In this 2-part podcast series, NAMI Chief Medical Officer Dr. Ken Duckworth guides discussions on bipolar disorder that offer insights from individuals, family members and mental health professionals. Read the transcript.
Note: Content includes discussions on topics such as suicide attempts and may be triggering.

Bipolar disorder is a mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly. People with bipolar experience high and low moods—known as mania and depression—which differ from the typical ups-and-downs most people experience.

The average age-of-onset is about 25, but it can occur in the teens, or more uncommonly, in childhood. The condition affects men and women equally, with about 2.8% of the U.S. population diagnosed with bipolar disorder and nearly 83% of cases classified as severe.

If left untreated, bipolar disorder usually worsens. However, with a good treatment plan including psychotherapy, medications, a healthy lifestyle, a regular schedule and early identification of symptoms, many people live well with the condition.

Symptoms

Symptoms and their severity can vary. A person with bipolar disorder may have distinct manic or depressed states but may also have extended periods—sometimes years—without symptoms. A person can also experience both extremes simultaneously or in rapid sequence.

Severe bipolar episodes of mania or depression may include psychotic symptoms such as hallucinations or delusions. Usually, these psychotic symptoms mirror a person’s extreme mood. People with bipolar disorder who have psychotic symptoms can be wrongly diagnosed as having schizophrenia.

Mania. To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania. Hypomania is a milder form of mania that doesn’t include psychotic episodes. People with hypomania can often function well in social situations or at work. Some people with bipolar disorder will have episodes of mania or hypomania many times throughout their life; others may experience them only rarely.

Although someone with bipolar may find an elevated mood of mania appealing—especially if it occurs after depression—the “high” does not stop at a comfortable or controllable level. Moods can rapidly become more irritable, behavior more unpredictable and judgment more impaired. During periods of mania, people frequently behave impulsively, make reckless decisions and take unusual risks.

Most of the time, people in manic states are unaware of the negative consequences of their actions. With bipolar disorder, suicide is an ever-present danger because some people become suicidal even in manic states. Learning from prior episodes what kinds of behavior signals “red flags” of manic behavior can help manage the symptoms of the illness.

Depression. The lows of bipolar depression are often so debilitating that people may be unable to get out of bed. Typically, people experiencing a depressive episode have difficulty falling and staying asleep, while others sleep far more than usual. When people are depressed, even minor decisions such as what to eat for dinner can be overwhelming. They may become obsessed with feelings of loss, personal failure, guilt or helplessness; this negative thinking can lead to thoughts of suicide.

The depressive symptoms that obstruct a person’s ability to function must be present nearly every day for a period of at least two weeks for a diagnosis. Depression associated with bipolar disorder may be more difficult to treat and require a customized treatment plan.

Causes

Scientists have not yet discovered a single cause of bipolar disorder. Currently, they believe several factors may contribute, including:

• Genetics. The chances of developing bipolar disorder are increased if a child’s parents or siblings have the disorder. But the role of genetics is not absolute: A child from a family with a history of bipolar disorder may never develop the disorder. Studies of identical twins have found that, even if one twin develops the disorder, the other may not.
• Stress. A stressful event such as a death in the family, an illness, a difficult relationship, divorce or financial problems can trigger a manic or depressive episode. Thus, a person’s handling of stress may also play a role in the development of the illness.
• Brain structure and function. Brain scans cannot diagnose bipolar disorder, yet researchers have identified subtle differences in the average size or activation of some brain structures in people with bipolar disorder.

Diagnosis

To diagnose bipolar disorder, a doctor may perform a physical examination, conduct an interview and order lab tests. While bipolar disorder cannot be seen on a blood test or body scan, these tests can help rule out other illnesses that can resemble the disorder, such as hyperthyroidism. If no other illnesses (or medicines such as steroids) are causing the symptoms, the doctor may recommend mental health care.

To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania. Mental health care professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose the “type” of bipolar disorder a person may be experiencing. To determine what type of bipolar disorder a person has, mental health care professionals assess the pattern of symptoms and how impaired the person is during their most severe episodes.

Four Types Of Bipolar Disorder

1. 1. Bipolar I Disorder is an illness in which people have experienced one or more episodes of mania. Most people diagnosed with bipolar I will have episodes of both mania and depression, though an episode of depression is not necessary for a diagnosis. To be diagnosed with bipolar I, a person’s manic episodes must last at least seven days or be so severe that hospitalization is required.

1. 2. Bipolar II Disorder is a subset of bipolar disorder in which people experience depressive episodes shifting back and forth with hypomanic episodes, but never a “full” manic episode.

1. 3. Cyclothymic Disorder or Cyclothymia is a chronically unstable mood state in which people experience hypomania and mild depression for at least two years. People with cyclothymia may have brief periods of normal mood, but these periods last less than eight weeks.

4. Bipolar Disorder, “other specified” and “unspecified” is when a person does not meet the criteria for bipolar I, II or cyclothymia but has still experienced periods of clinically significant abnormal mood elevation.

Treatment

Bipolar disorder is treated and managed in several ways:

• Psychotherapy, such as cognitive behavioral therapy and family-focused therapy.
• Medications, such as mood stabilizers, antipsychotic medications and, to a lesser extent, antidepressants.
• Self-management strategies, like education and recognition of an episode’s early symptoms.
• Complementary health approaches, such as aerobic exercise meditation, faith and prayer can support, but not replace, treatment.

The largest research project to assess what treatment methods work for people with bipolar disorder is the Systematic Treatment Enhancement for Bipolar Disorder, otherwise known as Step-BD. Step-BD followed over 4,000 people diagnosed with bipolar disorder over time with different treatments.

Related Conditions

People with bipolar disorder can also experience:

• Anxiety
• Attention-deficit hyperactivity disorder (ADHD)
• Posttraumatic stress disorder (PTSD)
• Substance use disorders/dual diagnosis

People with bipolar disorder and psychotic symptoms can be wrongly diagnosed with schizophrenia. Bipolar disorder can be also misdiagnosed as Borderline Personality Disorder (BPD).

These other illnesses and misdiagnoses can make it hard to treat bipolar disorder. For example, the antidepressants used to treat OCD and the stimulants used to treat ADHD may worsen symptoms of bipolar disorder and may even trigger a manic episode. If you have more than one condition (called co-occurring disorders), be sure to get a treatment plan that works for you.

Reviewed August 2017

Proper treatment helps most people living with bipolar disorder control their mood swings and other symptoms. Because bipolar disorder is a chronic illness, treatment must be ongoing. If left untreated, the symptoms of bipolar disorder get worse, so diagnosing it and beginning treatment early is important.

Treating bipolar disorder may include medication, psychotherapy, education, self-management strategies and external supports such as family, friends and support groups. There is no one approach to treating bipolar disorder.

Psychotherapy

Psychotherapy, support groups and psychoeducation about the illness are essential to treating bipolar disorder:

• Cognitive behavioral therapy (CBT) helps change the negative thinking and behavior associated with depression. The goal of this therapy is to recognize negative thoughts and to teach coping strategies.
• Family-focused therapy helps people with bipolar disorder learn about the illness and carry out a treatment plan.
• Psychotherapy focused on self-care and stress regulation, and helps a person improve self-care, recognize patterns of the onset of the symptoms and to manage stress.

An NIMH clinical trial, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) showed that patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive a combination of several intensive psychotherapy interventions. Individuals in the study received three types of psychotherapy, which focused on cognitive strategies, family involvement and stress regulation.

Medications

With the prescribing doctor, work together to review the options for medication. Different types of bipolar disorder may respond better to a particular type. The side effects can vary between medications and it may take time to discover the best medicine.

Lithium

Lithium (Lithobid, Eskalith) is effective at stabilizing mood and preventing the extreme highs and lows of bipolar disorder. Periodic blood tests are required because lithium can cause thyroid and kidney problems. Common side effects include restlessness, dry mouth and digestive issues. Lithium levels should be monitored carefully to ensure the best dosage and watch for toxicity.

Lithium is used for continued treatment of bipolar depression and for preventing relapse. There is evidence that lithium can lower the risk of suicide but the FDA has not granted approval specifically for this purpose.

Anticonvulsants

Many medications used to treat seizures are also used as mood stabilizers. They are often recommended for treating bipolar disorder. Common side effects include weight gain, dizziness and drowsiness. But sometimes, certain anticonvulsants cause more serious problems, such as skin rashes, blood disorders or liver problems.

Valproic acid and carbamazepine are used to treat mania. These drugs, also used to treat epilepsy, were found to be as effective as lithium for treating acute mania. They may be better than lithium in treating the more complex bipolar subtypes of rapid cycling and dysphoric mania.

Lamotrigine is used to delay occurrences of bipolar I disorder. Lamotrigine does not have FDA approval for treatment of the acute episodes of depression or mania. Studies of lamotrigine for treatment of acute bipolar depression have produced inconsistent results.

Second-Generation Antipsychotics (SGAs)

SGAs are commonly used to treat the symptoms of bipolar disorder and are often paired with other medications, including mood stabilizers. They are generally used for treating manic or mixed episodes.

SGAs are often prescribed to help control acute episodes of mania or depression. Finding the right medication is not an exact science; it is specific to each person. Currently, only quetiapine and the combination of olanzepine and fluoxetine (Symbax) are approved for treating bipolar depression. Regularly check with your doctor and the FDA website, as side effects can change over time.

Standard Antidepressants

Antidepressants present special concerns when used in treating bipolar disorder, as they can trigger mania in some people. A National Institute of Mental Health study showed that taking an antidepressant also to a mood stabilizer is no more effective that using a mood stabilizer alone for bipolar I. This is an essential area to review treatment risks and benefits.

Other Treatments

Electroconvulsive Therapy (ECT)

In rare instances, ECT can be considered as an intervention for severe mania or depression. ECT involves transmitting short electrical impulses into the brain. Although ECT is a highly effective treatment for severe depression, mania or mixed episodes, it is reserved for specific situations and for symptoms that have not responded to other treatments.

Treatment Considerations For Women And For Children

Women. Women with bipolar disorder who are of childbearing age, or who are considering getting pregnant, need special attention. A complex risk-benefit discussion needs to occur to look at the treatment options available. Some medicines can have risk to the developing fetus and to children in breast milk. However, there is also evidence that being off of all medications increases the likelihood of bipolar symptoms, which itself creates risks to both mother and fetus or baby. Planning ahead and getting good information from your health care team based on your individual circumstances improves your chance of a best outcome.

Children. The diagnosis of bipolar disorder in children has been controversial. Before receiving any psychiatric diagnosis, children must have a comprehensive evaluation of their physical and mental health. Children with bipolar disorder may also have other conditions including attention-deficit hyperactivity disorder, early childhood psychosis, posttraumatic stress disorder, learning disabilities or substance abuse problems. Each of these co-occurring conditions requires a thoughtful and individualized treatment plan. Children with bipolar disorder usually receive psychotherapy and psychosocial interventions before medications are considered.

The identification of a new mental health condition, Disruptive Mood Dysregulation Disorder (DMDD), could affect how bipolar disorder is diagnosed in children. DMDD better describes children who are intensely irritable, have temper tantrums, but do not have classic symptoms of mania. Early evidence suggests children with DMDD do not have an increased risk of developing bipolar disorder as adults, but they may have other co-occurring illnesses like depression.

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