What is bipolar disorder?
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.
Bipolar disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25.1 Some people have their first symptoms during childhood, while others may develop symptoms late in life.
Bipolar disorder is not easy to spot when it starts. The symptoms may seem like separate problems, not recognized as parts of a larger problem. Some people suffer for years before they are properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.
What are the symptoms of bipolar disorder?
People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.
Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania.
A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. Sometimes symptoms are so severe that the person cannot function normally at work, school, or home.
Symptoms of bipolar disorder are described below.
Symptoms of mania or a manic episode include:
Symptoms of depression or a depressive episode include:
A long period of feeling "high," or an overly happy or outgoing mood
Extremely irritable mood, agitation, feeling "jumpy" or "wired."
Talking very fast, jumping from one idea to another, having racing thoughts
Being easily distracted
Increasing goal-directed activities, such as taking on new projects
Having an unrealistic belief in one's abilities
Behaving impulsively and taking part in a lot of pleasurable,
high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.
A long period of feeling worried or empty
Loss of interest in activities once enjoyed, including sex.
Feeling tired or "slowed down"
Having problems concentrating, remembering, and making decisions
Being restless or irritable
Changing eating, sleeping, or other habits
Thinking of death or suicide, or attempting suicide.
In addition to mania and depression, bipolar disorder can cause a range of moods. One side of the scale includes severe depression, moderate depression, and mild low mood. Moderate depression may cause less extreme symptoms, and mild low mood is called dysthymia when it is chronic or long-term. In the middle of the scale is normal or balanced mood.
At the other end of the scale are hypomania and severe mania. Some people with bipolar disorder experience hypomania. During hypomanic episodes, a person may have increased energy and activity levels that are not as severe as typical mania, or he or she may have episodes that last less than a week and do not require emergency care. A person having a hypomanic episode may feel very good, be highly productive, and function well. This person may not feel that anything is wrong even as family and friends recognize the mood swings as possible bipolar disorder. Without proper treatment, however, people with hypomania may develop severe mania or depression.
During a mixed state, symptoms often include agitation, trouble sleeping, major changes in appetite, and suicidal thinking. People in a mixed state may feel very sad or hopeless while feeling extremely energized.
Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, psychotic symptoms for a person having a manic episode may include believing he or she is famous, has a lot of money, or has special powers. In the same way, a person having a depressive episode may believe he or she is ruined and penniless, or has committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes wrongly diagnosed as having schizophrenia, another severe mental illness that is linked with hallucinations and delusions.
People with bipolar disorder may also have behavioral problems. They may abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. At first, it's not easy to recognize these problems as signs of a major mental illness.
How is bipolar disorder diagnosed?
The first step in getting a proper diagnosis is to talk to a doctor, who may conduct a physical examination, an interview, and lab tests. Bipolar disorder cannot currently be identified through a blood test or a brain scan, but these tests can help rule out other contributing factors, such as a stroke or brain tumor. If the problems are not caused by other illnesses, the doctor may conduct a mental health evaluation. The doctor may also provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.
The doctor or mental health professional should conduct a complete diagnostic evaluation. He or she should discuss any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professionals should also talk to the person's close relatives or spouse and note how they describe the person's symptoms and family medical history.
People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania.17 Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depressive disorder, which is also called unipolar depression. Unlike people with bipolar disorder, people who have unipolar depression do not experience mania. Whenever possible, previous records and input from family and friends should also be included in the medical history.
How is bipolar disorder treated?
To date, there is no cure for bipolar disorder. But proper treatment helps most people with bipolar disorder gain better control of their mood swings and related symptoms. This is also true for people with the most severe forms of the illness.
Because bipolar disorder is a lifelong and recurrent illness, people with the disorder need long-term treatment to maintain control of bipolar symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity.
Bipolar disorder can be diagnosed and medications prescribed by people with an M.D. (doctor of medicine). Usually, bipolar medications are prescribed by a psychiatrist. In some states, clinical psychologists, psychiatric nurse practitioners, and advanced psychiatric nurse specialists can also prescribe medications. Check with your state's licensing agency to find out more.
Not everyone responds to medications in the same way. Several different medications may need to be tried before the best course of treatment is found.
Keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events can help the doctor track and treat the illness most effectively. Sometimes this is called a daily life chart. If a person's symptoms change or if side effects become serious, the doctor may switch or add medications.
Some of the types of medications generally used to treat bipolar disorder are listed on the next page. Information on medications can change. For the most up to date information on use and side effects contact the U.S. Food and Drug Administration (FDA).
Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods.
These medications are commonly used as mood stabilizers in bipolar disorder:
- Lithium (sometimes known as Eskalith or Lithobid) was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
- Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for treating mania, is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder.23, 24 Also see the section in this booklet, "Should young women take valproic acid?"
- More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for maintenance treatment of bipolar disorder.
- Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.
- Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.
Lithium and Thyroid Function
People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people.22 Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.
Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.
Should young women take valproic acid?
Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20.25, 26 PCOS causes a woman's eggs to develop into cysts, or fluid filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle, and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid.27 Young girls and women taking valproic acid should be monitored carefully by a doctor.
Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional" or "first-generation" antipsychotics.
Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.28 Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.
Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.
Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.
Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.
Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.29 To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.
Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.30
Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.
Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.
In addition to medication, psychotherapy, or "talk" therapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families.
Some psychotherapy treatments used to treat bipolar disorder include:
- Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
- Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication and problem-solving.
- Interpersonal and social rhythm therapy helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
Psychoeducation teaches people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.
A licensed psychologist, social worker, or counselor typically provides these therapies. This mental health professional often works with the psychiatrist to track progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. As with medication, following the doctor's instructions for any psychotherapy will provide the greatest benefit.
Electroconvulsive Therapy (ECT)—For cases in which medication and/or psychotherapy does not work, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to feel better with other treatments.
Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.
Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes, but is generally not a first-line treatment.
ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.
Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, the doctor may suggest a change in medications. If the problems still continue, the doctor may prescribe sedatives or other sleep medications.
People with bipolar disorder should tell their doctor about all prescription drugs, over-the-counter medications, or supplements they are taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.
In general, there is not much research about herbal or natural supplements. Little is known about their effects on bipolar disorder. An herb called St. John's wort (Hypericum perforatum), often marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar disorder.4St. John's wort can also make other medications less effective, including some antidepressant and anticonvulsant medications.46 Scientists are also researching omega-3 fatty acids (most commonly found in fish oil) to measure their usefulness for long-term treatment of bipolar disorder. Study results have been mixed.48 It is important to talk with a doctor before taking any herbal or natural supplements because of the serious risk of interactions with other medications.
Information taken from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.