Bipolar Disorder

Bipolar disorder is a lifelong mental health condition that causes extreme mood swings, from emotional highs called mania to lows known as depression. Although it cannot be cured, it can be managed effectively with the right treatment and lifestyle changes.

Table of contents

• What is Bipolar Disorder?
• Types of Bipolar Disorder
• Symptoms and Mood Episodes
• Who is Affected by Bipolar Disorder?
• How is Bipolar Disorder Diagnosed?
• Treatment Options
• Lifestyle Changes and Self-Management
• Living with Bipolar Disorder

manic depression, manic-depressive illness

What is Bipolar Disorder?

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings^[1]. These mood swings include emotional highs, known as mania or hypomania (a less severe form of mania), and lows, known as depression^[1].

When experiencing a manic episode, a person feels very excited and happy, full of energy, or unusually irritable. During a depressive episode, they may feel sad or hopeless and lose interest or pleasure in most activities^[1]. These mood swings can affect sleep, energy, activity levels, judgment, behavior, and the ability to think clearly^[1].

Episodes of mood swings from depression to mania may occur rarely or multiple times a year. Each bout usually lasts several days^[1]. Between episodes, some people have long periods of emotional stability known as euthymia. Others may frequently have mood swings from depression to mania, or experience both depression and mania at the same time^[4].

Although bipolar disorder is a lifelong condition, people can manage their mood swings and other symptoms by following a treatment plan. In most cases, healthcare professionals use medicines and talk therapy, also known as psychotherapy, to treat bipolar disorder^[1].

Types of Bipolar Disorder

There are several types of bipolar disorder, each with its own characteristics^[1]:

Bipolar I disorder is characterized by at least one manic episode that may come before or after hypomanic or major depressive episodes^[1]. To be diagnosed with bipolar I disorder, a person must have had at least one manic episode in their life for at least a week, with or without ever experiencing a depressive episode^[4]. In some cases, mania may cause a break from reality called psychosis^[1].

Bipolar II disorder is defined by at least one major depressive episode and at least one hypomanic episode, but the person has never had a full manic episode^[1]. The manic episodes are not as severe as in bipolar I and may be shorter in duration^[3].

Cyclothymic disorder, also called cyclothymia, involves many periods of hypomanic symptoms and periods of depressive symptoms lasting for at least two years, or one year in children and adolescents^[16]. People with this condition tend to move between episodes of depression and mania more quickly. The symptoms do not meet the criteria for bipolar I or bipolar II disorder^[3].

Symptoms and Mood Episodes

The main symptom of bipolar disorder is extreme changes in mood. People sometimes have either high moods such as mania or hypomania, or low moods such as depression^[7]. These moods usually last a few days or weeks at a time^[7].

High Mood Symptoms (Mania and Hypomania)

High moods in bipolar disorder can be severe, called mania, or mild, called hypomania^[7]. Symptoms of high mood include:

• Feeling very happy and excited
• Feeling very irritable or aggressive
• Having a lot of energy, feeling restless, or not needing much sleep
• Racing thoughts or difficulty concentrating
• Speaking fast or talking a lot, sometimes not making sense to others
• A high sex drive
• Feeling overly confident or adventurous
• Being impulsive or extravagant, such as spending lots of money
• Saying or doing things that are rude, inappropriate, or not usual
• Hearing things that are not real, believing things that are not true, or feeling paranoid^[7]

Mania is a condition in which a person has a period of abnormally elevated or irritable mood, as well as extreme changes in emotions, thoughts, energy, talkativeness, and activity level^[4]. This highly energized level of physical and mental activity and behavior is a change from their usual self and is noticeable by others^[4]. People who are in manic states may indulge in activities that cause them physical, social, or financial harm, such as suddenly spending or gambling extreme amounts of money or driving recklessly^[4].

Low Mood Symptoms (Depression)

During a depressive episode, a person experiences a low or depressed mood and loss of interest in most activities^[4]. Symptoms of low mood in bipolar disorder include:

• Feeling sad or upset
• Not being interested in things they usually enjoy
• Low energy or feeling very tired
• Difficulty sleeping or sleeping a lot
• Eating too much or too little
• Low confidence
• Feeling worthless or hopeless
• Not being able to concentrate
• Avoiding seeing or spending time with other people
• Having suicidal thoughts or thoughts about harming themselves^[7]

Mixed Episodes and Psychosis

Sometimes people experience both depressive and manic symptoms at the same time, which is called a mixed episode^[3]. Some people with bipolar disorder also experience symptoms of psychosis during a manic or depressive episode. Psychosis, or loss of contact with reality, leads the person to be unsure of what’s real and what’s not^[3]. Symptoms of psychosis include unusual beliefs or perceptions, like believing things that are not true or seeing or hearing things that others don’t^[3].

Who is Affected by Bipolar Disorder?

Approximately 10 million people in the United States have bipolar disorder^[3]. Worldwide, an estimated 37 million people, or 0.5% of the global population, were living with bipolar disorder in 2021^[6]. The condition affects approximately 2.8% of adults in the United States^[5].

Bipolar disorder impacts men and women equally^[3]. The condition is primarily observed among working-age people but also occurs in youth^[6]. Bipolar disorder is typically diagnosed during later teen years or early adulthood, though symptoms can often show up in young children^[3].

Data shows that people with specific genes may have a higher chance of developing bipolar disorder. In fact, bipolar disorder is one of the most heritable mental health conditions^[5]. Being mistreated in childhood is another possible contributor to developing bipolar disorder later in life, particularly when the mistreatment includes emotional abuse or neglect^[5].

How is Bipolar Disorder Diagnosed?

To find out if someone has bipolar disorder, the evaluation may include a physical exam, mental health assessment, and mood charting^[8].

A healthcare professional may do a physical exam and lab tests to find any medical problems that could be causing the symptoms^[8]. If a doctor thinks a person may have bipolar disorder or another mental health condition, they will refer them to a mental health specialist called a psychiatrist^[7].

The mental health specialist will ask about things like moods, behavior, health, and family history^[7]. The person may also answer a series of questions. With permission, family members or close friends may be asked to provide information about symptoms^[8].

A person may be asked to keep a daily record of their moods, sleep patterns, or other factors that could help make the right diagnosis and get the right treatment^[8]. Bipolar disorder can take time to diagnose because it affects everyone differently and the symptoms are similar to other mental health conditions^[7].

Treatment Options

Treatment is best guided by a psychiatrist who is skilled in treating bipolar and related disorders^[8]. A mental health specialist will work with each person to create a treatment plan^[7].

Medications

Medications are a first-line treatment for bipolar disorder and should be continued indefinitely because of the risk of relapse^[11]. Several types of medicines are used to treat bipolar disorder:

Mood stabilizers such as lithium are commonly used. Lithium has the strongest evidence for long-term relapse prevention^[10]. Lithium, valproic acid, and some antipsychotics are effective single agents for acute mania^[11].

Anticonvulsants such as valproate, lamotrigine, carbamazepine, and oxcarbazepine may be used^[1]. However, the evidence for anticonvulsants such as divalproex and lamotrigine is less robust compared to lithium^[10].

Antipsychotic drugs are effective in the acute treatment of mania^[10]. Their effectiveness in treating depression varies, with the clearest evidence for quetiapine^[10]. Quetiapine and cariprazine are effective single agents for the treatment of acute bipolar depression^[11]. There is much uncertainty about the longer-term benefits of antipsychotics^[10].

The medicines can cause side effects, which vary depending on which medicine is taken and how the body responds to it^[7]. It’s important not to stop taking bipolar disorder medicine unless told to by a doctor, even if feeling better^[7]. Some medicines for bipolar disorder are not safe to take if pregnant, so it’s important to talk to a doctor if pregnant or planning a pregnancy^[7].

Combination Therapy

Effective combination therapies for acute mania include lithium or valproic acid with quetiapine or risperidone^[11]. Lurasidone combined with lithium or valproic acid is an effective treatment for acute bipolar depression^[11]. Lithium, quetiapine, or a combination of quetiapine and lithium or valproic acid is effective for maintenance of bipolar disorder^[11].

Talk Therapy

Treatments may include talking therapy such as cognitive behavioral therapy, or CBT^[7]. Substantial progress has been made in the development and assessment of adjunctive psychosocial interventions. Long-term maintenance and possibly acute stabilization of depression can be enhanced by the combination of psychosocial treatments with drugs^[10].

Psychotherapy is a useful adjunct to pharmacotherapy^[11]. Cognitive behavioral, interpersonal, and psychodynamic therapies can be used in addition to medications. Psychoeducation is reported to be beneficial^[12].

Other Treatments

Electroconvulsive therapy, or ECT, can be used as a maintenance treatment^[12]. A person will usually have appointments at a doctor’s office, clinic, or hospital. If doctors are worried someone is at risk of self-harm, suicide, or harming someone else, they may need to stay in hospital or have support from a crisis team at home^[7].

Lifestyle Changes and Self-Management

If someone has bipolar disorder, it’s important to know what can trigger their high and low moods. This can include things like feeling stressed, not getting enough sleep, or being too busy^[7]. Incorporating lifestyle adjustments can act as powerful complements to professional treatment, helping to stabilize mood, reduce symptom severity, and improve overall well-being^[16].

Avoiding Triggers

Certain things are known to set off episodes of depression or mania^[15]. Some triggers may not be under a person’s control, such as the death of a loved one, a divorce, the loss of a job, or even a change in the weather. There is more control over other triggers, like stress, a lack of sleep, alcohol and drug use, and poor nutrition^[15].

Establishing a Regular Routine

Setting a regular routine can help stabilize mood and create a sense of predictability^[16]. Many people with bipolar disorder find that if they stick to a daily schedule, it helps them control their mood^[18]. Try to wake up, eat meals, take medication, and go to bed around the same time every day^[16].

Getting Regular Sleep

Sleep is especially important for people with bipolar disorder. Being sleep-deprived can sometimes trigger mania. A lack of sleep also can trigger more mood symptoms^[15]. Just a few nights of less sleep may mean that a manic episode could be coming on. Or if someone starts to sleep a lot more than normal, it might mean they’re depressed^[18].

Try to go to bed at the same time each night and wake up at the same time each morning to keep on a consistent schedule^[15]. Aim for seven to nine hours of sleep each night^[16]. Avoid anything stimulating before bedtime, like caffeine, alcohol, or engaging with a digital device^[15].

Staying Active

Aerobic activity, whether it takes the form of a daily brisk walk, a bike ride, or laps in the pool, is well known to release mood-boosting chemicals called endorphins^[15]. Exercise has been shown to be helpful during depressive episodes and can have a calming effect for some people with mania^[15]. It may improve mood whether or not someone has bipolar disorder, and they’ll probably sleep better, too^[18].

Following a Healthy Diet

In general, it is best to eat vegetables, fruits, fish, and whole grains. Try to limit or avoid sugar, caffeine, and alcohol, which may worsen mood disturbances^[15]. A review of 60 studies on nutrition and bipolar disorder found that omega-3 fatty acids, the unsaturated fats found in fatty fish like salmon and tuna as well as in flaxseeds and walnuts, may help improve bipolar symptoms^[15].

Managing Stress

Stress is a major trigger for bipolar episodes. Bipolar disorder can also make it more difficult to recover from stress^[15]. Find the stress relief strategy that works best. Some may respond best to a relaxation technique like yoga or meditation, prefer to release anxiety in a journal, or choose to distract themselves with a funny TV show or movie^[15].

Things to Avoid

There are some things that can help keep moods stable^[7]:

• Do not take recreational drugs
• Do not smoke
• Do not drink too much alcohol
• Do not do shift work or work very long hours if it can be avoided
• Do not fly at night or across time zones if it can be avoided
• Do not drink lots of caffeinated drinks such as coffee, tea, or cola^[7]

Alcohol and drugs can affect how medications work. They can also worsen bipolar disorder and trigger a mood episode, making the condition harder to treat. So don’t use them at all^[18].

Living with Bipolar Disorder

Bipolar disorder is a lifelong condition that is one of the leading causes of disability globally as it can affect many areas of life^[6]. People with bipolar disorder may experience strained relationships, problems at school or work, and difficulties in carrying out daily activities^[6].

Having bipolar disorder also increases the risk of suicide and of developing anxiety and substance use disorders^[6]. People with bipolar disorder are more likely to smoke, use alcohol, have a physical health condition such as cardiovascular or respiratory disease, and experience difficulties in accessing health care^[6].

On average, people with bipolar disorder die 13 years earlier than the general population^[6]. However, with treatment, people with bipolar disorder can truly thrive^[5]. While the condition cannot be cured, there are treatments that can help manage it^[7].

Patients and their support systems should be educated about the chronic nature of this illness, possible relapse, suicidality, environmental triggers such as seasonal light changes and shift work or other circadian disruption, and the effectiveness of early intervention to reduce complications^[11].

Stigma and discrimination against people with bipolar disorder are widespread, both in communities and health services. This can undermine access to health care and fuel social exclusion, limiting opportunities for education, employment, and housing^[6].

If someone has extreme changes in their moods that last a long time or impact their everyday life, or if they’ve been diagnosed with bipolar disorder and treatments are not helping, they should see a doctor^[7]. If worried about someone else, encourage them to speak to their doctor^[7].