Bipolar disorder, previously known as manic depression, is a serious mental health disorder characterized by periods of excitability or euphoria (mania or hypomania) alternating with periods of severe depression. During manic periods, a person with bipolar disorder may be overly impulsive and energetic, with an exaggerated sense of self. The depressive phase brings overwhelming feelings of anxiety, low self-worth, and suicidal thoughts or actions. These changes in mood and behavior can be unpredictable.
These periods of mood swings may last week or months, and can interfere with work, school, family life and relationships. If left untreated, bipolar disorder has a high risk of suicide. However, medication, psychological counseling, group support, and patient education can provide good outcomes in bipolar disorder. It is a lifelong illness that requires ongoing treatment.
Who gets bipolar disorder?
Neuropsychiatric disorders as a whole are the leading cause of disability in the U.S. Bipolar disorder affects approximately 5.7 million American adults, or about 2.5-4%% of the U.S. adult population age 18 and older in a given year. Roughly 1% to 4% of people worldwide have bipolar disorder.
Bipolar disorder affects men and women equally and usually appears between the ages of 15 and 30. The mean age of onset is 18 to 20 years. People older than 65 years of age are not usually first diagnosed with bipolar disorder.
Risk factors
Bipolar disorder is a result of disturbances in the areas of the brain that regulate mood. The exact cause is unknown, but it occurs more often in first-degree relatives of people with bipolar disorder (such as a sibling or parent), and may have a genetic component. It may result in an imbalance of chemicals in the brain, and medications can help to reset these imbalances.
Factors that can lead to, trigger, or worsen a bipolar event include:
- drug or alcohol abuse
- periods of high stress, such as a death of a loved one
- other traumatic event.
Most patients who have bipolar disorder have another comorbid psychiatric disorder, such as anxiety, substance use disorders, attention deficit hyperactivity disorder (ADHD), or post traumatic stress disorder (PTSD).
Types of bipolar disorder
The primary types of bipolar disorder, based on DSM-5 criteria, include:
Bipolar I Disorder: People with bipolar I disorder have had at least one fully manic episode with periods of major depression and hypomania usually occurring during their course. Periods of psychosis (losing touch with reality) can occur in the manic phase. A severe manic episode may involve suicidal or violent behavior, aggressiveness, psychosis (delusions or hallucinations), and putting others at risk of harm. Bipolar I disorder has also been referred to as manic-depression.
Bipolar II Disorder: People with bipolar disorder II do not experience full-fledged mania. Instead they experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of major depressive disorder. Psychosis does not occur in hypomania. Patients with bipolar II disorder may be incorrectly diagnosed with just major depression because the hypomania period is often not easily recognized, or patients only seek help in the depressive phase.
Symptoms for both bipolar I and bipolar II may be mixed, with manic and depressive symptoms occurring at the same time. Rapid-cycling between symptoms can occur, as well as catatonia (immobility, purposeless or fast movements, lack of speech). Anxious distress may also be a component of either bipolar I or II, with symptoms of depression with abnormal restlessness, with worry about events and loss of control.
Cyclothymic Disorder (cyclothymia): A form of bipolar disorder called cyclothymia involves many periods of more mild hypomania and depression, with less-severe mood swings. These symptoms occur over a period of at least 2 years, when patients have symptoms at least 50% of the time and are not symptom-free for any longer than 2 months. As with bipolar II disorder, people with cyclothymia may also be misdiagnosed as having depression alone.
Symptoms
Mania or hypomania
Typically at least 3 to 4 of the following symptoms must be present for at least a week, every day and most of the day (unless hospitalized), for the diagnosis of mania or hypomania. The manic phase may last from days to months and can include the following symptoms:
- elevated mood, euphoria
- racing thoughts
- hyperactivity, excessive, loud or pressure speech
- increased energy
- lack of self-control
- inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
- over-involvement in activities
- poor judgement, reckless behavior, impulsive, "super-powers"
- spending sprees
- binge eating, drinking, and/or drug use
- sexual promiscuity
- impaired judgment
- tendency to be easily distracted
- little need for sleep (feel energetic or "wired" even though only few hours of sleep, or no sleep at all)
- easily agitated or irritated, anger
- poor temper control
Manic symptoms in bipolar I disorder can occur abruptly and may progress rapidly over several days. Hospitalization is often required. It may takes weeks to several months for symptoms to resolve.
In people with bipolar II disorder, hypomanic episodes involve similar symptoms that are less severe; however hypomania can still occur in bipolar I disorder. Hypomanic symptoms last at least four days in a row, for most of the day. Hypomania is less intense and does not last as long as mania, and does not require hospitalization or involve psychosis. Psychosocial function is typically improved in these patients.
Bipolar major depression
The depressed phase of both bipolar I disorder and bipolar II disorder involves symptoms similar to major depressive disorder, and includes at least 5 of the following symptoms occurring in the same 2-week period (with at least one symptom either 1. depressed mood or 2. loss of interest or pleasure). The symptoms lead to significant impairment in social functioning or ability to work. These symptoms are not specifically due to another medical condition or substance abuse.
- persistent sadness, feeling empty, low self-esteem, tearfulness (in children and teenagers, depression may appear as anger or irritability)
- significantly diminished interest or pleasure in all, or most, activities for most of nearly every day
- fatigue or lethargy almost every day
- sleep disturbances
- excessive sleepiness (hypersomnia)
- inability to sleep (insomnia)
- eating disturbances
- loss of appetite and weight loss (when not dieting)
- overeating and weight gain (>5% of body weight in a month)
- in children, failure to meet expected weight gain
- restlessness or agitation most days and observed by others
- feelings of worthlessness, hopelessness and/or guilt nearly every day; may be delusional
- difficulty concentrating, remembering, or making decisions nearly every day
- recurrent thoughts of death (not just a fear of dying), or thinking about or planning for a suicide.
The "mood swings" in bipolar disorder that vary between mania and depression can be very abrupt and disabling. There may be an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state. A diagnosis may also be described as rapid-cycling pattern, occurring as 4 or more episodes (mania, hypomania, or major depressive disorder) during a 12-month period.
Seasonal changes can affect bipolar disorder, too. For example, spring and summer can aggravate manic symptoms, while winter can bring on more pronounced depression.
There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances in either the manic or the depressive phase and this can worsen the symptoms. Over 60% of people with bipolar disorder abuse alcohol or drugs.
Diagnosis
Diagnosis of bipolar disorder is important, as those who have experienced one manic episode are at risk of another episode without treatment. In order to make a diagnosis of bipolar disorder, your physician will consider a number of factors in addition to your symptoms.
Symptoms and diagnosis of bipolar disorder is aided with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published by the American Psychiatric Association, or the World Health Organization's International Classification of Diseases-10th Revision (ICD-10).
Your primary care doctor may refer you to work directly with a psychiatrist. Your doctor may:
- Take a history: ask about medical history, including any medical problems you have and any medications you take, and request lab tests. Your doctor may ask about your family medical and psychiatric medical history, particularly for bipolar disorder. With your permission, your provider may speak with your family members to discuss their observations about your behavior.
- Perform a physical exam: perform a thorough examination to identify or rule out physical causes of the symptoms you are experiencing.
- Make a psychiatric assessment: ask about your recent mood swings, how often they occur and how long you've experienced them; you may be asked to fill out a psychological self-assessment questionnaire. You might be questioned about any history of suicide attempts, hallucinations or other psychotic features of your mood changes.
- Request a mood chart: you may be asked to keep a daily chart of mood and sleep patterns.
Treatment of bipolar disorder
Medication treatment is the backbone of therapy for bipolar disorder. It is recommended in all phases of the condition, and is effective in many people to gain control of their mood swings. Adding psychotherapy (talk therapy) is also usually recommended, and may be helpful in the maintenance phase. Hospitalization may be required in the most severe cases until drug therapy takes effects.
The goals of bipolar disorder treatment are:
- to reduce symptoms
- prevent new mood episodes
- lower the risk of self-harm and suicide
- allow the patient to integrate back into family, work, and social functioning.
Common drug classes used to treat bipolar disorder are the mood stabilizers including anti-seizure medications, the atypical antipsychotics, and combinations of these medications.
Successful drug therapy used in the initial treatment of the acute mood disorder is usually recommended to be continued as maintenance therapy, if well-tolerated. Lithium is the most effective long‑term treatment for bipolar disorder, according to multiple studies. Most of these medications are available in the generic form and are affordable.
Relapses can occur frequently in bipolar disorder. Some patients may require a combination of medications for treatment, both in the short-term and long-term, if single therapy is not fully effective. It may be necessary to try several medications to find the one that best treats symptoms with the lowest risk for side effects.
The choice of medication depends on effectiveness and safety, a patient's past response to medications and side effects, other current medical illnesses and medications, and cost issues for patients. If female, childbearing potential may play a role in the choice of therapy.
Treatment will typically allow patients to regain restful sleep patterns, which can aid in keeping a stable mood.
Drug Interactions
Drug interactions can be a common problem with bipolar disorder therapy, and drug interaction reviews with a doctor or pharmacist should be employed with initial treatment and with any drug changes.
- Patients should report all drug therapy, including OTCs, vitamins and herbal supplements, to their doctor and pharmacist.
- Some medications such as carbamazepine can lower the effectiveness of birth control, and a non-hormonal form of birth control, such as condoms or an IUD, may be required.
- Birth control can also lower the effectiveness of some medications used for bipolar disorder, such as divalproex sodium or lamotrigine.
Table 1. Mood Stabilizers Used in Bipolar Disorder
|
Generic Name |
Brand Name(s) |
|---|---|
|
carbamazepine, carbamazepine ER |
Carbatrol, Epitol, Equetro, Tegretol, Tegretol XR |
|
divalproex sodium, valproic acid |
Depakote, Depakote ER, Depakene* |
|
lamotrigine |
Lamictal, Lamictal CD, Lamictal ODT, Lamictal XR |
|
lithium |
Eskalith*, Eskalith CR*, Lithobid, Lithonate*, Lithotabs* |
*product discontinued in the US
Bipolar disorder is often treated with mood-stabilizing medications such as lithium, divalproex sodium (valproate), and carbamazepine. Most mood stabilizers are anticonvulsants (antiepileptic drugs), with the exception of lithium. These are effective for treating both the manic and depressive phases, as well as preventing future symptoms. Anticonvulsants are linked with an increased risk for birth defects or developmental delays in pregnancy, and alternative treatments may be needed in women of childbearing potential.
Lithium, while an older drug, is still considered one of the most widely studied and effective mood stabilizers and has been shown to decrease the risk of suicide. It can be used as monotherapy or in combination with a mood stabilizer or antipsychotic. Important points to consider with lithium treatment:
- Lithium is available in many different forms - tablets, capsules, and liquid - and is usually given 2 or 3 times a day. It is available in a cost-saving generic form.
- Lithium can lead to side effects such as frequent urination, nausea, diarrhea, tremor, thirst, changes in memory and thinking, and weight gain. Take lithium with food to help decrease the nausea.
- Patients should have good kidney function while taking lithium, or they may need a lower dose. Kidney function will be monitored during treatment. Avoid dehydration.
- It requires blood tests to monitor drug levels and dose, usually every 6 to 12 months once stable.
- Thyroid and heart function may be adversely affected with long-term treatment.
- Women of childbearing potential should avoid use of lithium due to possible birth defects.
- Always check with your doctor or pharmacist for drug interactions before starting any new medication with lithium. This includes OTC drugs, vitamins and herbs.
Divalproex and lamotrigine are also common anticonvulsant mood stabilizers used for treatment. In some patients, especially those with mixed symptoms of mania and depression, or those with rapid-cycling bipolar disorder, divalproex may work better than lithium.
Valproate and lamotrigine use in women of child-bearing potential also have a risk of birth defects, and other options should usually be considered.
Side effects with mood stabilizers
Common side effects with mood stabilizers include: itching, rash, excessive thirst, frequent urination, tremor (shakiness) of the hands, nausea and vomiting, slurred speech, fast, slow, irregular, or pounding heartbeat, blackouts, changes in vision, seizures, hallucinations (seeing things or hearing voices that do not exist), loss of coordination, swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs. Side effects associated with mood stabilizers can vary from drug to drug. Check for specific side effects here.
Table 2. Atypical Antipsychotics Used in Bipolar Disorder
|
Generic Name |
Brand Name(s) |
|---|---|
|
aripiprazole |
Abilify, Abilify Maintena, Abilify MyCite |
|
asenapine |
Saphris |
|
cariprazine |
Vraylar |
|
lurasidone |
Latuda |
|
olanzapine |
Zyprexa, Zyprexa Zydis |
|
olanzapine and fluoxetine |
Symbyax |
|
quetiapine |
Seroquel, Seroquel XR |
|
risperidone |
Risperdal, Risperdal Consta, Risperdal M-Tab* |
|
ziprasidone |
Geodon |
*product discontinued in the US
Antipsychotic drugs can help a person who has lost touch with reality. They are often used initially during an acute phase of mania. Studies have also shown that some atypical antipsychotics are helpful with bipolar depression and in the maintenance phase. They can be combined with a mood stabilizer for longer term therapy.
However, metabolic side effects with atypical antipsychotic agents, such as weight gain, elevated blood sugar and cholesterol, and type 2 diabetes, can be troublesome. It is important to consider the risk versus benefit of using an antipsychotic, based upon the individual's cardiovascular health risks. Ziprasidone (Geodon), asenapine (Saphris), lurasidone (Latuda), and aripiprazole (Abilify) may have a lower risk of weight gain and type 2 diabetes, although clinicians should regularly monitor for this side effect with all antipsychotics.
The occurrence of extrapyramidal side effects (EPS) or movement disorders, and the risk for serious tardive dyskinesia is much lower with the atypical antipsychotics than with conventional, first generation antipsychotics.
Clozapine (Clozaril) is an older atypical antipsychotic and may be effective in patients who do not respond to treatment with other therapies for bipolar disorder. Regular blood testing is required due to a risk of agranulocytosis, a dangerous lowering of white blood cells that may increase the risk for infection. Clozapine may lead to agranulocytosis in roughly 1% of patients and requires frequent blood tests; for this reason, clozapine is not commonly used in bipolar disorder.
Older, first generation antipsychotics like haloperidol (Haldol), chlorpromazine (Thorazine) or perphenazine (Trilafon) are also rarely used. These agent may be linked with a higher incidence of severe movement disorders like tardive dyskinesia, which involves writhing movements of the body, lips smacking, and tongue protrusion, and may be irreversible.
A general list of possible side effects includes: drowsiness, dizziness, restlessness, weight gain, dry mouth, constipation, nausea, vomiting, blurred vision, low blood pressure, uncontrollable movements, seizures, lowered white blood cells. Side effects associated with antipsychotics can vary from drug to drug. Check for specific side effects here.
Antidepressant use in bipolar disorder
Use of antidepressants in bipolar disorder is controversial; antidepressants may trigger mania or rapid cycling in people with bipolar disorder. However, antidepressant drugs may be useful during the depressive phase in certain patients provided the antidepressants are used with a mood stabilizer or atypical antipsychotic. For example, olanzapine and fluoxetine (Symbyax) is available as a combination drug.
Patients who present acutely in a full manic or hypomanic episode should have antidepressants discontinued. Antidepressants are not recommended to be used alone in any phase of bipolar disorder
Keep in mind that people with bipolar II disorder may be misdiagnosed with depression only because they do not experience full-fledged mania or only present to their doctor in the depressive phase. If these patients take antidepressants without mood stabilizers, it can trigger a manic episode.
Benzodiazepine use in bipolar disorder
Benzodiazepine therapy may be needed in some acute manic episodes as adjunct therapy. In bipolar disorder, benzodiazepines would typically only be used short-term, if needed.
Commonly used benzodiazepines include:
- alprazolam (Xanax)
- clonazepam (Klonopin)
- lorazepam (Ativan)
- diazepam (Valium)
They may be used short-term to help with manic symptoms like agitation, insomnia, or anxiety while the mood stabilizer treatment takes effect.
Psychotherapy (talk therapy)
Psychotherapy may be a useful option when you reach the maintenance phase of treatment. Joining a support group may be particularly helpful for bipolar disorder patients and their caregivers or loved ones. Your doctor will recommend different options for counseling, an important part of your medical treatment.
Types of psychotherapy used in bipolar disorder include:
- Cognitive behavioral therapy: the goal is to change your negative pattern of thinking so you can view and respond to challenging situations more clearly
- Family-focused therapy: education about your illness with your family to allow for greater support
- Interpersonal and social rhythm therapy: used to treat the disruption in sleep patterns and social activity that is related to bipolar disorder
- Psychoeducation: activities to deliver education around bipolar disorder so you can take a more active role in your treatment
Electroconvulsive Therapy (ECT)
Electroconvulsive therapy (ECT) may be used to treat bipolar disorder, and has been found to be very effective. ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia. It is not used until medications have repeatedly failed or there some reason a patient cannot take drug therapy. For example, patients with severe mania during pregnancy may need ECT.
Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications. It can produce a quick and very effective relief from serious depression, with few side effects.
Abrupt discontinuation of treatment
Most patients will continue on a maintenance phase of medications to keep their symptoms from returning. Patients should not abruptly stop taking their bipolar disorder medication. Doing so may worsen symptoms and lead to withdrawal effects.
Patients should talk to their doctor before stopping any medical treatment. In addition, patients should tell their doctor about all prescription or over-the-counter (OTC) medications, vitamins and supplements they use, as there can be drug interactions or other concerns.
Substance abuse with bipolar disorder
Substance abuse can be a frequent concern in patients with bipolar disorder. Abusing drugs and alcohol can worsen symptoms and prevent therapy from working effectively. If you use illicit drugs or alcohol, talk to your doctor about getting help and treatment for this condition.
When to call your doctor:
- You are experiencing severe symptoms of depression or mania
- You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms
- You are experiencing serious side effects of medication
- You are female being treated for bipolar disorder and you are planning a pregnancy or find you are now pregnant
For immediate help:
- If you are in crisis, having thoughts of death or suicide, or considering suicide at this moment, tell someone right away who can help you.
- If you doctor is not available, go to the nearest hospital or call 911.
- Call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is free, available to anyone, and confidential.