Previously referred to as manic-depressive disorder, bipolar disorder affects about one out of every 100 people. It is a major risk for suicide, it has a high correlation with other physical and mental illnesses, and its economic impact on affected individuals and their families can be severe. While manic (highly energized, very active and sometimes euphoric), a person with bipolar illness may impulsively spend hundreds or even thousands of dollars, and while depressed may be completely unable to rise from bed in the morning. In 1991, the National Institute of Mental Health estimated that the disorder cost the United States $45 billion in patient care costs and lost productivity.
While manic symptoms are the hallmark distinguishing bipolar disorder from typical depression, they are frequently not apparent at the initial presentation of the illness. Thus, despite its potential severity, bipolar disorder can elude diagnosis. Some experts estimate only one-third of people with bipolar disorder are diagnosed, and of those, only one-third receive appropriate treatment. Many factors contribute to underdiagnosis. People with bipolar disorder may function well in between episodes, and since manic symptoms can feel good, patients often do not report them to their physicians. Because regular antidepressants often worsen mood symptoms in bipolar illness, a careful evaluation to rule out bipolar disorder should take place when depression fails to respond to a number of antidepressants.
Once it appears, bipolar disorder is generally a lifelong illness characterized by intermittent mood episodes lasting from days to weeks or months. The current classification system in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) recognizes bipolar I disorder and bipolar II disorder, distinguished from each other by the pattern and severity of symptoms in the manic phase. In instances where evidence of a bipolar pattern is present but the specific criteria for these two disorders are not met, the classification bipolar disorder not otherwise specified (NOS) may be used. Additional classification schemes have been proposed to expand the bipolar NOS category (including a bipolar III category for those whose illness is triggered by medications or other medical conditions) and may be incorporated into the next DSM edition.
Classic bipolar I disorder involves episodes of major depression alternating with episodes of acute mania. Mania is a distinct mood episode different from the person’s normal functioning, characterized by either euphoria (an intensely pleasurable feeling of being high), extreme irritability or both. Additionally, mania is accompanied by several of the following symptoms (often remembered with the acronym DIGFAST): Distractibility—inability to maintain attention for any significant period of time; Insomnia—high energy or a feeling the body requires less sleep; Grandiosity—an inflated sense of self-worth or ability that can reach delusional proportions (for instance, that people are very rich, know celebrities intimately, have multiple educational degrees, have special powers, possess unique religious or spiritual insights or have achieved breakthroughs in academics or logic that no one else can understand); Flight of ideas—thoughts that race through the person’s head, jumping quickly from one topic to another; Activity—a sense of physical restlessness or an increase in goal-directed activity, with a launch into multiple projects or unusual social or sexual interest; Speech—loud, rapid speech that is difficult to interrupt and irritable in tone, with frequent arguments that seem to come without provocation; Thoughtlessness—impulsive and high-risk activities (for instance, spending sprees, promiscuity or spur-of-the-moment trips) without thought to consequences. If symptoms threaten the safety of the person with bipolar disorder or those in his or her care, hospitalization may be necessary until the episode stabilizes.
The depressive phase of bipolar illness includes several of the following: sad mood; fatigue or loss of energy; changes in sleep (either insomnia or excessive sleeping); appetite changes (either decrease or increase); difficulty concentrating; loss of interest in most activities; loss of pleasure; feelings of guilt, helplessness or worthlessness; either restlessness or extreme slowing of thought and actions; and thoughts of death or suicide.
Two additional mood episode patterns are mixed episodes and rapid cycling. In mixed episodes, the agitation of mania and the low mood and hopelessness of depression occur simultaneously. Because the depressed mood in mixed episodes occurs along with physical restlessness and impulsivity, mixed episodes present a particularly high risk period for suicide. In rapid cycling, individuals switch between manic and depressive phases at least four times per year, and in severe cases several times within the same day.
At times during manic or depressive episodes, bipolar I patients may experience psychotic symptoms such as paranoia, delusions (false beliefs), hallucinations (seeing or hearing things that are not there) or disorganization (jumbled, nonsensical thought patterns). Because of these psychotic symptoms, it is sometimes hard during a single episode to distinguish bipolar disorder from other psychotic illnesses such as schizophrenia. One difference is that in bipolar disorder the psychotic symptoms resolve when the mood episode resolves, whereas in schizophrenia they are not mood-dependent.
The up mood cycle in bipolar II disorder is less severe than in bipolar I disorder and is described by the term hypomania, meaning just below mania. The irritability or euphoria is milder and frequently of shorter duration than in a full manic episode and never progresses to psychotic symptoms. Because the depressive symptoms are generally the most prominent symptoms in bipolar II disorder, the bipolar component of the illness is more likely to be missed.
Unlike the case with unipolar depression, for which psychotherapy (talk therapy) and medication are often equally effective in resolving symptoms, medication is a more vital component of treatment for bipolar disorder. The most commonly used medications, called mood stabilizers, are designed to reduce both the manic and depressive symptoms. The most extensively studied mood stabilizers are lithium, valproic acid (Depakote) and carbamazepine (Tegretol). Recently lamotrigine (Lamictal) has shown particular effectiveness for bipolar depression.
The atypical antipsychotics (medications originally developed for the treatment of schizophrenia and other psychotic disorders) are also increasingly showing effectiveness for bipolar disorder. In studies following patients for more than 12 months, olanzapine (Zyprexa) was highly effective, both alone and in combination with traditional mood stabilizers, in decreasing recurrence of both manic and depressive symptoms. Risperidone (Risperdal), ziprasidone (Geodon), aripiprazole (Abilify), and quetiapine (Seroquel) have all been shown in shorter-term studies to effectively resolve acute episodes of mania.
Antidepressants are sometimes used in conjunction with a mood stabilizer for patients with bipolar depression. Use of antidepressants alone is risky in patients with bipolar disorder because they can convert depression into a manic or mixed episode. The same is true for herbal or other natural antidepressant remedies such as St. John’s Wort or Sam-E; while these are useful therapies for individuals with typical unipolar depression, they are dangerous for people with bipolar disorder without guidance from their physicians. Similarly, many herbal weight loss products contain the stimulant ephedrine or other ephedrine-like compounds, which can trigger bipolar patients into manic or hypomanic episodes. It is important for people with bipolar disorder to discuss all medications, including over-the-counter medications, herbs and vitamins, with their physicians. Currently there are no herbal or natural therapies that on their own provide sufficient treatment of bipolar disorder. Some herbal remedies may, however, be safe to use when combined with standard medication (for instance, valerian root or melatonin for assistance with sleep). Such use should always be undertaken with physician guidance. Additional alternative remedies, such as acupuncture, are also being studied as potential add-on therapies.
Similarly, psychotherapy on its own cannot eliminate the mood episodes in bipolar disorder. Bipolar disorder is a highly biological disorder, and the propensity for its extreme fluctuations in mood cannot be attributed to thinking wrong. Studies have shown, however, that stress can contribute to triggering individual episodes, and therapy can help in a variety of ways. Psychotherapy can help people adjust to the impact of illness on their lives, can help them adhere to medication regimens more effectively, can help their families adjust and cope with the disorder, can help them reduce stressors that could trigger relapses, and can help them and their families recognize early signs of mood change so intervention can occur before a full relapse. There are many different types of psychotherapy, however, so consumers and families should make sure to ask if the type of therapy they will be receiving has been shown to address these specific problems.
It is important to start treatment for bipolar disorder as early as possible. There is some evidence that each mood episode is actually bad for the brain, increasing the likelihood the next episode will be more severe. Consequently, when the disorder is left untreated, episodes may become more frequent and more serious as people age.
by Gillian Friedman, MD
Depression and Bipolar Support Alliance (DBSA) 800.826.3632 www.dbsalliance.org
National Alliance for the Mentally Ill 800.950.NAMI www.NAMI.org
National Mental Health Association (NMHA) 800.969.NMHA www.NMHA.org