatment options during and after pregnancy with your health care professional.

ECT has also been used for decades (with appropriate adjustments) in pregnancy to treat severe mania or depression.

Prevention

Patients and their families need to understand that bipolar disorder will not go away, and there is no way to prevent the disorder from developing. The only way to keep the disorder under control is through continued compliance with treatment.

Facts to Know

1. Bipolar disorder involves episodes of mania and depression.
2. Traditionally, one percent of the population has been affected by bipolar disorder, but as the condition has expanded to include a spectrum of proposed bipolar conditions, this number has risen to an estimated 2.6 to 6.5 percent. According to the World Health Organization, bipolar disorder is the sixth leading cause of disability among people aged 15 to 44.
3. Most people with bipolar disorder can expect that even their most severe mood swings will be relieved with treatment.
4. Like other serious illnesses, bipolar disorder is not only difficult for the person who has it but also hard on family members, friends and employers. Family members of people with bipolar disorder often have to cope with serious behavioral problems (such as wild spending sprees) and the lasting consequences of these behaviors.
5. Bipolar disorder generally strikes between the ages of 15 and 30.
6. Bipolar disorder tends to run in families, and many researchers believe it is genetic. Researchers, however, have not associated a specific genetic defect with the disease.
7. Not everybody with a family history of manic depression develops the illness.
8. Studies suggest that stress, difficulty at work or with interpersonal relationships may trigger episodes in people with bipolar disorder, particularly if the stress causes loss of sleep.
9. Lithium has been the treatment of choice for people with bipolar disorder but doesn't work for everyone with the disorder. Other effective treatment options are available.
10. Bipolar disorder can get worse during and after pregnancy. Because of potential risk to the developing fetus due to both untreated illness as well as some medications, the disease must be carefully treated by a health care professional during this time.

Questions to Ask

Review the following Questions to Ask about bipolar disorder so you're prepared to discuss this important health issue with your health care professional.

1. Why did you diagnose me with bipolar disorder?
2. What are the names and types of my medications and what are they supposed to do?
3. How and when do I take these medications? Are there any side effects?
4. Will they react with one another?
5. What should I do if I notice side effects?
6. How long do I have to take these medications?
7. What if I want to become pregnant? How will my medications or my condition affect my pregnancy, my baby and the safety of my nursing my baby?
8. Would I benefit from counseling?
9. How can I keep my sleeping patterns regular?
10. How can I keep my sleep patterns as regular as possible with a new baby?
11. What should I do if I begin to have trouble sleeping or waking up?
12. Other than medication, counseling, and attention to my sleep-wake cycle, what other things could I do to increase my chances of staying well?

Key Q&A

Organizations and Support

For information and support on coping with Bipolar Disorder, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Child and Adolescent Psychiatry (AACAP)
Website: https://www.aacap.org
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016
Phone: 202-966-7300

American Association for Geriatric Psychiatry (AAGP)
Website: https://www.gmhfonline.org
Address: 6728 Old McLean Village Drive
McLean, VA 22101
Phone: 703-556-9222
Email: main@aagponline.org

American Psychological Association
Website: https://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1-800-374-2721
Phone: 202-336-5500

Association for Behavioral and Cognitive Therapies (ABCT)
Website: https://www.abct.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212 647-1890

Bazelon Center
Website: https://www.bazelon.org
Address: The Bazelon Center for Mental Health Law
1101 15th Street NW Suite 1212
Washington, DC 20005
Phone: 202-467-5730
Email: info@bazelon.org

Depression and Bipolar Support Alliance (DBSA)
Website: https://www.dbsalliance.org
Address: 730 N. Franklin Street, Suite 501
Chicago, IL 60610-7224
Hotline: 1-800-826-3632
Email: info@dbsalliance.org

Federation of Families for Children's Mental Health
Website: https://www.ffcmh.org
Address: 9605 Medical Center Drive, Suite 280
Rockville, MD 20850
Phone: 240-403-1901
Email: ffcmh@ffcmh.org

Mental Health America
Website: https://www.mentalhealthamerica.net
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722

National Alliance on Mental Illness (NAMI)
Website: https://www.nami.org
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
Phone: 703-524-7600

National Institute of Mental Health
Website: https://www.nimh.nih.gov
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513
Email: nimhinfo@nih.gov

National Mental Health Consumers' Self-Help Clearinghouse
Website: https://www.mhselfhelp.org
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
Hotline: 1-800-553-4539
Phone: 215-751-1810
Email: info@mhselfhelp.org

SAMHSA's National Mental Health Information Center
Website: https://www.mentalhealth.gov
Address: P.O. Box 2345
Rockville, MD 20847
Hotline: 1-800-789-2647
Phone: 240-221-4021

Screening for Mental Health (SMH)
Website: https://www.mentalhealthscreening.org
Address: One Washington Street, Suite 304
Wellesley Hills, MA 02481
Phone: 781-239-0071
Email: smhinfo@mentalhealthscreening.org

Books

Why Am I Up, Why Am I Down? Understanding Bipolar Disorder
by Roger Granet, Elizabeth Ferber

50 Signs of Mental Illness: A Guide to Understanding Mental Health
by Dr. James Whitney Hicks

Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression--The Essential Guide to Recognize and Treat the Mood Swings of This Increasingly Common Disorder
by Ronald R. Fieve

Spanish-language resources

Bipolar Disorder
Website: https://www.nlm.nih.gov/medlineplus/spanish/bipolardisorder.html
Address: U.S. National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Factsheet: Bipoloar Disorder in Children
Website: https://www.mentalhealthamerica.net/conditions/trastorno-bipolar-lo-que-usted-necesita-saber
Address: Mental Health America
2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722
Email: sjones@mentalhealthamerica.net