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).

Periods of high or irritable moods 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 a "hypomanic" episode.

Bipolar disorder is now divided into two subtypes (bipolar I and bipolar II). 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 severe depression. Bipolar II disorder may be more common than Bipolar I. A third disorder, closely related to bipolar disorder, is cyclothymia — people with this disorder fluctuate between hypomania and mild or moderate depression.

The vast majority of people who have manic episodes also experience periods of depression. If manic and depressive symptoms overlap for a period, it is called a "mixed" episode. In some people, moods alternate rapidly or it is difficult to tell which mood — depression or mania — is more prominent.

People who have 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. Bipolar I and II disorders occur in up to 4% of the population.

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

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
• 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

A mental health professional diagnoses bipolar disorder based on a person's medical history and symptoms. The diagnosis is based not just on the current symptoms, but also on understanding the person's problems and symptoms in the past.

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 healthcare provider 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, it's important that a psychiatrist and primary care physician work together. For example, a manic episode can be triggered by steroids and by antidepressant medication.

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 episodes from returning. Also, if you are able to talk to your healthcare provider as early as you can about milder forms of the disorder, you may be able to prevent more severe forms. Unfortunately, worries about stigma often stop people from mentioning their concerns to their primary care doctor.

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 class of medications known as mood stabilizers is the primary treatment for bipolar disorder.

The best known and oldest mood stabilizer is lithium carbonate, which can ease manic episodes and prevent them from returning. Lithium may reduce the risk of suicide. If you take lithium, you have to have periodic blood tests to make sure you are taking enough, but not too much. 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 look like 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, anticonvulsant medications, which are used to treat seizures, have also been used to treat bipolar disorder. The most common in use are valproic acid (Depakote), lamotrigine (Lamictal) and carbamazepine (Tegretol).

Valproic acid may have side effects that are more manageable than those of lithium. Nausea, loss of appetite, diarrhea, sedation and tremor (shaking) are common at the beginning of treatment, but these side effects 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, which help blood to clot.

Lamotrigine (Lamictal) has been used more frequently in recent years, because some studies show it to be more effective than lithium in preventing the depressive episodes 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, your provider is likely to start with a low dose and increase dosages very slowly. Other common side effects include nausea and headache.

Carbamazepine (Tegretol) is another anticonvulsant used to treat bipolar disorder. Its most common side effects are drowsiness, dizziness, blurred vision, nausea and vomiting. These can often be avoided by increasing the dose gradually. There are some serious but rare side effects, including liver inflammation, suppression of red and white blood cell counts, and severe skin rashes.

Lithium, valproate acid and carbamazepine should not be used during the first three months of pregnancy, because they are known to cause birth defects.

Antipsychotic Medications

In recent years, studies have shown that some of the newer antipsychotic medications can be effective in controlling bipolar disorder symptoms. Side effects are 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.

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 and quetiapine, 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

Antidepressants often are used to treat the depressive phase of the disorder, but they can trigger a manic episode or induce a pattern of rapid cycling. Therefore, many psychiatrists try to avoid using an antidepressant until other approaches have been tried. It is also generally not recommended to use an antidepressant alone — usually a mood stabilizer or antipsychotic medication is given with an antidepressant.

There are so many different forms bipolar disorder that using an antidepressant alone may be justified in some cases.

Psychotherapy

Talk therapy (psychotherapy) is important, as it provides education and support and helps a person come to terms with the illness. Recent research has demonstrated that it helps patients when family members learn about the illness and improve their communication and problem-solving skills. With this kind of help, patients adjust more easily, are more likely to take medication as prescribed and have a better quality of life. They have fewer episodes of illness, fewer days with symptoms and fewer admissions to the hospital.

Psychotherapy is also helpful if the person has to deal with painful consequences, practical difficulties or embarrassment stemming from manic behavior. The person may have suffered some losses either in relationships or at work. A number of psychotherapy techniques may be helpful depending on the origins of the person's problems. Cognitive behavioral therapy helps a person recognize patterns of thinking that keep you from managing your illness well. Psychodynamic, insight-oriented or interpersonal psychotherapy can help to sort out conflicts in important relationships or explore the history behind the symptoms.

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 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.

A person with known bipolar disorder who exhibits symptoms of worsening depression should promptly contact his or her mental health provider.

Prognosis

The natural course of the illness varies, but without treatment, the manic and depressive episodes tend to occur more frequently as people get older. A significant percentage of people with this disorder continue to have symptoms between episodes, as well as problems in relationships or at work. With treatment, many of these problems can be diminished and in some cases eliminated.

Additional Info

American Foundation for Suicide Prevention

120 Wall St.

22nd Floor

New York, NY 10005

Phone: (212) 363-3500

Toll-Free: (888) 333-2377

Fax: (212) 363-6237

E-Mail: inquiry@afsp.org

http://www.afsp.org/index-1.htm

American Psychiatric Association

1400 K St., NW

Washington, DC 20005

Toll-Free: (888) 357-7924

Fax: (202) 682-6850

E-Mail: apa@psych.org

http://www.psych.org/

American Psychological Association

750 First St., NE

Washington, DC 20002-4242

Phone: (202) 336-5510

Toll-Free: (800) 374-2721

TTY: (202) 336-6123

Fax: (202) 336-5500

http://www.apa.org/

National Alliance for the Mentally Ill

Colonial Place Three

2107 Wilson Blvd.

Suite 300

Arlington, VA 22201-3042

Phone: (703) 524-7600

Toll-Free: (800) 950-6264

http//www.nami.org/

Depression and Bipolar Support Alliance (DBSA)

730 North Franklin

Suite 501

Chicago, IL 60610

Toll-Free: (800) 826-3632

http://www.ndmda.org/

National Mental Health Association

2001 N. Beauregard St., 12th Floor

Alexandria, VA 22311

Phone: (703) 684-7722

Fax: (703) 684-5968

Toll-Free: (800) 969-6642

TTY: (800) 433-5959

http://www.nmha.org/

Depression and Related Affective Disorders Association (DRADA)

2330 West Joppa Rd.

Suite 100

Lutherville, MD 21093

Phone: (410) 583-2919

E-Mail: drada@jhmi.edu

http://www.drada.org/