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.

The vast majority of people who have manic episodes also experience periods of severe depression. If manic and depressive symptoms overlap for a period of time, 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. The disorder occurs in approximately 1 percent 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.

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

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.

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.

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.

There is no way to prevent bipolar disorder, but treatment can prevent episodes from returning.

A combination of medication and talk therapy is most helpful.

The class of medications known as mood stabilizers is the primary treatment for bipolar disorder. The best known and oldest of these is lithium carbonate, which can ease manic episodes and prevent them from returning. Lithium is probably more helpful to people who have depressive as well as manic episodes and it 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.

In recent years, anticonvulsant medications, which are used to treat seizures, have also been used to treat bipolar disorder. The most common is valproic acid (Depakene, Depakote). For many people, the side effects 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.

Carbamazepine (Tegretol and other brand names) 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.

Many other anticonvulsants have been used to treat bipolar disorder, but they have not been proven to be as effective as valproate acid and carbamazepine. The other anticonvulsants include lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax).

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

Psychotic symptoms can be treated with antipsychotic medications such as risperidone (Risperdal) and olanzapine (Zyprexa). These medications also can be used to treat symptoms of mania, even if the person is not psychotic. Antianxiety medications such as lorazepam (Ativan) and clonazepam (Klonopin) sometimes are used to calm the anxiety and agitation associated with a manic episode.

Antidepressants often are used to treat the depressive phase of the disorder, but there is a risk of triggering a manic episode, or inducing a pattern of rapid cycling. Therefore, many psychiatrists try to avoid using an antidepressant until other approaches have been tried. Antidepressants can be a useful part of treatment, but if one is used, it is important for the person to be taking a mood stabilizer first. There is some evidence that the antidepressant bupropion (Wellbutrin) is less likely to cause manic symptoms.

Talk therapy (psychotherapy) is important, as it provides education and support, and helps the person come to terms with the illness. Sometimes psychotherapy is 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. The choice of technique depends upon the availability of family support and other social support, and personal preference. It is important to become educated about bipolar disorder and to learn what resources are available for getting support. Cognitive behavioral therapy is designed to help you recognize patterns of thinking that keep you from managing your illness well. Psychodynamic, insight-oriented or interpersonal psychotherapy can help a person to sort out conflicts in important relationships or explore the history behind the symptoms.

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.

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.

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.