One of the more enigmatic mental illnesses, bipolar disorder (or manic depressive illness) causes shifts in mood, energy, and activity levels that are often severe enough to affect one's day-today functioning. Characterized by unpredictable highs and lows and self-destructive behavior, the illness affects approximately 5.7 million adults in the United States.
While bipolar disorder usually strikes initially in adolescence or early adulthood, experts estimate that about 10% of people with the condition have their first episode after age 50. Some of these people remain undiagnosed, as their symptoms are mistaken for such disorders as cognitive impairment, delirium, or substance abuse.
As with any chronic illness, managing bipolar disorder requires lifelong attention. Without treatment, episodes become more frequent and severe. When successfully controlled, however, people with bipolar disorder can lead full and productive lives.
Beyond Typical Mood Swings
Bipolar disorder involves mood swings that are more exaggerated than typical fluctuations. The "up" periods are known as manic episodes, mania, or hypomania (a less severe form of mania); the "down" periods are called depressive episodes, or depression.
Manic episodes are characterized by aggression, agitation, or irritation; a decreased need for sleep; euphoria; high distractibility; an increased sex drive; inflated self-esteem; racing thoughts; rapid speech; spending sprees; and delusions, hallucinations, or psychosis.
Depressive episodes are marked by difficulty concentrating, remembering, or making decisions; eating disturbances; loss of appetite and weight loss, or overeating and weight gain; fatigue or listlessness; feelings of worthlessness, hopelessness, and/or guilt; loss of self-esteem; persistent sadness; sleep disturbances; suicidal thoughts; or withdrawal from people and activities that were once enjoyed.
Mood swings vary in length and frequency. Some people suffer mostly with major depression, with only the occasional manic episode; others experience "rapid cycling," with at least four episodes of depression, mania, or hypomania occurring within one year.
Sometimes, people with bipolar disorder have "mixed" states, during which mania and depression occur simultaneously or in rapid sequence. A person in a mixed state might have tremendous energy but also feel extremely sad or hopeless. In between mood swings, many people have periods of stable mood.
Types of Bipolar Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), there are four types of bipolar disorder, differing primarily in symptom severity and the length of time between manic and depressive episodes.
Bipolar type I is the most severe and potentially dangerous form of the illness, capable of causing great difficulty in daily activities and relationships. It is characterized by manic or mixed episodes that last at least seven days or by manic symptoms that are so severe that the person needs emergency hospital care.
Manic or mixed episodes are followed by episodes of major depression that last weeks or even years. Fortunately, many people with bipolar I disorder experience long symptom-free periods.
Bipolar type II involves alternating hypomanic (lasting at least four days) and depressive episodes but no full-blown manic or mixed episodes. While "up" periods are marked by milder symptoms, depressive episodes may be severe and debilitating.
Generally, people with bipolar type II can function in their normal daily routine while hypomanic and might simply seem to be extremely cheerful, sociable, or "the life of the party." During the depressive phase, the level of functioning varies significantly among individuals. Typically, an episode of significant depression follows soon after hypomania. Rapid cycling of moods is more likely to occur with bipolar II than with bipolar I.
Cyclothymia is an even more mild form of mood cycling with highs and lows that continue for at least two years but never reach the severity of major depression or mania. This can make it hard to distinguish from normal variations in mood and personality. In most people, the pattern is irregular and unpredictable, and hypomania or depression can last for days or weeks. In between up and down moods, a person might have normal moods for more than a month.
Bipolar disorder not otherwise specified (BP-NOS) is diagnosed when symptoms don't meet the criteria for bipolar I or II or cyclothymia. Symptoms may not last long enough, or the person may have too few of them. But the symptoms are clearly out of the person's normal range of behavior.
Getting a Diagnosis
One of the biggest challenges for people with mood swings is an accurate diagnosis. Doctors must rule out any medical conditions and medications that could explain the symptoms.
A head injury, stroke, delirium, thyroid disorders, lupus, substance abuse, and HIV infection can cause symptoms that mimic bipolar disorder. In addition, commonly used medications like corticosteroids (for example, prednisone), used to treat inflammatory diseases such as rheumatoid arthritis and psoriasis, as well as thyroid medication for hypothyroidism can cause mood swings.
Another barrier to an accurate diagnosis is that most people visit their doctor for depressive rather than manic symptoms and are subsequently diagnosed with major depression. In addition, people with bipolar disorder often have a co-occurring anxiety condition (like obsessive-compulsive disorder) that can complicate the diagnosis.
Treating Bipolar Disorder
Once an accurate diagnosis is made, determining the appropriate treatment is the next challenge. Given the variations in how the disease manifests itself, not all treatments will have the same results for everyone.
Still, the goals remain the same regardless of the type of bipolar disorder diagnosed: to control a manic or depressive episode in progress, to prevent further episodes, to increase the time between episodes, and to decrease the severity of episodes when they occur. The latter is called maintenance therapy.
The mood-stabilizing drug lithium (Lithobid) is the mainstay for treating a manic episode. Many other types of medications are used as well. For example, mood stabilizers like valproic acid (Depakene, Stavzor) and divalproex (Depakote) are increasingly used as an alternative to lithium when side effects are a problem. Other options include antipsychotics (neuroleptics) like aripiprazole (Abilify) and olanzapine (Zyprexa), anticonvulsants like carbamazepine (Equetro), and benzodiazepines like lorazepam (Ativan). Most of these drugs are effective for mixed episodes as well.
For depressive episodes, lithium and antipsychotics such as quetiapine (Seroquel) are typically used. When they do not offer relief, doctors often turn to the anticonvulsant lamotrigine (Lamictal). Antidepressants are an option but must be used with extreme care because they can trigger manic episodes. Electroconvulsive therapy (ECT) is also a choice but only for severe depressive episodes that do not respond to medication. ECT is also sometimes used for difficult-to-treat mania.
After a depressive, manic, or mixed episode is brought under control, people with bipolar disorder must continue to take medication to prevent further episodes. The most commonly prescribed maintenance therapy is lithium alone or in combination with valproic acid, Depakote, Equetro, or Lamictal. Antipsychotics like Abilify and Zyprexa also help prevent relapses, especially when used in combination with lithium.
Psychotherapy is another important component of treatment, helping a person manage stress, stay on medications, solve problems, and prevent relapse.
Treating Older Adults
Few studies have examined bipolar treatments for older adults, but experts expect them to work just as well as they do in younger patients. Still, it's important for older people to take the following precautions to ensure the best outcome with bipolar drugs.
First, your doctor should start you at a low dosage, and any dose increases should be done gradually, in part because your body metabolizes medication more slowly with age.
Second, make sure your doctor knows all of your medications and health conditions. Some can interact with your bipolar drugs, making them less effective or more likely to cause side effects.
Third, contact your doctor if you experience dizziness on standing, mental impairment, or movement problems. These common side effects of certain bipolar medications can increase your risk of falls and fractures.