What is bipolar disorder?
(Taken from the Royal college of Psychiatrists Website, www.rcpsych.ac.uk)
Bipolar disorder used to be called ‘manic depression’. As the older name suggests, someone with bipolar disorder will have severe mood swings. These usually last several weeks or months and are far beyond what most of us experience. They are:
Low or ‘depressive’ feelings of intense depression and despair
High or ‘manic’ feelings of extreme happiness and elation
Mixed for example, depressed mood with the restlessness and overactivity of a manic episode
How common is bipolar disorder?
About 1 in every 100 adults has bipolar disorder at some point in their life. It usually starts during or after the teenage years. It is unusual for it to start after the age of 40. Men and women are affected equally.
What types are there?
¦There has been at least one high or manic episode, which has lasted for longer than one week.
¦Some people with Bipolar I will have only manic episodes, although most will also have periods of depression.
¦Untreated, manic episodes generally last 3 to 6 months.
¦Depressive episodes last rather longer – 6 to 12 months without treatment.
¦There has been more than one episode of severe depression, but only mild manic episodes – these are called ‘hypomania’.
¦More than four mood swings happen in a 12 month period. This affects around 1 in 10 people with bipolar disorder, and can happen with both types I and II.
¦The mood swings are not as severe as those in full bipolar disorder, but can be longer. This can develop into full bipolar disorder.
What causes bipolar disorder?
We don’t understand this well, but research suggests that:
¦Bipolar disorder runs in families – it seems to have more to do with genes than with upbringing.
¦There may be a physical problem with the brain systems which control our moods – this is why bipolar disorder can often be controlled with medication.
¦Episodes can sometimes be brought on by stressful experiences or physical illness.
What does it feel like?
This depends on which way your mood has swung.
The feeling of depression is something we all experience from time to time. It can even help us to recognise and deal with problems in our lives but in clinical depression or bipolar disorder, the feeling of depression is worse. It goes on for longer and makes it difficult or impossible to deal with the normal things of life. If you become depressed, you will notice some of these changes:
¦feelings of unhappiness that don’t go away
¦feeling that you want to burst into tears for no reason
¦losing interest in things
¦being unable to enjoy things
¦feeling restless and agitated
¦feeling useless, inadequate and hopeless
¦feeling more irritable than usual
¦thinking of suicide.
¦can’t think positively or hopefully
¦finding it hard to make even simple decisions
¦difficulty in concentrating.
¦losing appetite and weight
¦difficulty in getting to sleep
¦waking earlier than usual
¦feeling utterly tired
¦going off sex.
¦difficulty in starting or completing things – even everyday chores
¦crying a lot – or feeling like you want to cry, but not being able to
¦avoiding contact with other people.
Mania is an extreme sense of well-being, energy and optimism. It can be so intense that it affects your thinking and judgement. You may believe strange things about yourself, make bad decisions, and behave in embarrassing, harmful and – occasionally – dangerous ways.
Like depression, it can make it difficult or impossible to deal with life in an effective way. A period of mania can affect both relationships and work. When it isn’t so extreme, it is called ‘hypomania’.
If you become manic, you may notice that you are:
¦very happy and excited
¦irritated with other people who don’t share your optimistic outlook
¦feeling more important than usual.
¦full of new and exciting ideas
¦moving quickly from one idea to another
¦hearing voices that other people can’t hear.
¦full of energy
¦unable or unwilling to sleep
¦more interested in sex.
¦making plans that are grandiose and unrealistic
¦very active, moving around very quickly
¦talking very quickly – other people may find it hard to understand what you are talking about
¦making odd decisions on the spur of the moment, sometimes with disastrous consequences
¦recklessly spending your money
¦over-familiar or recklessly critical with other people
¦less inhibited in general.
If you are in the middle of a manic episode for the first time, you may not realise that there is anything wrong – although your friends, family or colleagues will. You may even feel offended if someone tries to point this out to you. You increasingly lose touch with day-to-day issues – and with other people’s feelings.
If an episode of mania or depression becomes very severe, you may develop psychotic symptoms.
¦In a manic episode – these will tend to be grandiose beliefs about yourself – that you are on an important mission or that you have special powers and abilities.
¦In a depressive episode – that you are uniquely guilty, that you are worse than anybody else, or even that you don’t exist.
As well as these unusual beliefs, you might experience hallucinations – when you hear, smell, feel or see something, but there isn’t anything (or anybody) there to account for it.
It used to be thought that if you had bipolar disorder, you would return to normal in between mood swings. We now know that this is not so for many people with bipolar disorder. You may continue to experience mild depressive symptoms and problems in thinking even when you seem to be better.
There are some things you can try to control mood swings so that they stop short of becoming full-blown episodes of mania or depression. These are mentioned below, but medication is still often needed to:
¦keep your mood stable (prophylaxis)
¦treat a manic or depressive episode.
Medications to stabilise mood
There are several mood stabilisers, most of which are also used to treat epilepsy. However, Lithium (a naturally occurring salt) was the first effective mood stabiliser.
Lithium has been used as a mood stabiliser for 50 years – but how it works is still not clear. It can be used to treat both manic and depressive episodes.
Treatment with Lithium should be started by a psychiatrist. The difficulty is getting the level of Lithium in the body right – too low and it won’t work, too high and it becomes toxic. So, you will need regular blood tests in the first few weeks to make sure that you are getting the right dose. Once the dose is stable, your GP can prescribe your Lithium and arrange the regular blood tests.
The amount of Lithium in your blood is very sensitive to how much, or how little, water there is in your body. If you become dehydrated, the level of Lithium in your blood will rise, and you will be more likely to get side-effects, or even toxic effects. So, it’s important to:
¦drink plenty of water – more in hot weather or when you are active
¦be careful with tea and coffee – they increase the amount of water you pass in your urine.
It can take three months or longer for Lithium to work properly. It’s best to carry on taking the tablets, even if your mood swings continue during this time.
These can start in the first few weeks after starting Lithium treatment. They can be irritating and unpleasant, but often disappear or get better with time.
¦passing more urine than usual
Less common side-effects are:
¦slight muscle weakness
¦fine trembling of the hands
¦a feeling of being mildly ill.
These can usually be improved by lowering the dose of Lithium.
The following signs suggest that your Lithium level is too high. Contact your doctor immediately if you notice:
¦you feel very thirsty
¦you have bad diarrhoea or vomiting
¦obvious shaking of your hands and legs
¦twitching of your muscles
¦you get muddled or confused.
At first you will need blood tests every few weeks to make sure that you have the right level of Lithium in your blood. You will need these tests for as long as you take Lithium, but less often after the first few months.
Long-term use of Lithium can affect the kidneys or the thyroid gland. It is wise to have blood tests every few months to make sure that they are working properly. If there is a problem, you may need to stop Lithium and consider an alternative.
Taking care of yourself
¦Eat a well-balanced diet.
¦Drink unsweetened fluids regularly. This helps to keep your body salts and fluids in balance.
¦Eat regularly – this will also help to maintain your fluid balance.
¦Watch out for caffeine – in tea, coffee or cola. This makes you urinate more, and so can upset your Lithium level.
Other mood stabilisers
There are other medications, apart from Lithium, that can be used to help.
¦It is possible that Sodium Valproate, an anti-convulsant, works just as well as Lithium, but we don’t yet have enough evidence to be sure. It should not be prescribed to women of child-bearing age.
¦Olanzapine, an antipsychotic medication.
¦Carbamazepine and Lamotrigine are also effective for some people.
What is the best treatment for me?
You need to discuss this with your doctor, but some general principles are:
¦Lithium, Sodium Valproate and Olanzapine will usually be recommended for long-term treatment.
¦Carbamazepine may be suggested if you have faster and more frequent mood swings.
¦Lamotrigine may be suggested for bipolar II disorder.
¦Sometimes a combination of drugs is needed.
Much depends on how well you get on with a particular medication. What suits one person may not suit another, but it makes sense to first try the medications for which there is better evidence.
What will happen without medication?
Lithium reduces your chance of relapse by 30–40%, but the more manic episodes you’ve had, the more likely you are to have another one.
As you get older, the risk of getting further episodes stays much the same. Even if you have been well for a long time, you still run the risk of having another episode.
When to start a mood stabiliser
After just one episode, it’s difficult to predict how likely you are to have another. You may not want to start medication at this stage – unless your episode was very severe and disruptive.
If you have a second episode, there is a strong chance of further episodes – so most psychiatrists would usually recommend a mood stabiliser at this point.
For how long should a mood stabiliser be continued?
For at least two years after one episode of bipolar disorder, and for up to five years if there have been:
¦frequent previous relapses
¦alcohol or substance misuse
¦continuing stress at home or at work.
If you continue to have troublesome mood swings, you may need to continue medication for longer.
In between episodes of mania or depression, psychological treatments can be helpful. Treatment usually involves around 16 one-hour sessions over a period of 6 to 9 months.
Psychological treatment should include:
¦psychoeducation – finding out more about bipolar disorder
¦mood monitoring – helps you to pick up when your mood is swinging
¦mood strategies – to help you stop your mood swinging into a full-blown manic or depressive episode
¦help to develop general coping skills
¦cognitive behavioural therapy (CBT) for depression.
You should discuss any pregnancy plans with your psychiatrist. Together, you can arrange how to manage your mood during the pregnancy and for the first few months after the baby arrives.
If you are pregnant, it’s best to discuss with your psychiatrist whether or not to stop Lithium. Although Lithium is safer in pregnancy than the other mood stabilisers, the risk to the baby needs to be weighed against the risk of you becoming depressed or manic. The risk is greatest during the first three months of pregnancy. Lithium is safe after the 26th week of pregnancy, although you should not breastfeed your baby if you are taking Lithium.
During pregnancy, everyone involved – the obstetrician, midwives, health visitors, GP, psychiatrist, and community psychiatric nurse – need to stay in touch with each other.
Treating a manic or depressive episode
¦If your depression is moderately severe, your doctor may well recommend an SSRI antidepressant.
¦If you are already on Lithium or Sodium Valproate, then sometimes adding Quetiapine can help.
¦If you have had a recent manic episode or have a rapid-cycling disorder, an antidepressant may push you into a manic swing. It may be safer to increase the dose of the mood stabiliser, without an antidepressant.
¦Antidepressants can take between 2 and 6 weeks to improve your mood, but sleep and appetite often improve first. Antidepressants should be continued for at least 8 weeks after the depression has improved, and then consider stopping them by tailing off the dose slowly.
¦If you have repeated depressive episodes, but have never switched to mania on antidepressants, you can continue on both a mood stabiliser and an antidepressant to prevent further episodes.
¦If you have had manic episodes, you should not continue antidepressants long-term.
Mania and mixed depressive episodes
Any antidepressant should be stopped. Lithium, Sodium Valproate, Olanzapine, Quetiapine or Risperidone are most often used to treat a manic episode.
Once the treatment has started, symptoms usually improve within a few days, but it may take several weeks for a full recovery. You should check with your doctor if you want to drive while taking this sort of medication.
Stopping the mood swings – helping yourself
Learn how to recognise the signs that your mood is swinging out of control so you can get help early. You may be able to avoid both full-blown episodes and hospital admissions. Keeping a mood diary can help to identify the things in your life that help you – and those that don’t.
Find out as much as you can about your illness.
Try to avoid particularly stressful situations – these can trigger off a manic or depressive episode. It’s impossible to avoid all stress, so it may be helpful to learn ways of handling it better. You can do relaxation training with CDs or DVDs, join a relaxation group, or seek advice from a clinical psychologist.
¦Depression or mania can cause great strain on friends and family – you may have to rebuild some relationships after an episode.
¦It’s helpful if you have at least one person that you can rely on and confide in. When you are well, try explaining the illness to people who are important to you. They need to understand what happens to you – and what they can do for you.
Try to balance your life and work, leisure, and relationships with your family and friends. If you get too busy you may bring on a manic episode.
Make sure that you have enough time to relax and unwind. If you are unemployed, think about taking a course, or doing some volunteer work that has nothing to do with mental illness.
Reasonably intense exercise for 20 minutes or so, three times a week, seems to improve mood.
Make sure you regularly do things that you enjoy and that give your life meaning.
Continue with medication
You may want to stop your medication before your doctor thinks it is safe – unfortunately this often leads to another mood swing. Talk it over with your doctor and your family when you are well.
Have your say in how you are treated
If you have been admitted to hospital for bipolar disorder, you may want to write an ‘advance directive’ with your doctor and family to say how you want to be treated if you become ill again.
What can I expect from my GP? (England & Wales only)
If you are taking Lithium or any other medication for your bipolar disorder, your GP is now expected to give you an annual physical health check. This will include:
¦a blood pressure
¦smoking and alcohol use
¦plasma glucose levels
¦lipid levels – for all patients over the age of 40.
A Lithium level check will need to be done every 3-6 months and a blood test for thyroid and kidney function at least every 15 months.
Advice for family and friends
Mania or depression can be distressing – and exhausting – for family and friends.
Dealing with a mood episode
It can be difficult to know what to say to someone who is very depressed. They see everything in a negative light and may not be able to say what they want you to do. They can be withdrawn and irritable, but at the same time need your help and support. They may be worried, but unwilling or unable to accept advice. Try to be as patient and understanding as possible.
At the start of a manic mood swing, the person will appear to be happy, energetic and outward-going – the ‘life and soul’ of any party or heated discussion. However, the excitement of such situations will tend to push their mood even higher. So try to steer them away from such situations. You can try to persuade them to get help, or get them information about the illness and self-help.
Practical help is very important – and much appreciated. Make sure that your relative or friend is able to look after themselves properly.
Helping your loved ones stay well
In between mood episodes, find out more about bipolar disorder. It may be helpful to go with your friend or loved one to any appointments with the GP or psychiatrist.
Staying well yourself
Give yourself space and time to recharge your batteries. Make sure that you have some time on your own, or with trusted friends who will give you the support you need. If your relative or friend has to go into hospital, share the visiting with someone else. You can support your friend or relative better if you are not too tired.
Dealing with an emergency
¦In severe mania, a person can become hostile, suspicious and verbally or physically explosive.
¦In severe depression, a person may start to think of suicide.
If you find that they are:
¦seriously neglecting themselves by not eating or drinking
¦behaving in a way that places them, or others, at risk
¦talking of harming or killing themselves
get medical help immediately.
Keep the name of a trusted professional (and their telephone number) for any such emergency. A short admission to hospital may sometimes be needed.