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Bipolar Disorder


Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news; bipolar disorder can be treated, and people with this illness can lead full and productive lives.

More than 5.7 million American adults, or about 2.6 percent of the population age 18 and older in any given year, have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them later in life. It is often not recognized as an illness, and people may suffer for years before it is 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?


Bipolar disorder causes dramatic mood swings- from overly – “high” and/ or irritable to sad and hopeless, and then back again. These mood swings are often accompanied with severe changes in energy and behavior and are called episodes of mania and depression.

Signs and symptoms of mania (or manic episode) include:

• Increased energy, activity, and restlessness
• Excessively “high,” overly euphoric mood
• Extreme irritability
• Racing thoughts and talking very fast, jumping from one idea to another
• Overall lack of concentration
• No desire for sleep
• Unrealistic beliefs in one’s abilities and powers
• Poor judgment
• Spending sprees
• A lasting period of behavior that is different from usual
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
• Provocative, intrusive, or aggressive behavior
• Denial that anything is wrong

A manic episode is diagnosed if an elevated mood continues with 3 or more of the other symptoms most of the day, nearly every day, for one week or longer. For example, if you’re feeling irritable four additional symptoms must be present to have it classified as a manic episode.

Signs and symptoms of depression (or a depressive episode) include:

• Lasting sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest in activities that you once enjoyed, including sex
• Decreased energy, a feeling of fatigue or of being “slowed down”
• Difficulty concentrating, remembering, making decisions
• Restlessness or irritability
• Sleeping too much or not being able to sleep
• Change in appetite and/or unintended weight loss or gain
• Chronic pain or other persistent bodily symptoms that are not caused by illness or injury
• Thoughts of death or suicide, or suicidal attempts

A depressive episode is diagnosed if five or more of these symptoms last more of the day, nearly every day, for a period of 2 weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.

Sometimes, severe episodes of mania or depression include symptoms of psychosis, or psychotic symptoms. Common psychotic symptoms are hallucinations (hearing, seeing or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person’s usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect one’s extreme state of mind at the time. For example, delusions of grandiosity, such as believing that one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.

It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call “the blues”. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state.

Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.
Bipolar disorder may appear to be a problem other than mental illness- for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.

Suicide

Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide. Signs and symptoms that may accompany suicidal feelings include:

• Talking about feeling suicidal or wanting to die
• Feeling hopeless, that nothing will ever change or get better
• Feeling helpless, that nothing anyone does makes any difference
• Feeling like a burden to family and friends
• Abusing alcohol or drugs

What is the course of bipolar disorder?


Episodes of mania and depression typically occur throughout one’s life but between episodes, most people with bipolar disorder are free of symptoms yet as many as one-third have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. And when four or more episodes of illness occur within a 12-month period, a person is said to have rapid cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycle tends to develop later in the course of the illness and is more common among women than among men.

People with bipolar disorder can lead healthy and productive lives when their illness is effectively treated. Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time, a person may suffer more frequent and more severe manic and depressive episodes than those experienced when the illness first appeared. In most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Can children and adolescents have bipolar disorder?


Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness. Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youth with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

Bipolar disorder in children and adolescents can be hard to distinguish from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also my lead to such symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a medical health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialists.

What causes bipolar disorder?


Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder- rather, many factors act together to produce the illness.
Because bipolar disorder tends to run in families, researchers have been searching for specific genes- the microscopic “building blocks” of DNA inside all cells that influence how the body and mind work- through generations that many increase a person’s chance of developing the illness. But genes are no the whole story. Studies of identical twins, who share all the same genes, indicate that genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would also develop the illness, and research has shown that this is not that case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than another sibling.

How is bipolar disorder treated?


Most people with bipolar disorder- even those with the most severe forms- can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In most cases, bipolar disorder is controlled more effectively if treatment is continuous than if it is sporadic. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. Your doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with your doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

Additionally, keeping a chart of daily mood swings, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help your doctor track and treat the illness most effectively.

Medications

Medications for bipolar disorder are prescribed by psychiatrists with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

Medications known as “mood stabilizers” usually are prescribed to help control bipolar disorder. Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite using mood stabilizers.

Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

Anti-convulsant medications, such as valproate (Depakote) or carbamazepine (Tegretol), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.

Newer anti-convulsant medications, including lamotrigine (Lamictal), gabapentin (Neutontin), and topiramate (Topamax), are being studied to determine how well they work in stabilizing mood cycles.

Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other non-psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovarian syndrome in women who begin taking the medication before age 20. Therefore young female patients taking valproate should be monitored carefully by a physician.

Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Atypicl anti-psychotic medications, including clozapine (Clozaril), olanzapin (Zyprexa), risperidone (Risperdal), and ziprasidone (Geodon), can be used as possible treatments for bipolar disorder. Evidence suggests that clozapine may be helpful as a mood stabilizer for people who do not respond well to lithium or anticonvulsants. Other research has supported the efficacy of olanzpine for acute mania, an indication that has recently received FDA approval.

Aripiprazole (Abilify) is another atypical anti-psychotic medication used to treat the symptoms of schizophrenia and mania, or mixed (manic and depressive) episodes of bipolar I disorder. Aripiprazole is in tablet and liquid form. An injectable form is used in the treatment of symptom of agitation in schizophrenia and manic or mixed episodes of bipolar I disorder. Olanzapine may also help relieve psychotic depression.

If insomnia is a problem, a high-potency benzdiazepine medication such as clonazepam (Klonopin) or loraepam (Ativan) may be helpful to promote better sleep. However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Other types of sedative medications, such as zolppidem (Ambien), are sometimes used instead.

Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.
Be sure to tell your psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions.

To reduce the chance of relapse or of developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medication.

Psychosocial Treatments

In addition to medication, psychosocial treatments – including certain forms of psychotherapy (or “talk” therapy)- are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial intervention can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient’s progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psycho-education, family therapy, and a newer technique, interpersonal and social rhythm therapy. National Institute of Mental Health (NIMH) researchers are studying how these interventions compare to one another when added to medication for bipolar disorder.

Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

Psycho-education involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psycho-education also may be helpful for family members.

Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person’s symptoms.

Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.

As with medication, it is important to follow the treatment plan for any psychological intervention to achieve the greatest benefit.

Other Treatments

In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidal tendencies, electro-convulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medication too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.

Herbal or natural supplements, such as St. John’s wort (hypericum perforatum), have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. Johns wort can reduce the effectiveness of certain medications (see http://www.fda.gov/cder/drug/advisory/stjwort.htm). Like prescription antidepressants, St. John’s Wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.

Omega-3 fatty acids found in fish oil are bing studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.

Do other illness occur with bipolar disorder?


Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood swings either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance abuse disorders. Treatment for co-occurring substance abuse, when presented, is an important part of the overall treatment plan.

Anxiety disorders, such as Post-traumatic Stress Disorder and obsessive-compulsive disorder (OCD), also may be common in people with bipolar disorder. Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment.

How can individuals and families get help for bipolar disorder?


Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease. Other mental health professionals, such as psychologists and psychiatric social workers, can assist in providing the person and family with additional approaches to treatment. Help can be found at:

• University or medical school affiliated programs
• Hospital departments of psychiatry
• Private psychiatric offices and clinics
• Health maintenance organizations (HMOs)
• Offices of family physicians, internists, and pediatricians
• Public community mental health centers

People with bipolar disorder may need your help to get the help that they need. Here are some ways you could help:
Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.

A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral information to a mental health professional.
Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.

A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much needed treatment. There may be times when the person must be hospitalized against his or her wishes.
Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.

Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
Family members of someone with bipolar disorder often have to cope with the person’s serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.

Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMADA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations.

What about clinical studies for bipolar disorder?


Some people with bipolar disorder receive medication and/or psychosocial therapy by volunteering to participate in clinical studies (clinical trials). Clinical studies involve the scientific investigation of illness in humans. Clinical studies in mental health can yield information about the efficacy of a medication or a combination of treatments, the usefulness of a behavioral intervention or type of psychotherapy, the reliability of a diagnostic procedure, or the success of a prevention method. Clinical studies also guide scientists in learning how illness develops, progresses, lessens, and affects both mind and body. Millions of Americans diagnosed with mental illness lead healthy, productive lives because of information discovered through clinical studies. These studies are not always right for everyone, however. It is important for each individual to consider carefully the possible risks and benefits of a clinical study before making a decision to participate.

In recent years, NIMH has introduced a new generation of “real world” clinical studies. They are called “real world” studies for several reasons. Unlike traditional clinical trials, they offer multiple different treatments and treatment combinations. In addition, they aim to include large numbers of people with mental disorders living in communities throughout the U.S. and receiving treatment across a wide variety of settings. Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies. The main goal of the real world studies is to improve treatment strategies and outcomes for all people with these disorders. In addition to measuring improvement in illness symptoms, the studies will evaluate how treatments influence other important, real-life issues such as quality of life, ability to work, and social functioning. They also will assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans.

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) completed data collection at the end of September 2005 for the largest-ever, “real world” study of treatments for bipolar disorder. To learn more about STEP-BD or other clinical studies, see the Clinical Trials page on the NIMH web site http://www.nimh.nih.gov, or visit the National Library of Medicine’s clinical trials database http://www.clinicaltrials.gov or contact NIMH.