Bipolar Disorder

Bipolar disorder, formerly known as manic depression, is a condition that affects your moods, which can swing from one extreme to another.

People with bipolar disorder have periods or episodes of:

• depression – feeling very low and lethargic
• mania – feeling very high and overactive (less severe mania is known as hypomania)

Symptoms of bipolar disorder depend on which mood you’re experiencing. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer), and some people may not experience a “normal” mood very often.

Depression

You may initially be diagnosed with clinical depression before having a future manic episode (sometimes years later), after which you may be diagnosed with bipolar disorder.

During an episode of depression, you may have overwhelming feelings of worthlessness, which can potentially lead to thoughts of suicide.

If you’re feeling suicidal or having severe depressive symptoms, contact your GP, care coordinator or local mental health emergency services as soon as possible.

Mania

During a manic phase of bipolar disorder, you may feel very happy and have lots of energy, ambitious plans and ideas. You may spend large amounts of money on things you can’t afford and wouldn’t normally want.

Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common characteristics of this phase.

You may feel very creative and view the manic phase of bipolar as a positive experience. However, you may also experience symptoms of psychosis, where you see or hear things that aren’t there or become convinced of things that aren’t true.

Living with bipolar disorder

The high and low phases of bipolar disorder are often so extreme that they interfere with everyday life.

However, there are several options for treating bipolar disorder that can make a difference. They aim to control the effects of an episode and help someone with bipolar disorder live life as normally as possible.

The following treatment options are available:

• medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilizers and are taken every day on a long-term basis
• medication to treat the main symptoms of depression and mania when they occur
• learning to recognize the triggers and signs of an episode of depression or mania
• psychological treatment – such as talking therapy, which can help you deal with depression, and provides advice about how to improve your relationships
• lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, as well as advice on improving your diet and getting more sleep

It’s thought using a combination of different treatment methods is the best way to control bipolar disorder.

Help and advice for people with a long-term condition or their carers is also available from charities, support groups and associations.

This includes self-help and self-management advice and learning to deal with the practical aspects of a long-term condition.

Bipolar disorder and pregnancy

Bipolar disorder, like all other mental health problems, can get worse during pregnancy. However, specialist help is available if you need it.

What causes bipolar disorder?

The exact cause of bipolar disorder is unknown, although it’s believed a number of things can trigger an episode. Extreme stress, overwhelming problems and life-changing events are thought to contribute, as well as genetic and chemical factors.

Who’s affected?

Bipolar disorder is fairly common and one in every 100 adults will be diagnosed with the condition at some point in their life.

Bipolar disorder can occur at any age, although it often develops between the ages of 15 and 19 and rarely develops after 40. Men and women from all backgrounds are equally likely to develop bipolar disorder.

The pattern of mood swings in bipolar disorder varies widely between people. For example, some people only have a couple of bipolar episodes in their lifetime and are stable in between, while others have many episodes.

Symptoms

Bipolar disorder is characterized by extreme mood swings. These can range from extreme highs (mania) to extreme lows (depression).

Episodes of mania and depression often last for several weeks or months.

Depression

During a period of depression, your symptoms may include:

• feeling sad, hopeless or irritable most of the time
• lacking energy
• difficulty concentrating and remembering things
• loss of interest in everyday activities
• feelings of emptiness or worthlessness
• feelings of guilt and despair
• feeling pessimistic about everything
• self-doubt
• being delusional, having hallucinations and disturbed or illogical thinking
• lack of appetite
• difficulty sleeping
• waking up early
• suicidal thoughts

Mania

The manic phase of bipolar disorder may include:

• feeling very happy, elated or overjoyed
• talking very quickly
• feeling full of energy
• feeling self-important
• feeling full of great new ideas and having important plans
• being easily distracted
• being easily irritated or agitated
• being delusional, having hallucinations and disturbed or illogical thinking
• not feeling like sleeping
• not eating
• doing things that often have disastrous consequences – such as spending large sums of money on expensive and sometimes unaffordable items
• making decisions or saying things that are out of character and that others see as being risky or harmful

Patterns of depression and mania

If you have bipolar disorder, you may have episodes of depression more regularly than episodes of mania, or vice versa.

Between episodes of depression and mania, you may sometimes have periods where you have a “normal” mood.

The patterns aren’t always the same and some people may experience:

• rapid cycling – where a person with bipolar disorder repeatedly swings from a high to low phase quickly without having a “normal” period in between
• mixed state – where a person with bipolar disorder experiences symptoms of depression and mania together; for example, overactivity with a depressed mood

If your mood swings last a long time but aren’t severe enough to be classed as bipolar disorder, you may be diagnosed with cyclothymia (a mild form of bipolar disorder).

Living with bipolar disorder

Bipolar disorder is a condition of extremes. A person with the condition may be unaware they’re in the manic phase.

After the episode is over, they may be shocked at their behavior. However, at the time, they may believe other people are being negative or unhelpful.

Some people with bipolar disorder have more frequent and severe episodes than others. The extreme nature of the condition means staying in a job may be difficult and relationships may become strained. There’s also an increased risk of suicide.

During episodes of mania and depression, someone with bipolar disorder may experience strange sensations, such as seeing, hearing or smelling things that aren’t there (hallucinations).

They may also believe things that seem irrational to other people (delusions). These types of symptoms are known as psychosis or a psychotic episode.

Causes

The exact cause of bipolar disorder is unknown. Experts believe there are a number of factors that work together to make a person more likely to develop the condition.

These are thought to be a complex mix of physical, environmental and social factors.

Chemical imbalance in the brain

Bipolar disorder is widely believed to be the result of chemical imbalances in the brain.

The chemicals responsible for controlling the brain’s functions are called neurotransmitters and include noradrenaline, serotonin and dopamine.

There’s some evidence that if there’s an imbalance in the levels of one or more neurotransmitters, a person may develop some symptoms of bipolar disorder.

For example, there’s evidence that episodes of mania may occur when levels of noradrenaline are too high, and episodes of depression may be the result of noradrenaline levels becoming too low.

Genetics

It’s also thought bipolar disorder is linked to genetics, as the condition seems to run in families. The family members of a person with the condition have an increased risk of developing it themselves.

However, no single gene is responsible for bipolar disorder. Instead, a number of genetic and environmental factors are thought to act as triggers.

Triggers

A stressful circumstance or situation often triggers the symptoms of bipolar disorder. Examples of stressful triggers include:

• the breakdown of a relationship
• physical, sexual or emotional abuse
• the death of a close family member or loved one

These types of life-altering events can cause episodes of depression at any time in a person’s life.

Bipolar disorder may also be triggered by:

• physical illness
• sleep disturbances
• overwhelming problems in everyday life – such as problems with money, work or relationships

Diagnosis

If your GP thinks you may have bipolar disorder, they’ll usually refer you to a psychiatrist (a medically qualified mental health specialist).

If your illness puts you at risk of harming yourself, your GP will arrange an appointment immediately.

Specialist assessment

You’ll be assessed by the psychiatrist at your appointment. They’ll ask you a few questions to determine if you have bipolar disorder. If you do, they’ll decide what treatments are most suitable.

During the assessment, you’ll be asked about your symptoms and when you first experienced them. The psychiatrist will also ask about how you feel leading up to and during an episode of mania or depression, and if you have thoughts about harming yourself.

The psychiatrist will also want to know about your medical background and family history, especially whether any of your relatives have had bipolar disorder.

If someone else in your family has the condition, the psychiatrist may want to talk to them. However, they’ll ask for your agreement before doing so.

Other tests

Depending on your symptoms, you may also need tests to see whether you have a physical problem, such as an underactive thyroid or an overactive thyroid.

If you have bipolar disorder, you’ll need to visit your GP regularly for a physical health check.

Treatment

Treatment for bipolar disorder aims to reduce the severity and number of episodes of depression and mania to allow as normal a life as possible.

Treatment options for bipolar disorder

If a person isn’t treated, episodes of bipolar-related mania can last for between three and six months. Episodes of depression tend to last longer, for between six and 12 months.

However, with effective treatment, episodes usually improve within about three months.

Most people with bipolar disorder can be treated using a combination of different treatments. These can include one or more of the following:

• medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilizers and are taken every day on a long-term basis
• medication to treat the main symptoms of depression and mania when they occur
• learning to recognize the triggers and signs of an episode of depression or mania
• psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
• lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.

However, hospital treatment may be needed if your symptoms are severe, or if you’re being treated under the Mental Health Act, as there’s a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medication

Several medications are available to help stabilize mood swings. These are commonly referred to as mood stabilizers and include:

• lithium carbonate
• anticonvulsant medicines
• antipsychotic medicines

If you’re already taking medication for bipolar disorder and you develop depression, your GP will check you’re taking the correct dose. If you aren’t, they’ll change it.

Episodes of depression are treated slightly differently in bipolar disorder, as the use of antidepressants alone may lead to a hypomanic relapse.

Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabilizer. However, antidepressants are commonly used alongside a mood stabilizer or antipsychotic.

If your GP or psychiatrist recommends you stop taking medication for bipolar disorder, the dose should be gradually reduced over at least four weeks, and up to three months if you are taking an antipsychotic or lithium.

If you have to stop taking lithium for any reason, see your GP about taking an antipsychotic or valproate instead.

Lithium carbonate

Lithium is a long-term method of treatment for episodes of mania, hypomania and depression. It’s usually prescribed for at least six months.

If you’re prescribed lithium, stick to the prescribed dose and don’t stop taking it suddenly (unless told to by your doctor).

For lithium to be effective, the dosage must be correct. If it’s incorrect, you may get side effects such as diarrhea and vomiting. However, tell your doctor immediately if you have side effects while taking lithium.

You’ll need regular blood tests at least every three months while taking lithium. This is to make sure your lithium levels aren’t too high or too low.

Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you’re taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they’re prescribed by your GP.

Anticonvulsant medicines

Anticonvulsant medicines include:

• valproate 
• carbamazepine
• lamotrigine

These medicines are sometimes used to treat episodes of mania. They’re also long-term mood stabilizers.

Anticonvulsant medicines are often used to treat epilepsy, but they’re also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used, or they may be used in combination with lithium when the condition doesn’t respond to lithium on its own.

Valproate

Valproate isn’t usually prescribed for women of childbearing age because there’s a risk of physical defects to babies such as spina bifida, heart abnormalities and cleft lip. There may also be an increased risk of developmental problems such as lower intellectual abilities, poor speaking and understanding, memory problems, autistic spectrum disorders and delayed walking and talking.

In women, your GP may decide to use valporate if there’s no alternative or if you’ve been assessed and it’s unlikely you’ll respond to other treatments, although they’ll need to check you’re using a reliable contraception and advise you on the risks of taking the medicine during pregnancy.

If you’re prescribed valproate, you’ll need to visit your GP to have a blood count when you begin the medication, and then again six months later.

Carbamazepine

Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.

Your progress will be carefully monitored if you’re taking other medication, including the contraceptive pill.

Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine, and again after six months.

You’ll also need to have a blood count at the start and after six months, and you may also have your weight and height monitored.  

Lamotrigine

If you’re prescribed lamotrigine, you’ll usually be started on a low dose, which will be increased gradually.

See your GP immediately if you’re taking lamotrigine and develop a rash. You’ll need to have an annual health check, but other tests aren’t usually needed.

Women who are taking the contraceptive pill should talk to their GP about taking a different method of contraception.

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania or hypomania. Antipsychotic medicines include:

• aripiprazole
• olanzapine
• quetiapine
• risperidone

They may also be used as a long-term mood stabilizer. Quetiapine may also be used for long-term bipolar depression.

Antipsychotic medicines can be particularly useful if symptoms are severe or behavior is disturbed. As antipsychotics can cause side effects – such as blurred vision, dry mouth, constipation and weight gain – the initial dose will usually be low.

If you’re prescribed an antipsychotic medicine, you’ll need to have regular health checks at least every three months, but possibly more often, particularly if you have diabetes. If your symptoms don’t improve, you may be offered lithium and valproate as well.

Rapid cycling

You may be prescribed a combination of lithium and valproate if you experience rapid cycling (where you quickly change from highs to lows without a “normal” period in between).

If this doesn’t help, you may be offered lithium on its own or a combination of lithium, valproate and lamotrigine.

However, you won’t usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.

Learning to recognize triggers

If you have bipolar disorder, you can learn to recognize the warning signs of an approaching episode of mania or depression.

A community mental health worker, such as a psychiatric nurse, may be able to help you identify your early signs of relapse from your history.

This won’t prevent the episode occurring, but it will allow you to get help in time.

This may mean making some changes to your treatment, perhaps by adding an antidepressant or antipsychotic medicine to the mood-stabilizing medication you’re already taking. Your GP or specialist can advise you on this.

Psychological treatment

Some people find psychological treatment helpful when used alongside medication in between episodes of mania or depression. This may include:

• psychoeducation – to find out more about bipolar disorder
• cognitive behavioral therapy (CBT) – this is most useful when treating depression
• family therapy – a type of psychotherapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of six to nine months.

Pregnancy

The management of bipolar disorder in women who are pregnant, or those who are trying to conceive, is complex and challenging.

One of the main problems is the risks of taking medication during pregnancy aren’t always that well understood.

A written plan for managing the treatment of a pregnant woman with bipolar disorder should be developed as soon as possible.

The plan should be drawn up with the patient, her partner, her obstetrician (pregnancy specialist), midwife, GP and health visitor.

The following medication isn’t routinely prescribed for pregnant women with bipolar disorder:

• valproate – there’s a risk to the fetus and the subsequent development of the child
• carbamazepine – it has limited effectiveness and there’s risk of harm to the fetus
• lithium – there’s a risk of harm to the fetus, such as cardiac problems
• lamotrigine – there’s a risk of harm to the fetus
• paroxetine – there’s a risk of harm to the fetus, such as cardiovascular malformations
• benzodiazepines – if used long term, there are risks during the pregnancy and immediately after the birth, such as cleft palate and floppy baby syndrome

If you become pregnant while taking medication prescribed to treat bipolar disorder, it’s important that you don’t stop taking it until you’ve discussed it with your doctor.

If medication is prescribed for bipolar disorder after the baby is born, it may also affect a mother’s decision to breastfeed her child. Your pharmacist, midwife or mental health team can give you advice based on your circumstances.

Living with bipolar disorder

Although it’s usually a long-term condition, effective treatments for bipolar disorder, combined with self-help techniques, can limit the condition’s impact on your everyday life.

Staying active and eating well

Eating well and keeping fit are important for everyone. Exercise can also help reduce the symptoms of bipolar disorder, particularly depressive symptoms.

It may also give you something to focus on and provide a routine, which is important for many people.

A healthy diet, combined with exercise, may also help limit weight gain, which is a common side effect of medical treatments for bipolar disorder.

Some treatments also increase the risk of developing diabetes or worsen the illness in people that already have it. Maintaining a healthy weight and exercising are an important way of limiting that risk.

You should have a check-up at least once a year to monitor your risk of developing cardiovascular disease or diabetes.

This will include recording your weight, checking your blood pressure and having any appropriate blood tests.

Self-care and self-management

Self-care

Self-care is an essential part of daily life. It involves taking responsibility for your own health and wellbeing with support from the people involved in your care.

It includes:

• staying fit and maintaining good physical and mental health
• preventing illness or accidents
• caring more effectively for minor ailments and long-term conditions

People with long-term conditions can benefit enormously from being helped with self-care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life, and be more active and independent.

Self-management programs

Self-management programs aim to help people with bipolar disorder take an active part in their own recovery so they’re not controlled by their condition.

 

Talking about it

Some people with bipolar disorder find it easy to talk to family and friends about their condition and its effects. Other people find it easier to turn to charities and support groups.

Many organizations run self-help groups that can put you in touch with other people with the condition. This enables people to share helpful ideas and helps them realize they’re not alone in feeling the way they do. These organizations also provide online support in forums and blogs.

 

Services that can help

You may be involved with many different services during treatment for bipolar disorder. Some are accessed through referral from your GP, others through your local authority.

These services may include:

• Community mental health teams (CMHT) – these provide the main part of local specialist mental health services. They offer assessment, treatment and social care to people with bipolar disorder and other mental illnesses.
• Early intervention teams – these provide early identification and treatment for people who have the first symptoms of psychosis. Your GP may be able to refer you directly to an early intervention team.
• Crisis services – these allow people to be treated at home, instead of in hospital, for an acute episode. These are specialist mental health teams that deal with crises that occur outside normal office hours.
• Acute day hospital – these are an alternative to inpatient care in a hospital. You can visit every day or as often as you need.
• Assertive outreach teams – these deliver intensive treatment and rehabilitation in the community for people with severe mental health problems, providing rapid help in a crisis. Staff often visit people at home and liaise with other services, such as your GP or social services. They can also help with practical problems, such as helping to find housing and work, or doing your shopping and cooking.

Avoiding drugs and alcohol

Some people with bipolar disorder use alcohol or illegal drugs to try to take away their pain and distress. Both have well-known harmful physical and social effects and are not a substitute for effective treatment and good healthcare.

Some people with bipolar disorder find they can stop misusing alcohol and drugs once they’re using effective treatment.

Others may have separate but related problems of alcohol and drug abuse, which may need to be treated separately.

Avoiding alcohol and illegal drugs is an important part of recovery from episodes of manic, hypomanic or depressive symptoms, and can help you gain stability.

Money and benefits

It’s important to avoid too much stress, including work-related stress. If you’re employed, you may be able to work shorter hours or in a more flexible way, particularly if job pressure triggers your symptoms.

Living with or caring for someone with bipolar disorder

People living with or caring for someone with bipolar disorder can have a tough time. During episodes of illness, the personalities of people with bipolar disorder may change, and they may become abusive or even violent.

Sometimes social workers and the police may become involved. Relationships and family life are likely to feel the strain.

 

You may feel at a loss if you’re caring for someone with bipolar disorder. Finding a support group and talking to other people in a similar situation might help.

If you’re having relationship or marriage difficulties, you can contact specialist relationship counsellors, who can talk things through with you and your partner.

Dealing with suicidal feelings

Having suicidal thoughts is a common depressive symptom of bipolar disorder. Without treatment, these thoughts may get stronger.

Some research has shown the risk of suicide for people with bipolar disorder is 15 to 20 times greater than the general population.

Studies have also shown that as many as 25-50% of people with bipolar disorder attempt suicide at least once.

The risk of suicide seems to be higher earlier in the illness, so early recognition and help may prevent it.

If you’re feeling suicidal or you’re having severe depressive symptoms, contact your GP, care coordinator or the local mental health emergency services as soon as possible.

 

Self-harm

Self-harm (sometimes called self-injury) is often a symptom of mental health problems such as bipolar disorder.

For some people, self-harm is a way of gaining control over their lives or temporarily distracting themselves from mental distress. It may not be related to suicide or attempted suicide.