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Bipolar Disorder

ImmuneSupport.com Introduction
What Are the Symptoms of Bipolar Disorder?
Suicide
What Is the Course of Bipolar Disorder?
Can Children and Adolescents Have Bipolar Disorder?
What Causes Bipolar Disorder?
How Is Bipolar Disorder Treated?
Do Other Illnesses Co-occur with Bipolar Disorder?
How Can Individuals and Families Get Help for Bipolar Disorder?
What About Clinical Studies for Bipolar Disorder?
For More Information
References
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.

More than 2 million American adults, or about or about 1 percent of the population age 18 and older in any given year,2 have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.

"I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do."

What Are the Symptoms of Bipolar Disorder?

Signs and symptoms of mania (or a manic episode) include:

  • Excessively "high," overly good, euphoric mood
  • Racing thoughts and talking very fast, jumping from one idea to another
  • Little sleep needed
  • Poor judgment
  • A lasting period of behavior that is different from usual
  • Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
  • Denial that anything is wrong

Signs and symptoms of depression (or a depressive episode) include:

  • Feelings of hopelessness or pessimism
  • Loss of interest or pleasure in activities once enjoyed, including sex
  • Difficulty concentrating, remembering, making decisions
  • Sleeping too much, or can't sleep
  • Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
  • A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

    Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.

    In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.


Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?

Mania: The fast ideas become too fast and there are far too many… overwhelming confusion replaces clarity… you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable, and trapped.


Suicide

Signs and symptoms that may accompany suicidal feelings include:

  • feeling hopeless, that nothing will ever change or get better
  • feeling like a burden to family and friends
  • putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one's death)
  • putting oneself in harm's way, or in situations where there is a danger of being killed

If you are feeling suicidal or know someone who is:
  • call a doctor, emergency room, or 911 right away to get immediate help

  • make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm


What Is the Course of Bipolar Disorder?

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated (see below—"How Is Bipolar Disorder Treated?"). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared.  But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.


Can Children and Adolescents Have Bipolar Disorder?

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day.  Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.


What Causes Bipolar Disorder?

Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and grow—passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.7

It appears likely that many different genes act together, and in combination with other factors of the person or the person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.

New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.


How Is Bipolar Disorder Treated?

Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications for bipolar disorder are prescribed by psychiatrists—medical doctors (M.D.) with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.

  • Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine (Tegretol®), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.
  • Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.
  • Therefore, young female patients taking valproate should be monitored carefully by a physician.
  • Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication.16 Therefore, "mood-stabilizing" medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.


  • Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval.18  Olanzapine may also help relieve psychotic depression.19
  • Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.
  • To reduce the chance of relapse or of developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.

People with bipolar disorder often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.

Before starting a new medication for bipolar disorder, always talk with your psychiatrist and/or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremor, reduced sexual drive or performance, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects you notice during treatment. He or she may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist's guidance.


As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas.13 A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

  • Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.
  • Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms.
  • As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.

Herbal or natural supplements, such as St. John's wort (Hypericum perforatum), have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient.

Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's wort can reduce the effectiveness of certain medications (see In addition, like prescription antidepressants, St. John's wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.


Do Other Illnesses Co-occur with Bipolar Disorder?

Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment. For more information on anxiety disorders, contact NIMH (see below).


How Can Individuals and Families Get Help for Bipolar Disorder?

Help can be found at:

  • Hospital departments of psychiatry

  • Health maintenance organizations (HMOs)

  • Public community mental health centers

Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.

  • Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.

  • Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.

  • Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.

  • Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations. For contact information, see the "For More Information" section at the back of this booklet.


  • What About Clinical Studies for Bipolar Disorder?

    In recent years, NIMH has introduced a new generation of "real-world" clinical studies. They are called "real-world" studies for several reasons. Unlike traditional clinical trials, they offer multiple different treatments and treatment combinations. In addition, they aim to include large numbers of people with mental disorders living in communities throughout the U.S. and receiving treatment across a wide variety of settings. Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies. The main goal of the real-world studies is to improve treatment strategies and outcomes for all people with these disorders. In addition to measuring improvement in illness symptoms, the studies will evaluate how treatments influence other important, real-world issues such as quality of life, ability to work, and social functioning. They also will assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans.

    http://www.nimh.nih.gov, visit the National Library of Medicine's clinical trials database http://www.clinicaltrials.gov, or contact NIMH.


     

    For More Information

    nimhinfo@nih.gov; Web site: http://www.nimh.nih.gov

    Depression and Related Affective Disorders Association (DRADA)
    Johns Hopkins Hospital, Meyer 3-181
    600 North Wolfe Street
    Baltimore, MD 21287-7381
    Phone: (410) 955-4647 or (202) 955-5800 (Washington, DC)
    E-mail: drada@jhmi.edu; Web site: http://www.drada.org

    Depression & Bipolar Support Alliance (DBSA)
    730 North Franklin Street, Suite 501
    Chicago, IL 60610-7204
    Toll-Free: 1-800-826-3632
    Phone: (312) 642-0049; Fax: (312) 642-7243
    Internet: http://www.DBSAlliance.org

    National Mental Health Association (NMHA)
    2001 N. Beauregard Street, 12th Floor
    Alexandria, VA 22314-2971
    Phone: 1-800-969-6642 or (703) 684-7722
    TTY-800-443-5959
    Internet: http://www.nmha.org


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    2Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993; 50(2): 85-94.

    3American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.

    4Hyman SE, Rudorfer MV. Depressive and bipolar mood disorders. In: Dale DC, Federman DD, eds. Scientific American®; Medicine. Vol. 3. New York: Healtheon/WebMD Corp., 2000; Sect. 13, Subsect. II, p. 1.

    5Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.

    6Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(9): 1168-76.

    7NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.

    8Hyman SE. Introduction to the complex genetics of mental disorders. Biological Psychiatry, 1999; 45(5): 518-21.

    9Soares JC, Mann JJ. The anatomy of mood disorders—review of structural neuroimaging studies. Biological Psychiatry, 1997; 41(1): 86-106.

    10Soares JC, Mann JJ. The functional neuroanatomy of mood disorders. Journal of Psychiatric Research, 1997; 31(4): 393-432.

    11Sachs GS, Printz DJ, Kahn DA, Carpenter D, Docherty JP. The expert consensus guideline series: medication treatment of bipolar disorder 2000. Postgraduate Medicine, 2000; Spec No:1-104.

    12Sachs GS, Thase ME. Bipolar disorder therapeutics: maintenance treatment. Biological Psychiatry, 2000; 48(6): 573-81.

    13Huxley NA, Parikh SV, Baldessarini RJ. Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harvard Review of Psychiatry, 2000; 8(3): 126-40.

    14Vainionpaa LK, Rattya J, Knip M, Tapanainen JS, Pakarinen AJ, Lanning P, Tekay A, Myllyla VV, Isojarvi JI. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999; 45(4): 444-50.

    15Llewellyn A, Stowe ZN, Strader JR Jr. The use of lithium and management of women with bipolar disorder during pregnancy and lactation. Journal of Clinical Psychiatry, 1998; 59(Suppl 6): 57-64; discussion 65.

    16Thase ME, Sachs GS. Bipolar depression: pharmacotherapy and related therapeutic strategies. Biological Psychiatry, 2000; 48(6): 558-72.

    17Suppes T, Webb A, Paul B, Carmody T, Kraemer H, Rush AJ. Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment-resistant illness and a history of mania. American Journal of Psychiatry, 1999; 156(8): 1164-9.

    18Tohen M, Sanger TM, McElroy SL, Tollefson GD, Chengappa KN, Daniel DG, Petty F, Centorrino F, Wang R, Grundy SL, Greaney MG, Jacobs TG, David SR, Toma V. Olanzapine versus placebo in the treatment of acute mania. Olanzapine HGEH Study Group. American Journal of Psychiatry, 1999; 156(5): 702-9.

    19Rothschild AJ, Bates KS, Boehringer KL, Syed A. Olanzapine response in psychotic depression. Journal of Clinical Psychiatry, 1999; 60(2): 116-8.

    20U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.

    21Henney JE. Risk of drug interactions with St. John's wort. From the Food and Drug Administration. Journal of the American Medical Association, 2000; 283(13): 1679.

    22Nierenberg AA, Burt T, Matthews J, Weiss AP. Mania associated with St. John's wort. Biological Psychiatry, 1999; 46(12): 1707-8.

    23Stoll AL, Severus WE, Freeman MP, Rueter S, Zboyan HA, Diamond E, Cress KK, Marangell LB. Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-controlled trial. Archives of General Psychiatry, 1999; 56(5): 407-12.

    24Strakowski SM, DelBello MP. The co-occurrence of bipolar and substance use disorders. Clinical Psychology Review, 2000; 20(2): 191-206.

    25Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher FC, Vidaver R, Auciello P, Foy DW. Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 1998; 66(3): 493-9.

    26Strakowski SM, Sax KW, McElroy SL, Keck PE Jr, Hawkins JM, West SA. Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization. Journal of Clinical Psychiatry, 1998; 59(9): 465-71.


    NIH Publication No. 02-3679  

    nimhinfo@nih.gov
    Web site: http://www.nimh.nih.gov


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