Bipolar Disorder

Depression in bipolar disorder resembles depression that occurs alone. People with depression feel excessively sad and lose interest in their activities. They think and move slowly and may sleep more than usual. Their appetite may be increased or decreased, and they may gain or lose weight. They may be overwhelmed with feelings of hopelessness and guilt. They may be unable to concentrate or make decisions.

Psychotic symptoms (such as hallucinations and delusions) are more common in depression that occurs in bipolar disorder than in depression that occurs alone.

Episodes of mania end more abruptly than those of depression and are typically shorter, lasting a week or longer.

People with mania feel exuberant, noticeably more energetic, and elated or irritable. They may also feel overly confident, act or dress extravagantly, sleep very few hours, and talk more than usual. Their thoughts race. They are easily distracted and constantly shift from one theme or endeavor to another. They pursue one activity (such as risky business endeavors, gambling, or dangerous sexual behavior) after another, without thinking about the consequences (such as loss of money or injury). However, people often think that they are in their best mental state.

People with mania lack insight into their condition. This lack plus their huge capacity for activity can make them impatient, intrusive, meddlesome, and aggressively irritable when crossed. As a result, they may have problems with social relationships and may feel that they are being treated unjustly or are being persecuted.

Some people have hallucinations, hearing and seeing things that are not there.

Manic psychosis is an extreme form of mania. People have psychotic symptoms that resemble those present in schizophrenia. They may have extremely grandiose delusions, such as of being Jesus. Others may feel persecuted, such as being pursued by the Federal Bureau of Investigation (FBI). Activity level increases markedly. People may race about and scream, swear, or sing. Mental and physical activity may be so frenzied that there is a complete loss of coherent thinking and behavior (delirious mania), causing extreme exhaustion. People so affected require immediate treatment.

Hypomania is not as severe as mania. People feel cheerful, need little sleep, and are mentally and physically active.

For some people, hypomania is a productive time. They have a lot of energy, feel creative and confident, and often function well in social situations. They may not wish to leave this pleasurable state. However, other people with hypomania are easily distracted and easily irritated, sometimes resulting in angry outbursts. They often make commitments that they cannot keep or start projects that they do not finish. They rapidly change moods. They may recognize such effects and be bothered by them, as are the people around them.

When depression and mania or hypomania occur in one episode, people may momentarily become tearful in the middle of elation, or their thoughts may start racing in the middle of depression. Often, people go to bed depressed and wake early in the morning and feel elated and energetic.

The risk of suicide during mixed episodes is particularly high.

Lithium helps prevent mood swings in many people with bipolar disorder. Because lithium takes 4 to 10 days to work, a medication that works more rapidly, such as an antiseizure or a newer (second-generation) antipsychotic medication, is often given to control excited thought and activity. People with a family history of typical bipolar disorders are more likely to respond to lithium.

Lithium can have side effects. It can cause drowsiness, confusion, involuntary shaking (tremors), muscle twitching, nausea, vomiting, diarrhea, thirst, excessive urination, and weight gain. It often worsens a person's acne or psoriasis. However, these side effects are usually temporary and are often lessened or relieved when doctors adjust the dose. Sometimes lithium must be stopped because of side effects, which then resolve.

Doctors monitor the level of lithium in the blood with regular blood tests because if levels are too high, side effects are more likely. Long-term use of lithium can cause low levels of thyroid hormone (hypothyroidism) and can impair kidney function. Therefore, thyroid and kidney function must be monitored with regular blood tests, and the lowest effective dose is used.

occurs when the level of lithium in the blood is very high. It causes persistent headaches, mental confusion, drowsiness, seizures, and abnormal heart rhythms. Toxicity is more likely to occur in the following:

• Older adults

• People with impaired kidney function

• People who have lost a lot of sodium through vomiting, diarrhea, or use of diuretics (which make the kidneys excrete more sodium and water in urine)

Women who are trying to become pregnant or are pregnant must stop taking lithium because rarely, lithium can cause heart defects in a developing fetus.

The antiseizure medications valproate and act as mood stabilizers. They may be used to treat mania when it first occurs or to treat mania and depression when they occur together (mixed episode). Unlike lithiumValproate is usually not prescribed for women with bipolar disorder if they are pregnant or of childbearing age because the medication appears to increase the risk of brain or spinal cord birth defects (neural tube defects), attention-deficit/hyperactivity disorder, and autism in the fetus. Valproate and carbamazepine can be useful, especially when people have not responded to other treatments.

is sometimes used to help control mood swings and treat depression. Lamotrigine can cause a serious rash. Rarely, the rash becomes the life-threatening Stevens-Johnson syndrome. People who are taking lamotrigine should watch for any new rash (particularly in the area around the rectum and genitals), fever, swollen glands, blistering sores in the mouth or on the eyes, and swelling of the lips or tongue. They should report these symptoms to the doctor. To reduce the risk of developing these symptoms, doctors carefully follow the recommended schedule for increasing the dose. The medication is started at a relatively low dose, which is increased very slowly (over a period of weeks) to the recommended maintenance dose. If doses are interrupted for 3 days or more, the schedule for gradually increasing the dose must begin again.

Sudden manic episodes are increasingly treated with second-generation antipsychotics

For bipolar depression, certain antipsychotics may be the best choice. Some of them are given with an antidepressant.

Long-term side effects of antipsychotics may include weight gain and the metabolic syndrome. Metabolic syndrome is excess fat in the abdomen with reduced sensitivity to insulin’s effects (insulinrisperidone, which has been associated with a small increase the risk of birth defects.

Certain antidepressants are sometimes used to treat severe depression in people with bipolar disorder, but their use is controversial. Therefore, these medications are used only for short periods and usually are given along with a mood-stabilizing medication or an atypical antipsychotic.

Electroconvulsive therapy (ECT—sometimes known as "shock therapy") is sometimes used for treatment-resistant depression and mania. 

Phototherapy, in which people look at bright lights that simulate sunlight, can be useful in treating seasonal (with autumn-winter depression and spring-summer hypomania) or nonseasonal bipolar I or bipolar II disorder. It is probably most useful when used to supplement other treatments. 

Transcranial magnetic stimulation, in which a device applies a harmless magnetic field to the head, used in the treatment of severe, resistant depression, has also proven effective in the treatment of bipolar depression.

Psychotherapy is often recommended for people taking mood-stabilizing medications, mostly to help them take their treatment as directed.

Group therapy often helps people and their partners or relatives understand bipolar disorder and its effects.

Individual psychotherapy may help people learn how to better cope with problems of daily living.

Learning about the effects of the medications used to treat the disorder can help people take them as directed. People may resist taking the medications because they believe that these medications make them less alert and creative. However, decreased creativity is relatively uncommon because mood stabilizers usually enable people to function better at work and school and in relationships and artistic pursuits.

Doctors or therapists may talk to people about the consequences of their actions. For example, if people are inclined to sexual excesses, they are given information about how their actions can affect their relationships and about health risks of promiscuity, particularly AIDS. If people tend to be financially extravagant, they may be advised to turn their finances over to a trusted family member.

It is important for family members to understand bipolar disorder, be involved in treatment, and provide support.

Support groups can help by providing a forum to share common experiences and feelings.