Bipolar disorder

Manic depression; Bipolar affective disorder

Bipolar disorder is a condition in which people go back and forth between periods of a very good or irritable mood and depression. The "mood swings" between mania and depression can be very quick.

Causes, incidence, and risk factors

Bipolar disorder affects men and women equally. It usually starts between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.

Types of bipolar disorder:

• People with bipolar disorder type I have had at least one manic episode and periods of major depression. In the past, bipolar disorder type I was called manic depression.
• People with bipolar disorder type II have never had full mania. Instead they experience periods of high energy levels and impulsiveness that are not as extreme as mania (called hypomania). These periods alternate with episodes of depression.
• A mild form of bipolar disorder called cyclothymia involves less severe mood swings. People with this form alternate between hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be wrongly diagnosed as having depression.

In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people with bipolar disorder:

• Life changes such as childbirth
• Medications such as antidepressants or steroids
• Periods of sleeplessness
• Recreational drug use

Symptoms

The manic phase may last from days to months. It can include the following symptoms:

• Easily distracted
• Little need for sleep
• Poor judgment
• Poor temper control
• Reckless behavior and lack of self control
• Binge eating drinking, and/or drug use
• Poor judgment
• Sex with many partners (promiscuity)
• Spending sprees
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• Very elevated mood
• Excess activity (hyperactivity)
• Increased energy
• Racing thoughts
• Talking a lot
• Very high self-esteem (false beliefs about self or abilities)
• Very involved in activities
• Very upset (agitated or irritated)

These symptoms of mania occur with bipolar disorder I. In people with bipolar disorder II, the symptoms of mania are similar but less intense.

The depressed phase of both types of bipolar disorder includes the following symptoms:

• Daily low mood or sadness
• Difficulty concentrating, remembering, or making decisions
• Eating problems
• Loss of appetite and weight loss
• Overeating and weight gain
• Fatigue or lack of energy
• Feeling worthless, hopeless, or guilty
• Loss of pleasure in activities once enjoyed
• Loss of self-esteem
• Thoughts of death and suicide
• Trouble getting to sleep or sleeping too much
• Pulling away from friends or activities that were once enjoyed

There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances, which can make the symptoms and suicide risk worse.

Sometimes the two phases overlap. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.

Signs and tests

Many factors are involved in diagnosing bipolar disorder. The health care provider may do some or all of the following:

• Ask about your family medical history, such as whether anyone has or had bipolar disorder
• Ask about your recent mood swings and for how long you've had them
• Perform a thorough examination to look for illnesses that may be causing the symptoms
• Run laboratory tests to check for thyroid problems or drug levels
• Talk to your family members about your behavior
• Take a medical history, including any medical problems you have and any medications you take
• Watch your behavior and mood

Note: Drug use may cause some symptoms. However, it does not rule out bipolar affective disorder. Drug abuse may be a symptom of bipolar disorder.

Treatment

Periods of depression or mania return in most patients, even with treatment. The main goals of treatment are to:

• Avoid moving from one phase to another
• Avoid the need for a hospital stay
• Help the patient function as well as possible between episodes
• Prevent self-injury and suicide
• Make the episodes less frequent and severe

The health care provider will first try to find out what may have triggered the mood episode. The provider may also look for any medical or emotional problems that might affect treatment.

The following drugs, called mood stabilizers, are usually used first:

• Carbamazepine
• Valproic acid
• Lithium
• Lamotrigine
• Other anti seizure drugs may also be tried.

Other drugs used to treat bipolar disorder include:

• Antipsychotic drugs and anti-anxiety drugs (benzodiazepines) for mood problems
• Antidepressant medications can be added to treat depression. People with bipolar disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, antidepressants are only used in people who also take a mood stabilizer.

Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar disorder if it does not respond to medication. ECT uses an electrical current to cause a brief seizure while the patient is under anesthesia. ECT is the most effective treatment for depression that is not relieved with medications.

Trans cranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain. It is most often used after ECT.

Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stable and their behavior is under control.

Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the possible risks and benefits of treatment for their children.

SUPPORT PROGRAMS AND THERAPIES

Family treatments that combine support and education about bipolar disorder (psychoeducation) may help families cope and reduce the odds of symptoms returning. Programs that offer outreach and community support services can help people who do not have family and social support.

Important skills include:

• Coping with symptoms that are present even while taking medications
• Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
• Learning to take medications correctly and how to manage side effects
• Learning to watch for the return of symptoms, and knowing what to do when they return
• Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients find the right support services, and make sure the patient takes medication correctly.

Getting enough sleep is very important in bipolar disorder. A lack of sleep can trigger a manic episode. Therapy may be helpful during the depressive phase. Joining a support group may help bipolar disorder patients and their loved ones.

• A patient with bipolar disorder cannot always tell the doctor about the state of the illness. Patients often have trouble recognizing their own manic symptoms.
• Changes in mood with bipolar disorder are not predictable. It it is sometimes hard to tell whether a patient is responding to treatment or naturally coming out of a bipolar phase.
• Treatments for children and the elderly are not well-studied.
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Expectations (prognosis)

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to make sure that mania and depression are treated as early as possible.

Some people stop taking the medication as soon as they feel better or because the mania feels good. Stopping medication can cause serious problems.

Suicide is a very real risk during both mania and depression. People with bipolar disorder or think or talk about suicide need immediate emergency attention.

Complications

Stopping medication or taking it the wrong way can cause your symptoms to come back, and lead to the following complications:

• Alcohol and/or drug abuse
• Problems with relationships, work, and finances
• Suicidal thoughts and behaviors

This illness is hard to treat. Patients, their friends, and family must know the risks of not treating bipolar disorder.

Calling your health care provider

Call your health provider or an emergency number right way if:

• You are having thoughts of death or suicide
• 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

References

1.    Beynon S, Soares-Weiser K, Woolacott N, Duffy S, Geddes JR. Pharmacological interventions for the prevention of relapse in bipolar disorder: a systematic review of controlled trials. J Psychopharmacol. 2009; 23(5):574-591.

2.    Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 420.

3.    Benazzi F. Bipolar disorder -- focus on bipolar II disorder and mixed depression. Lancet. 2007;369:935-945.

4.    Morriss RK, Faizal MA, Jones AP, Williamson PR, Bolton C, McCarthy JP. Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database Syst Rev. 2007;24;(1):CD004854  Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722. [Review Date: 3/29/2011.

Reviewed by: Fred K. Berger, MD, Addiction and Forensic Psychiatrist, Scripps Memorial Hospital, La Jolla, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.