Bipolar disorder (manic depressive illness or manic depression)

What is it?

Bipolar disorder, which used to be called manic depressive illness or manic depression, is a mental disorder characterized by wide mood swings from high (manic) to low (depressed).

The expert view of bipolar disorder will continue to evolve, but it is now commonly divided into two subtypes (bipolar I and bipolar II) based on the dividing line between mania and hypomania described above.Periods of high or irritable mood are called manic episodes. The person becomes very active, but in a scattered and unproductive way, sometimes with painful or embarrassing consequences. Examples are spending more money than is wise or getting involved in sexual adventures that are regretted later. A person in a manic state is full of energy or very irritable, may sleep far less than normal, and may dream up grand plans that could never be carried out. The person may develop thinking that is out of step with reality -- psychotic symptoms -- such as false beliefs (delusions) or false perceptions (hallucinations). During manic periods, a person may run into trouble with the law. If a person has milder symptoms of mania and does not have psychotic symptoms, it is called "hypomania" or a hypomanic episode.

• Bipolar I disorder is the classic form where a person has had at least one manic episode.
• In bipolar II disorder, the person has never had a manic episode, but has had at least one hypomanic episode and at least one period of significant depression.

Most people who have manic episodes also experience periods of depression. In fact, there is some evidence that the depression phase is much more common than periods of mania in this illness. Bipolar depression can be much more distressing than mania and, because of the risk of suicide, is potentially more dangerous.

A disorder that is classified separately, but is closely related to bipolar disorder, is cyclothymia. People with this disorder fluctuate between hypomania and mild or moderate depression without ever developing a full manic or depressive episode.

Some people with bipolar disorder switch frequently or rapidly between manic and depressive symptoms, a pattern that is often called "rapid cycling." If manic and depressive symptoms overlap for a period, it is called a "mixed" episode. During such periods, it may be difficult to tell which mood -- depression or mania -- is more prominent.

People who have had one manic episode most likely will have others if they do not seek treatment. The illness tends to run in families. Unlike depression, in which women are more frequently diagnosed, bipolar disorder happens nearly equally in men and women.

Since bipolar disorder can come in so many forms, it is difficult to determine its prevalence. Depending on how they define the disorder, researchers estimate that bipolar disorder occurs in up to 4% of the population. When a particularly broad definition is used, the estimate can be even higher.

The most important risk of this illness is the risk of suicide. People who have bipolar disorder are also more likely to struggle with alcohol use or other substance use.

Symptoms

During the manic phase, symptoms can include:

• High level of energy and activity
• Irritable mood
• Decreased need for sleep
• Exaggerated, puffed-up self-esteem ("grandiosity")
• Rapid or "pressured" speech
• Rapid thoughts
• Tendency to be easily distracted
• Increased recklessness
• False beliefs (delusions) or false perceptions (hallucinations)

During elated moods, a person may have delusions of grandeur, while irritable moods are often accompanied by paranoid or suspicious feelings.

During a depressive period, symptoms may include:

• Distinctly low or irritable mood
• Loss of interest or pleasure
• Eating more or less than normal
• Gaining or losing weight
• Sleeping more or less than normal
• Appearing slowed or agitated
• Fatigue and loss of energy
• Feeling worthless or guilty
• Poor concentration
• Indecisiveness
• Thoughts of death, suicide attempts or plans

Diagnosis

Since there are no medical tests to establish this diagnosis, a mental health professional diagnoses bipolar disorder based on a person's history and symptoms. The diagnosis is based not just on the current symptoms, but also take into account the problems and symptoms that have occurred through a person's life.

People with bipolar disorder are more likely to seek help when they are depressed than when manic or hypomanic. It is important to tell your doctor about any history of manic symptoms (like those described above). If a doctor prescribes an antidepressant for a person with such a history, the antidepressant could trigger a manic episode.

Because medications and other illnesses can cause symptoms of mania and depression, a psychiatrist and primary care physician must sometimes work together with other mental health professionals to evaluate the problem. For example, the course of the illness can be affected by steroid treatment or a thyroid problem.

Expected duration

If left untreated, a first episode of mania lasts an average of two to four months and a depressive episode up to eight months or longer, but there can be many variations. If the person does not get treatment, episodes tend to become more frequent and last longer as time passes.

Prevention

There is no way to prevent bipolar disorder, but treatment can prevent manic and depressive episodes or at least reduce their intensity or frequency. Also, if you are able to talk to your health care provider as early as you can about milder forms of the disorder, you may be able to ward off more severe forms. Unfortunately, worries about stigma often stop people from mentioning their concerns to their primary care doctor or other caregiver.

Treatment

A combination of medication and talk therapy is most helpful. Often more than one medication is needed to keep the symptoms in check.

Mood Stabilizers

The best-known and oldest mood stabilizer is lithium carbonate, which can reduce the symptoms of mania and prevent them from returning. Although it is one of the oldest medicines used in psychiatry, and although many other drugs have been introduced in the meantime, much evidence shows that it is still the most effective of the available treatments.

Lithium also may reduce the risk of suicide.

If you take lithium, you have to have periodic blood tests to make sure the dose is high enough, but not too high. Side effects include nausea, diarrhea, frequent urination, tremor (shaking) and diminished mental sharpness. Lithium can cause some minor changes in tests that show how well your thyroid, kidney and heart are functioning. These changes are usually not serious, but your doctor will want to know what your blood tests show before you start taking lithium. You will have to get an electrocardiogram (EKG), thyroid and kidney function tests, and a blood test to count your white blood cells.

For many years, antiseizure medications (also called "anticonvulsants") have also been used to treat bipolar disorder. The most common in use are valproic acid (Depakote) and lamotrigine (Lamictal). A doctor may also recommend treatment with other antiseizure medications — gabapentin (Neurontin), topiramate (Topamax), or oxcarbazepine (Trileptal).

Some people tolerate valproic acid better than lithium. Nausea, loss of appetite, diarrhea, sedation and tremor (shaking) are common when starting valproic acid, but, if these side effects occur, they tend to fade over time. The medication also can cause weight gain. Uncommon but serious side effects are damage to the liver and problems with blood platelets (platelets are necessary for the blood to clot).

Lamotrigine (Lamictal) may or may not be effective for treating a depression that is active, but some studies show that it is more effective than lithium for preventing the depression of bipolar disorder. (Lithium, however, is more effective than lamotrigine in preventing mania.) The most troubling side effect of lamotrigine is a severe rash -- in rare cases, the rash can become dangerous. To minimize the risk, usually the doctor will recommend a low dose to start and increase dosages very slowly. Other common side effects include nausea and headache.

Lithium and valproic acid should be avoided during the first three months of pregnancy, because they are known to cause birth defects. In some cases, however, the return of manic or depressive symptoms could present a more significant risk to the fetus than medicines would. Therefore, it is important to discuss the various treatment options and risks with your doctor.

For valproic acid, lamotrigine, and other antiseizure medications, there is a small risk that suicidal thoughts or behaviors will increase. The risk is quite low. However, anyone being treated with psychotropic medications should report to their doctor immediately if new or more intense symptoms occur — symptoms of depression, changes in mood, thoughts of suicide or any self-destructive behavior.

Antipsychotic Medications

In recent years, studies have shown that some of the newer antipsychotic medications can be effective for controlling bipolar disorder symptoms. Side effects often have to be balanced against the helpful effects of these drugs:

• Olanzapine: sleepiness, dry mouth, dizziness and weight gain.
• Risperidone: sleepiness, restlessness and nausea.
• Quetiapine: dry mouth, sleepiness, weight gain and dizziness.
• Ziprasidone: sleepiness, dizziness, restlessness, nausea and tremor.
• Aripiprazole: nausea, stomach upset, sleepiness (or sleeplessness) or restlessness.
• Asenapine: sleepiness, restlessness, tremor, stiffness, dizziness, mouth or tongue numbness.

Some of these new antipsychotic drugs can increase the risk of diabetes and cause problems with blood lipids. Olanzapine is associated with the greatest risk. With risperidone, quetiapine and asenapine, the risk is moderate. Ziprasidone and aripiprazole cause minimal weight change and not as much risk of diabetes.

Antianxiety Medications

Antianxiety medications such as lorazepam (Ativan) and clonazepam (Klonopin) sometimes are used to calm the anxiety and agitation associated with a manic episode.

Antidepressants

The use of antidepressants in bipolar disorder is controversial. Many psychiatrists avoid prescribing antidepressants because of evidence that they may trigger a manic episode or induce a pattern of rapid cycling. Once a diagnosis of bipolar disorder is made, therefore, many psychiatrists try to treat the illness using mood stabilizers.

Some studies, however, continue to show the value of antidepressant treatment to treat low mood, usually when a mood stabilizer or antipsychotic medication is also being prescribed.

There are so many different forms of bipolar disorder that it is impossible to establish one general rule. Using an antidepressant alone may be justified in some cases, especially if other treatments have not given relief. This is another area where the pros and cons of treatment should be reviewed carefully with your doctor.

Psychotherapy

Talk therapy (psychotherapy) is important in bipolar disorder as it provides education and support and helps a person come to terms with the illness. Therapy can help between mood episodes to help people recognize the early symptoms follow a course of treatment more closely. For depression, psychotherapy can help people develop coping strategies. Family education helps family members communicate and solve problems. When families are kept involved, patients adjust more easily, are more likely to make good decisions about their treatment and have a better quality of life. They have fewer episodes of illness, fewer days with symptoms and fewer admissions to the hospital.

Psychotherapy helps a person deal with painful consequences, practical difficulties, losses or embarrassment stemming from manic behavior. A number of psychotherapy techniques may be helpful depending on the nature of the person's problems. Cognitive behavioral therapy helps a person recognize patterns of thinking that may keep him or her from managing the illness well. Psychodynamic, insight-oriented or interpersonal psychotherapy can help to sort out conflicts in important relationships or explore the history that has contributed to current problems.

When to call a professional

A manic episode is a serious problem requiring immediate treatment. However, a person in a manic episode may not be aware that he or she is sick. Some people with this illness may have to be brought to a hospital, even when they don't want to go. Many patients are grateful later when they learn that they avoided a loss or embarrassment and were pushed to get the treatment they needed.

If you observe manic symptoms in a person who is unaware of his or her condition, arrange a consultation with a health care provider. Treatment can prevent symptoms from accelerating, and can improve a person's progress and functioning over time.

If you notice worsening symptoms of depression in a person with known bipolar disorder, have a low threshold to connect them with their doctor, as they are at elevated risk of suicide.

Prognosis

The natural course of bipolar disorder varies. Without treatment, manic and depressive episodes tend to occur more frequently as people get older, causing increasing problems in relationships or at work. It often takes persistence to find the most helpful drug combination that has the fewest side effects. Treatment can be very effective; many of the symptoms can be diminished and in some cases eliminated. As a result, many people with bipolar disorder are able to function completely normally and have highly successful lives.

Additional info

American Foundation for Suicide Prevention
http://www.afsp.org

American Psychological Association
http://www.apa.org/

National Alliance for the Mentally Ill
http://www.nami.org/

Mental Health America
http://www.mentalhealthamerica.org/