Evening Out the Highs and Lows of Bipolar Disorder—The Tipping Point
Imagine this: One month you're so full of energy that you’re ready to launch a new company, write a best-selling book or save the world from global warming. The next, you're so low and dejected that getting out of bed seems like a Herculean chore. 
For approximately 6 million people in the U.S., such mood swings are the result of bipolar disorder.
Formerly known as manic-depression, bipolar disorder is a mental illness that occurs in several forms:
- Bipolar I is the classic form, with distinct highs and lows. While in a manic state, patients are exuberant and overly confident, often bursting with energy and having little need for sleep. They may go on lavish spending sprees, engage in extramarital affairs and perform other risky behaviors they normally wouldn’t. In the depressive state, they become despondent, withdrawn and even dangerously suicidal. About 1 percent of the population will develop bipolar I during their lifetime.
- Bipolar II has a distinct depressive stage, but the manic phase, known as hypomania, is less profound and bothersome. Hypomania may be marked by additional energy and confidence, but usually without the agitation and disorganized thinking that occurs in mania. Bipolar II may be just as common as bipolar I.
- Rapid cycling bipolar disorder is diagnosed in people who have four or more episodes of extreme moods in a year. This form of the disease occurs in 15 to 20% of all patients but is more common in women and in people with bipolar II.
- Mixed state bipolar disorder is diagnosed in people who experience depression and mania simultaneously. It occurs in about a third of all patients with bipolar I disorder.
Most cases of bipolar disorder are first diagnosed between ages 15 and 25, particularly among people with a family history of the disease. Episodes of mania and depression can recur throughout a lifetime, though over time most sufferers experience significant symptom-free periods.
Pinpointing the Problem
Diagnosing bipolar disorder can be difficult, especially when the manic phase is mild. It may take as long as 12 years to get an accurate diagnosis. "Doctors may recognize the depression, but when patients have brief periods of elevated moods, those can be explained away," says Francis M. Mondimore, M.D., associate professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and author of Bipolar Disorder: A Guide for Patients and Families. "So then they're treated for depression, and it's usually not terribly successful and can actually make it worse.”
Treating bipolar depression with anti-depressants can send some patients into a manic phase, he says. The telltale sign in people with bipolar disorder is what Dr. Mondimore calls a "disconnect" between a person's mood and circumstances. "Their moods have a rhythm of their own," he says. "They react in a way that doesn’t make sense or is stronger than it should be."
Bipolar disorder can also emerge in children, who may be especially hard to diagnose—since the symptoms may resemble other conditions, such as attention-deficit hyperactivity disorder or unipolar depression, and also vary with developmental age. According to the Child and Adolescent Bipolar Foundation, approximately 750,000 children and teens in the U.S. may suffer from bipolar disorder.
One clue: the unusual severity and duration of a child's temper tantrums. "These kids spend many hours a week having serious tantrums," says Stuart J. Goldman, M.D., co-director of the Mood Disorders Program at Children’s Hospital in Boston. "These children may also exhibit extreme behaviors—for example clogging all the drains in a house as a way of showing anger at a parent."
Taken alone, these behaviors do not mean a child has bipolar disorder, just that it should be considered. The best way to find out is to see a psychiatrist for an evaluation, says Gary Sachs, M.D., chair and director of the Bipolar Clinic and Research Program at Massachusetts General Hospital. "We look for the whole constellation of bipolar symptoms, and must pin them down to a time period and examine the quality and duration of these mood states," Dr. Sachs says. "We also look at family history and age of onset, as well as alternative explanations, such as interpersonal conflicts or other situations that might account for these moods."
Mending the Mood
Treating bipolar disorder is a challenge. Not only do doctors have to treat the mania and depression, but sufferers also need long-term medication to prevent relapses. "It's arguably one of the most difficult diseases to treat," says Husseini Manji, M.D., former director of the Mood and Anxiety Disorders Program for the National Institute of Mental Health. "Sometimes, drugs may work for a while, then stop."
Treatment is always highly individualized and typically requires mood stabilizers like lithium, or anticonvulsants such as valproate (Depakote), lamotrigine (Lamictal) and carbamazepine (Tegretol).
Patients may also be given antipsychotic medications such as risperidone (Risperdal), quetiapine (Seroquel), and ziprasidone (Geodon). Sufferers who have trouble sleeping may require a sedative such as clonazepam (Klonopin) or lorazepam (Ativan). Less than half of patients have success with lithium alone, and most people need a combination of drugs to achieve relief and prevent recurrence.
Many drugs have bothersome side effects such as weight gain, nausea, tremors, hair loss and loss of libido, which is why there's often a lengthy trial and error period before finding the right drug or combination of drugs.
Taking medications is only part of the equation. Many people with bipolar disorder –—along with loved ones — need psychotherapy, too. "Bipolar disorder can be catastrophic for relationships and marriages, and interpersonal psychotherapy and marital therapy can help," Dr. Manji says. Therapy can help family members better understand the illness and the patient understand the hardships on the family. Also, certain kinds of psychotherapy, along with medication, might help reduce the risk of relapse and improve medication adherence, adds Manji.
Dr. Mondimore also recommends patients control stress with regular exercise, relaxation techniques, and good sleep hygiene. Eating foods rich in omega-3 fatty acids such as tuna, salmon and mackerel, may help, too. Preliminary studies suggest these fats may help stabilize moods.
But according to Dr. Manji, patients should avoid simple carbs, like bagels and soda, which can cause fluctuations in blood sugar and worsen depression, and stimulants like caffeine and alcohol, which can destabilize moods.
