Bipolar disorder is a serious, long-term (chronic) condition where you have 'lows' (periods of depression) and 'highs' (periods of mania or hypomania). Treatment with mood stabiliser medicines such as lithium, anticonvulsants or antipsychotic medicines aims to keep your mood within normal limits. Psychological therapies (which involve talking to a trained psychologist or interacting through the internet) may also help.
What is bipolar disorder?
Bipolar disorder is sometimes called bipolar affective disorder. It used to be called manic depression. In this condition you have periods where your mood (affect) is in one extreme or another:
- One extreme is called depression, where you feel low and have other symptoms.
- The other extreme is called mania (or hypomania if symptoms are less severe), where you feel high or elated along with other symptoms.
The length of time you spend in each extreme can vary. It is usually for several weeks at a time or longer. Bipolar disorder is very different from the mood swings that moody people have which last a few minutes or hours.
You can have any number of episodes of highs and lows throughout your life. In between episodes of highs or lows there may be gaps of weeks, months or years when your mood is normal. However, some people swing from highs to lows quite quickly without a period of normal mood in between. This is called rapid cycling. (If you have the rapid cycling form of the condition you have at least four mood swings per year.)
Note: some people with bipolar disorder can have periods of mixed symptoms where they quickly alternate between depressive symptoms and manic symptoms (usually within a few hours). This is known as a mixed bipolar episode.
There are two types of bipolar disorder:
- Type I - this may start with manic symptoms or mixed episodes, both of which develop at some point in the condition.
- Type II - in this type you just get hypomania.
Who gets bipolar disorder?
About 2 in 100 people develop this condition. It can occur at any age but most commonly first develops between the ages of 17 and 29. It occurs in the same number of men as women. The rapid cycling form of the condition occurs in about 1 in 6 cases. Note: mania or hypomania occur in only a small number of people who develop depression. It is much more common just to have depression without episodes of mania or hypomania.
What causes bipolar disorder?
The exact cause is not known. However, your genetic 'makeup' seems to play a part, as your chance of developing this condition is higher than average if other members of your family are affected. Stressful situations may trigger an episode of mania or depression in people prone to this condition. It is thought that an imbalance of some chemicals in the brain may also be present in people with bipolar disorder.
What are the symptoms of mania and hypomania?
Mania causes an abnormally high or irritable mood which lasts at least one week - but usually lasts much longer than this. It can develop quite quickly - over a few days or so. When you are high you will usually have at least three or four of the following:
- Grand ideas about yourself and your own self-importance.
- Increased energy. You also tend to move quickly and need less sleep than usual.
- Being more talkative than usual. You tend to talk quickly.
- Flight of ideas. This means that you tend to change quickly from one idea to another. You may feel as if your thoughts are racing.
- Easily distracted. Your attention is easily drawn to unimportant or irrelevant things.
- Full of new ideas and plans. Often the plans are grandiose and unrealistic.
- Irritation or agitation, particularly with people who do not seem to understand your great ideas and plans. Sometimes this can make you aggressive towards people.
- Wanting to do lots of pleasurable things (but these can often lead to painful consequences). For example, you may:
- Spend a lot of money (which you often cannot afford).
- Be less inhibited about your sexual behaviour.
- Make rash decisions, often on the spur of the moment. These can be about jobs, relationships, money, health, etc, and are often disastrous.
- Take part in risky exciting adventures.
- Drink a lot of alcohol, or take illegal drugs.
Severe mania may also cause psychotic symptoms where you lose touch with reality. For example, you may hear voices which are not real (hallucinations), or have false beliefs (delusions). These tend to be delusions of importance (such as believing that you are a famous celebrity).
Usually, you do not realise that you have a problem when you are high. But, as the illness develops, to others your behaviour can be bizarre. Family and friends tend to be the ones who realise that there is a problem. But, if someone tries to point out that you are behaving oddly, you tend to become irritated as you can feel really good.
If mania is not treated, the bizarre and uninhibited behaviour may cause great damage to your relationships, job, career and finances. When you recover from an episode of mania you often regret many of the things that you did when you were high.
Hypomania is the term used when you are high but the symptoms are not as severe or extreme as in true mania. You may function quite well if you have hypomania. For example, you may just appear to be full of energy, the life and soul of the party, work too much but find it difficult to switch off and relax. However, you are still at risk of making rash and dangerous decisions. Family and friends will recognise that you are not your normal self.
What are the symptoms of depression?
The word depressed is a common everyday word. People might say "I'm depressed" when in fact they mean "I'm fed up because I've had a row, or failed an exam, or lost my job", etc. These ups and downs of life are common and normal.
With true depression, you have low mood and other symptoms each day for at least two weeks. Symptoms also become severe enough to interfere with day-to-day functions. The following is a list of common symptoms of depression. You may not have them all but you usually develop several if you have depression:
- Low mood for most of the day, nearly every day.
- Loss of enjoyment and interest in life, even for activities that you normally enjoy.
- Abnormal sadness, often with weepiness.
- Feeling guilty, worthless, or useless.
- Poor motivation. Even simple tasks seem difficult.
- Poor concentration. It may be difficult to read, work, etc.
- Sleeping problems:
- Sometimes difficulty in getting off to sleep.
- Sometimes waking early and being unable to get back to sleep.
- Sleeping too much sometimes occurs.
- Lacking in energy, always feeling tired.
- Difficulty with affection, including going off sex.
- Poor appetite and weight loss. Sometimes the reverse happens with comfort eating and weight gain.
- Being irritable, agitated, or restless.
- Symptoms often seem worse first thing each day.
- Physical symptoms such as headaches, a 'thumping heart' (palpitations), chest pains and aches and pains.
- Repeated (recurrent) thoughts of death. This is not usually a fear of death, more a preoccupation with death and dying. Some people get suicidal ideas - "life's not worth living".
Some people do not realise when they develop depression. They may know that they are not right and are not functioning well but don't know why. Some people think that they have a physical illness - for example, if they lose weight.
How is bipolar disorder diagnosed?
As discussed above, if you have symptoms of mania, often you do not realise that there is anything wrong. It is often your friends or family who are the ones who can see that you are not your usual self. They may encourage you to see your doctor who can usually diagnose an episode of mania from your typical symptoms and the way that you are behaving.
If you go to see your doctor because you have an episode of depression, it can be more difficult to diagnose bipolar disorder. Bipolar disorder is commonly underdiagnosed in people who see a doctor because of depression. This is because depression is common and you may not recognise that in the past you may have had some of the symptoms of mania or hypomania. Equally, this may be your first episode of depression and you may not yet have had any episodes of mania or hypomania.
To help increase the chances of the right diagnosis (if you have had unrecognised episodes of mania or hypomania in the past), your doctor may ask you to complete a simple mood questionnaire to look for possible bipolar disorder. This questionnaire includes questions such as:
- Are there any times in the past when you have felt that you have increased energy?
- Are there any times in the past when you have felt more self-confident than usual?
- Are there any times in the past when you have felt that your thoughts were racing?
Your doctor may also ask if there is a history of bipolar disorder in your family, as this can make it more likely for you.
Sometimes people who are treated with antidepressants for an episode of depression can develop symptoms of mania or hypomania or may fail to respond to the antidepressants. This can also be a sign for your doctor that you actually have bipolar disorder and not just depression.
If your doctor suspects that you may have bipolar disorder, they will usually refer you to a specialist mental health team to confirm the diagnosis and so that treatment can be started.
What is the usual pattern and outcome of bipolar disorder?
Bipolar disorder is a lifelong condition. Some general points include the following:
- The average length for an episode of mania is four months. But for some people it can last much longer.
- In some people, their mood recovers completely between episodes of mania or depression. In others, their mood does not completely recover.
- The average length for an episode of depression is six months but, again, it can be longer.
- You cannot predict how often episodes of mania and depression will occur.
- After recovering from a mood episode, a further episode of mania or depression occurs within one year in about half of cases. Within four years, three out of four people will have had another episode.
- Some people only ever have one episode of mania for a few weeks or months.
- The average number of episodes in a lifetime (where your mood is either very low or elated) is ten.
- As time goes on, the time period of normal mood between episodes of mania or depression tends to get shorter. Also, episodes of depression tend to become more frequent and last for longer.
So, some people have more frequent and severe episodes than others. Because of the nature of the condition, your chance of holding down a job is less than average. Relationships can be strained. Also, you have an increased risk of suicide if depression becomes severe and an increased risk of death from risky adventures during an episode of mania. The outlook is worse if you take street drugs or drink a lot of alcohol.
The course, pattern and outlook of the condition can be improved. However, there is no once and for all cure. Treatment usually means that episodes of mania or depression are shorter and/or may be prevented.
What is the treatment for bipolar disorder?
- Medicines that aim to prevent episodes of mania, hypomania and depression. These are called mood stabilisers. You take these every day, long-term. Mood stabilisers are not needed in everyone. They may be considered, for example, if you have had two episodes of mania, or if you have had suicidal thoughts, or if bipolar disorder is severely affecting your life. You will usually continue treatment for at least two years and often longer.
- Treating episodes of mania, hypomania and depression when they occur.
Lithium is the most commonly used medicine for bipolar disorder in the UK. It comes as a tablet and has been used for many years. However, it is not clear how it works. It is used to treat episodes of mania, hypomania and depression. It is also taken by many people long-term as a mood stabiliser to prevent episodes. Lithium often works well but does not work for everyone. It tends to prevent episodes of mania better than episodes of depression.
One problem with lithium is that the dose for an individual has to be just right. Too low a dose has little effect. Too high a dose and side-effects can be a problem. So, if you take lithium, you need to have blood tests from time to time to check the dose is just right for you.
Sodium valproate, carbamazepine and lamotrigine are used to treat episodes of mania. They are also used long-term as mood stabilisers. (Anticonvulsant medicines are commonly used to treat epilepsy but have been found to work in bipolar disorder too. However, it is not clear how they work in this condition.) Sometimes one of these medicines is used alone. Some people take an anticonvulsant in addition to lithium, if lithium alone does not work so well.
Note: sodium valproate is not usually used in women who could get pregnant. This is because there is a chance that it could harm a developing baby.
An antipsychotic medicine may be used to treat an episode of mania or hypomania. Another name for these is major tranquillisers. They include olanzapine, quetiapine and risperidone - but there are others. Some are more sedating than others. Once one of these medicines is started, the symptoms of mania or hypomania often settle within a week or so.
If an antipsychotic medicine is not effective by itself, you may be advised to take lithium or sodium valproate as well. Antipsychotic medicines may be stopped when the episode of mania or hypomania is over. But olanzapine may sometimes be used as a long-term mood stabiliser.
You will need to have regular check-ups whilst you are taking these medicines. The dose of the medicine is usually built up gradually to help prevent side-effects (including weight gain).
Treating episodes of depression
The treatment of depression in people with bipolar affective disorder is similar to that for people who develop depression without episodes of mania.
- Antidepressant medicines are commonly prescribed:
- Antidepressants work well to relieve symptoms for about 7 out of 10 people.
- The most common one used is fluoxetine.
- They do not usually work straightaway. It takes 2-4 weeks before their effect builds up fully. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. So, do persevere if you are prescribed an antidepressant medicine.
- A normal course of antidepressants is for six months or more after the symptoms of depression have eased. If you stop them too soon the depression may quickly return.
- There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. (The leaflet that comes in the medicine packet provides a full list of possible side-effects.)
- One uncommon problem with antidepressants is that they can trigger an episode of hypomania in some people. For this reason, your doctor may suggest that you are also given a treatment for mania as well as an antidepressant if you are not already on such treatment.
- Lithium may also be used to treat depression as well as being a long-term mood stabiliser. A combination of lithium and an antidepressant may be used to treat an episode of depression.
- Quetiapine may also be used to treat depression if you are not already taking an antipsychotic medicine.
- Cognitive therapy (if available in your area) is another option which can work well to treat depression. It is a talking treatment.
- Other forms of talking treatment include interpersonal therapy and behavioural couples therapy.
- Regular exercise may also help to ease symptoms of depression.
When you have an episode of mania or hypomania, usually you do not realise that you are ill. It is sometimes necessary to give treatment against your will if you have symptoms which are putting you, or other people, at risk of harm. A short admission to hospital is sometimes needed.
Other treatments and new developments
Electroconvulsive therapy (ECT) in which a mild electrical current is passed through the brain, is recommended for severe bipolar disorder which does not respond to treatment with medicines. Research continues to try to find better mood stabiliser medicines. New non-drug treatments such as vagal nerve stimulation are being studied.
Self-help for bipolar disorder
- Try to avoid stressful situations which may trigger an episode of mania or depression. This is often easier said than done. But, a change in lifestyle may be appropriate for some people. The leaflet called Stress and Tips on How to Avoid It may be useful.
- Try to establish a daily routine and schedule daily activities so that you have things to occupy your time. Make sure that you are eating regularly and healthily and getting plenty of sleep. Regularly working excessively long hours and shift work may not be helpful if you have bipolar disorder.
- Try to do some regular relaxing activities (for example, resting in a quiet place). Also, try to become more aware of how you are thinking, feeling and behaving. You may want to keep a diary of your moods, thoughts and reactions to help this.
- Try not to drink much alcohol or take any street drugs. These may trigger an episode of mania.
- If you are prescribed a mood stabiliser medicine, take it regularly. Sometimes, suddenly stopping a mood stabiliser can trigger an episode of mania. So, if you get any side-effects, tell a doctor. The dose or type of medication can often be changed but do this with the advice of a doctor.
- Consider being quite open to family and friends about your condition. If they understand the condition, they may be able to tell if you are becoming ill, even if you do not realise it yourself - particularly, if you are developing an episode of mania. Rather than thinking of you as bizarre they may think of you as ill and may encourage you to get help.
- Learn about your condition. It has been shown that if you are taught to recognise the early stages of mania, you are more likely to seek help and treatment which may prevent a major episode developing. Your doctor or psychiatrist may help to teach you about recognising when to seek help.
- Consider joining a self-help or patient group (see below for details). They are a great source of advice, information, support and help.
- When you are well, consider putting some safeguards on your money so that you cannot overspend if you become high. For example, if you are married, consider putting your bank account solely in the name of your spouse.
- If you are the main or only carer of children (for example, if you are a single parent), it is important that someone else who knows you well should be aware that you may become ill quite quickly and not be able to care for your children properly.
Family and friends
Episodes of mania or depression can be distressing for family and friends; particularly, a first episode of mania. Bizarre and odd behaviour in a close relative or friend, which is out of character, can cause a lot of upset.
It may help once you know the diagnosis. You may then understand that odd behaviour of your friend or loved one is due to mental illness. People with mania usually do not realise they are ill. So, family and friends are often of great help in alerting a doctor or other healthcare worker if symptoms of a new episode of illness develop. Also, try to encourage the affected person to take their medication as prescribed and also to try the self-help measures listed above. Support groups may also provide support for family and carers.
Pregnancy and bipolar disorder
If you are planning to become pregnant, or if you have an unplanned pregnancy, you should contact your doctor or specialist mental health team as soon as possible. You may need a change to your medication. This is because there may be a risk to the development of your unborn baby with some of the medicines used to treat bipolar disorder. However, do not stop any medication abruptly without first speaking to a doctor.
Further reading & references
- Bipolar disorder - the assessment and management of bipolar disorder in adults children and young people in primary and secondary care; NICE Clinical Guideline (Sept 2014, updated 2016)
- Smith DJ, Griffiths E, Kelly M, et al; Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry. 2011 Jul;199:49-56. Epub 2011 Feb 3.
- Lee S, Tsang A, Kessler RC, et al; Rapid-cycling bipolar disorder: cross-national community study. Br J Psychiatry. 2010 Mar;196(3):217-25.
- Zimmerman M, Galione JN; Screening for bipolar disorder with the Mood Disorders Questionnaire: a review. Harv Rev Psychiatry. 2011 Sep-Oct;19(5):219-28.
- Loo C, Katalinic N, Mitchell PB, et al; Physical treatments for bipolar disorder: a review of electroconvulsive therapy, J Affect Disord. 2011 Jul;132(1-2):1-13. Epub 2010 Sep 21.
- Evidence-based guidelines for treating bipolar disorder: revised second edition; British Association for Psychopharmacology (March 2009)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Laurence Knott
Dr John Cox