Bipolar Disorder

What is bipolar disorder?

Bipolar disorder, or manic depression, is a serious brain disorder that causes extreme shifts in mood, energy, and functioning. It affects 2.3 million adult Americans, or 1.2 percent of the population. Bipolar disorder is characterized by episodes of mania and depression that can last from days to months. Bipolar disorder is a chronic condition with recurring episodes that often begin in adolescence or early adulthood. It generally requires ongoing treatment.

What are the symptoms of mania?

Mania is the word that describes the activated phase of bipolar disorder. The symptoms of mania may include:

• either an elated, happy mood or an irritable, angry, unpleasant mood
• increased activity or energy
• more thoughts and faster thinking than normal
• increased talking, more rapid speech than normal
• ambitious, often grandiose, plans
• increased sexual interest and activity
• decreased sleep and decreased need for sleep

What are the symptoms of depression?

Depression is the other phase of bipolar disorder. The symptoms of depression may include:

• depressed or apathetic mood
• decreased activity and energy
• restlessness and irritability
• fewer thoughts than usual and slowed thinking
• less talking and slowed speech
• less interest or participation in, and less enjoyment of activities normally enjoyed
• decreased sexual interest and activity
• hopeless and helpless feelings
• feelings of guilt and worthlessness
• pessimistic outlook
• thoughts of suicide
• change in appetite
• change in sleep patterns

What is a "mixed" state?

A mixed state is when symptoms of mania and depression occur at the same time. During a mixed state depressed mood accompanies manic activation. The symptoms during a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking.

What is rapid cycling?

Sometimes individuals may experience regularly alternating periods of mania and depression. When four or more episodes of illness occur within a 12-month period, the individual is said to have bipolar disorder with rapid cycling. Rapid cycling is more common in women.

What are the causes of bipolar disorder?

While the exact cause of bipolar disorder is not known, researchers believe it is the result of a chemical imbalance in the certain parts of the brain. Scientists have found evidence of a genetic predisposition to the illness. Bipolar disorder tends to run in families, and close relatives of someone with bipolar disorder are more likely to be affected by the disorder. Sometimes serious life events such as a serious loss, chronic illness, or financial problem, can trigger an episode in some individuals with a predisposition to the disorder. There are other possible "triggers" of bipolar episodes: the treatment of depression with an antidepressant medication may trigger a switch into mania, sleep deprivation may trigger mania, or hypothyroidism may produce depression or mood instability. It is important to note that bipolar episodes can also occur without an obvious trigger.

How is bipolar disorder treated?

While there is no cure for bipolar disorder it is a highly treatable and manageable illness. After an accurate diagnosis, most people (80 to 90 percent) can be successfully treated. Medication is an essential part of successful treatment for people with bipolar disorder. Maintenance treatment with a mood stabilizer substantially reduces the number and severity of episodes for most people, although episodes of mania or depression may occur and require a specific additional treatment. In addition, psychosocial therapies including, cognitive-behavioral therapy, interpersonal therapy, family therapy, and psychoeducation are important to help people understand the illness and cope with the stresses that can trigger episodes. Changes in medications or doses may be necessary, as well as changes in treatment plans during different stages of the illness.

• Medications used to treat mania. Two medications commonly used to treat manic episodes of bipolar disorder are called mood stabilizers, and they include lithium (Eskalith or Lithobid) and divalproex sodium (Depakote).
• Lithium has long been used as a first line treatment for acute mania in people with bipolar disorder. Lithium is effective for preventing episodes of mania from occurring and for treating an episode after it has begun. However, for some individuals, lithium is ineffective and for others, lithium has a variety of side effects that may make it an undesirable treatment option.
• Depakote is an anticonvulsant that has been used to treat epilepsy since 1983, but it was approved as a treatment for manic episodes of bipolar disorder in 1995. Depakote seems to be as effective as lithium for treating mania and it has fewer side effects, although it may not be appropriate for people with a history of liver problems.
• Other anticonvulsant medications have also been found to be effective treatments for mania, including carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax). However, these four medications have not been officially approved by the FDA for the treatment of bipolar disorder and have their own side effects.
• Mania may also be treated acutely with antipsychotic medications in addition to a mood stabilizer. More research is needed to test the safety and efficacy of atypical antipsychotics, which may prove to be alternatives in the long-term treatment of bipolar disorder.
• Medications used to treat depression. During depressive episodes, people with bipolar disorder may need additional treatment with an antidepressant medication. Because of the risk of triggering mania, doctors often prescribe lithium or an anticonvulsant mood stabilizer with an antidepressant. Antidepressant medications relieve depression, elevate mood, and activate behavior, but it often takes three to four weeks to respond. Sometimes a variety of different antidepressants and doses will be tried before finding the medication that works best for a particular individual.
• There are several different types of antidepressants used to treat depression including tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), or newer antidepressants that function in different ways.
• Consumers and their families must be cautious during the early stages of treatment when energy levels and the ability to take action return before mood improves. At this time - when decisions are easier to make, but depression is still severe - the risk of suicide may temporarily increase.

What are the side effects of the medications used to treat bipolar disorder?

All medications have side effects. Different medications produce different side effects, and people differ in the amount and severity of side effects they experience. Side effects can often be treated by changing the dose of the medication, switching to a different medication, or treating the side effect directly with an additional medication.

• Side effects of medications used to treat mania.
• Lithium tends to have the most side effects of the mood stabilizers - including hand tremors, excessive thirst, excessive urination, and memory problems - but they often become less troublesome after a few weeks as the body adjusts to the medication. Particularly bothersome tremors can be treated with additional medication. Low thyroid function can be treated with thyroid supplements. In very few people, long-term lithium treatment can interfere with kidney function.
• The other anticonvulsant mood stabilizers tend to have fewer side effects than lithium. Common side effects include nausea, drowsiness, dizziness, and tremors. Some people taking anticonvulsant mood stabilizers may develop liver problems or problems with white blood cell count and blood platelets, which can be severe. Therefore, blood tests to monitor liver function and blood cells may be an important part of treatment with some of these medications.
• Side effects of medications used to treat depression. About half of the people taking antidepressant medications have mild side effects during the first few weeks of treatment.
• Common side effects of tricyclic antidepressants (TCAs) include dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness, drowsiness, skin rash, or weight gain or loss.
• Individuals taking monoamine oxidase inhibitors (MAOIs) may have to be careful about eating certain smoked, fermented, or pickled foods, drinking certain beverages, or taking some medications because they can cause severe high blood pressure in combination with the medication. MAOIs have other, less severe side effects as well.
• The SSRIs and newer antidepressants tend to have fewer and different side effects, such as nausea, nervousness, insomnia, diarrhea, rash, agitation, or sexual problems.

Reviewed by Rex Cowdry, M.D. NAMI medical director, May 2001

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