Bipolar Disorder

Overview

What is bipolar disorder?

Bipolar disorder, also called "manic-depressive" disease, is a mental illness that causes people to have high and low moods. People with this illness have periods of feeling overly happy and joyful (or irritable) or of feeling very sad or feeling normal. Because of the highs and the lows – or two poles of mood – the condition is referred to as "bipolar” disorder. However, patients’ moods may not necessarily follow a cyclic pattern, and sometimes the highs and lows can be experienced at the same time (mixed state). The hallmark of bipolar illness is the occurrence of the manic episode. In fact, by definition, to meet the criteria for bipolar disorder, patients must have at least one manic episode in their lifetime with or without ever experiencing a depressive episode.

The word “hypomania” or “manic” describes the periods when the person feels overly excited and confident. These feelings can quickly turn to confusion, irritability, anger, and even rage. The word “depressive” describes the periods when the person feels very sad or depressed. Because the symptoms are similar, sometimes people with bipolar depression are incorrectly diagnosed as having major depression. This is why it is especially important to screen for mania.

Most individuals with bipolar disorder spend three times the amount of time in depressed phases than in manic phases.

Who experiences bipolar disorder?

Bipolar disorder usually begins in older teens and young adults, with at least half of all cases appearing before age 25. Children and adolescents, however, can develop this disease in more severe forms and often in combination with attention deficit hyperactivity disorder (ADHD). Some studies have indicated that bipolar depression is genetically inherited, occurring more commonly within families.

While bipolar disorder occurs equally in women and men, women are more likely to meet criteria for bipolar II disorder. (With bipolar II, patients experience both depressive and hypomanic episodes, but do not experience the severe manic episodes seen in bipolar I.) Women with bipolar disorder may switch moods more quickly – this is called "rapid cycling." Varying levels of sex hormones and activity of the thyroid gland in the neck, together with the tendency to be prescribed antidepressants, may contribute to the more rapid cycling seen in women. Women may also experience more periods of depression than men.

An estimated 60 percent of all people with bipolar disorder have drug or alcohol dependence. It has also been shown to occur frequently in people with seasonal depression and certain anxiety disorders, like post-traumatic stress disorder (PTSD).

Symptoms and Causes

What causes bipolar disorder?

A definite cause for any type of depression is difficult to determine but include:

  • Genetics
  • Changes in the brain
  • Environmental factors like stress and major life changes

More research is being done to determine the relationship that these factors have in bipolar disorder, how they may help prevent its onset, and what role they may play in its treatment.

What are the symptoms of bipolar disorder?

The changing mood states do not always follow a set pattern, and depression does not always follow manic phases. A person may also experience the same mood state several times before experiencing the opposite mood. Mood changes can happen over a period of weeks, months, and sometimes even years.

An important aspect of the mood changes are that they are a departure from the person’s regular self and that the mood change is sustained for a long period of time. It may be many days or weeks in the case of mania and many weeks or months in the case of depression. Shorter periods of mania or depression may be an indicator of more severe episodes in the future but are usually not enough to diagnose a person with bipolar disorder.

The severity of the depressive and manic phases can differ from person to person and in the same person at different times. Symptoms of mania (“the highs”) include:

  • Excessive happiness, hopefulness, and excitement
  • Sudden changes from being joyful to being irritable, angry, and hostile
  • Restlessness
  • Rapid speech and poor concentration
  • Increased energy and less need for sleep
  • High sex drive
  • Tendency to make grand and unattainable plans
  • Tendency to show poor judgment, such as deciding to quit a job
  • Drug and alcohol abuse
  • Increased impulsivity

Some patients can become psychotic, seeing and hearing things that aren't there and holding false beliefs from which they cannot be swayed. In some instances they see themselves as having superhuman skills and powers, or think they are god-like.

The symptoms of bipolar depression are the same as those of major depression and include:

  • Sadness
  • Loss of energy
  • Feelings of hopelessness or worthlessness
  • Loss of enjoyment from things that were once pleasurable
  • Difficulty concentrating
  • Uncontrollable crying
  • Difficulty making decisions
  • Irritability
  • Increased need for sleep
  • Insomnia or excessive sleep
  • A change in appetite causing weight loss or gain
  • Thoughts of death or suicide
  • Attempting suicide

Patients with depression can also become psychotic and hear things or have delusions.

Diagnosis and Tests

How is bipolar disorder diagnosed?

A diagnosis of bipolar disorder is made only by taking careful note of symptoms, and their severity, length, and frequency. The most telling are periods of hypomania or mania. Reviewing history from close friends and family is often very helpful to distinguish bipolar disorder from major depression.

If you or someone you know has symptoms of bipolar disorder, see your family healthcare provider or a psychiatrist. A referral may then be made to an appropriate mental health expert.

A thorough medical evaluation should be performed. Your doctor will ask questions about your personal and family history of mental illness. You may also be asked to complete a mood disorders or depression-screening questionnaire. This is a series of questions that you will be asked to answer verbally or in writing.

Management and Treatment

What are the treatments for bipolar disorder?

Bipolar disorder is a long-term illness that requires management throughout a person's life. People who have numerous (four or more) episodes of mood changes (rapid cycling) in a year can be much more difficult to treat. Medication is the primary form of treatment, but the additional use of psychotherapy or "talk" therapy is sometimes recommended to help prevent future episodes.

There are many drugs available to treat bipolar disorder. Proposed guidelines for treatment options are based on the three main phases of bipolar disorder, which include the acutemanic/mixed mood states, acute major depressive episodes, and finally the continuation/maintenance phase. As a general rule, avoiding antidepressants and taking two mood stabilizers has proven to be an effective strategy for most patients.

Mood-stabilizing drugs

Lithium (brand names Eskalith®, Lithobid®, Lithonate®) is a mood-stabilizing drug. It has proven helpful in controlling mania and depression and preventing depression and manic episodes. Lithium will reduce symptoms of mania within two weeks of starting therapy, but it may take weeks to months before the condition is completely controlled. Thus other drugs like antipsychotic drugs or antidepressant drugs may also be used to help control symptoms.

Common side effects of lithium include:

  • Frequent need to urinate
  • Weight gain
  • Increased thirst
  • Slight trembling of the hands
  • Nausea

Thyroid and kidney problems are a concern, so your doctor will monitor the function of your thyroid and kidneys as well as monitor the levels of lithium in your blood since levels can easily become too high. Anything that lowers the level of sodium in the body, such as switching to a low-sodium diet, heavy sweating, fever, vomiting, or diarrhea may cause a buildup of lithium in the body and toxicity. Be aware of these conditions and alert your doctor if you are on lithium and experience them.

The following are signs of a lithium overdose. Call your doctor immediately or go to the nearest emergency room if you experience:

  • Blurred vision
  • Irregular pulse
  • Extremely fast or slow heartbeat
  • Difficulty breathing
  • Confusion
  • Convulsions
  • Dizziness
  • Severe trembling
  • Need to pass large amounts of urine
  • Uncontrolled eye movements
  • Double vision
  • Unusual bruising or bleeding

Antiseizure medications

Valproate (Depakote®) is an antiseizure medicine also effective for controlling mania. It is also effective for people with rapid-cycling bipolar disorder. The drug has some side effects, can cause inflammation of the liver and can decrease the amount of platelets (blood cells needed for blood to clot) that the body makes so your doctor will monitor levels of valproate as well as liver function and platelet counts.

Common side effects of valproate include:

  • Sedation
  • Stomach cramps
  • Diarrhea
  • Indigestion
  • Nausea
  • Weight gain
  • Slight trembling of hands

Other antiseizure medicines often used to treat bipolar disorder include carbamazepine (Tegretol®) and lamotrigine (Lamictal®). Lamotrigine is used alone or in combination with other mood stabilizer medications. It is more effective at treating the depressed phase of bipolar and/or as a mood stabilizer to reduce "cycling." Lamotrigine is available as a generic drug. It is very well tolerated and is free of side effects for most patients.

Serious side effects of lamotrigine you should report to your doctor include:

  • Rash
  • Worsening depression or suicidal thoughts
  • Flu-like symptoms, such as body aches or swollen glands

Atypical neuroleptics

This class of medications is sometimes classified as antipsychotics but is also effective in treating bipolar disorder mania and depression. These include medications such as olanzapine (Zyprexa®), quetiapine (Seroquel®), aripiprazole (Abilify®), lurasidone (Latuda®), ziprasidone (Geodon®), Iloperidone (Fanapt®), brexpiprazole (Rexulti®), cariprazine (Vraylar®), clozapine (Clozaril®), risperidone (Risperidol®) among others.

Common side effects of these medications include:

  • Tremors
  • Muscle spasms/contractions
  • Involuntary movements
  • Weight Gain
  • Increased glucose and lipids
  • Sedation
  • Irregular, jerky movements; rigidity; slowness of movement (symptoms known as extrapyramidal symptoms)

Most people with bipolar disorder take more than one medication. In addition to a mood stabilizer, patients may take a medication for agitation, anxiety, insomnia, or depression.

Many antidepressants can be used with mood stabilizing drugs to manage the depression of bipolar disorder. If used alone, an antidepressant can push a person with the condition into a manic state.

Additional treatment options

Other treatment options your doctor may consider include:

  • Stimulants are sometimes used to treat depression.
  • Thyroid medications can act like mood stabilizers. Studies have shown positive results in reducing symptoms in female patients with hard-to-treat, rapid-cycling bipolar disorder.
  • Light therapy uses a light box that gives off a bright light similar to natural sunlight. It can be used to treat depression.
  • Electroconvulsive therapy (ECT) passes electric current through the brain to treat severe depression.
  • Transcranial magnetic stimulation uses a short electromagnetic coil to pass electric current into the brain; used to treat depression in patients in whom medication has not worked and is an alternative to ECT.
  • Vagus nerve stimulator is a device implanted under the skin that sends electrical pulses through the vegas nerve (a nerve that runs from the brainstem through the neck and down to each side of the chest and abdomen). The pulse has been found helpful in treating depressive symptoms.
  • Ketamine treatment, given intravenously, along with other medicines has been shown to be helpful in treating bipolar depression.

Prevention

Can bipolar disorder be prevented?

There is no known method to prevent bipolar disorder. Because its exact cause has not yet been determined, it is especially important to know its symptoms and seek early intervention. Regular and continued use of medication can help reduce episodes or mania and depression. Some people who experience bipolar disorder may become suicidal. By knowing how to recognize these symptoms, there is a better chance for effective treatment and finding coping methods that may prevent long periods of illness, extended hospital stays, and suicide.

Outlook / Prognosis

What can I expect after treatment?

For most people, a good treatment program can stabilize severe moods and provide effective symptom relief. Treatment that is continual has proven more effective in preventing relapses. Those who also have a substance abuse problem may need more specialized treatment.

Last reviewed by a Cleveland Clinic medical professional on 01/27/2018.

References

  • National Institute of Mental Health. Bipolar disorder. (https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml) Accessed 5/15/2018.
  • National Institute of Mental Health. Brain Stimulation Therapies. (https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml) Accessed 5/15/2018.
  • Brent DA, Pan RJ. Brent D.A., Pan R.J. Brent, David A., and Raymond J. Pan.Chapter 39. Bipolar Disorder. In: Ebert MH, Loosen PT, Nurcombe B, Leckman JF. Ebert M.H., Loosen P.T., Nurcombe B, Leckman J.F. Eds. Michael H. Ebert, et al.eds. CURRENT Diagnosis & Treatment: Psychiatry, 2e New York, NY: McGraw-Hill; 2008.
  • Depression and Bipolar Support Alliance. Bipolar Disorder. (https://secure2.convio.net/dabsa/site/SPageServer/?pagename=education_bipolar) Accessed5/15/2018.
  • National Alliance on Mental Illness. Bipolar Disorder. (https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder) Accessed 5/15/2018.

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