Bipolar disorder

Overview

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings. These include emotional highs, also known as mania or hypomania, and lows, also known as depression. Hypomania is less extreme than mania.

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania, you may feel very excited and happy (euphoric), full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

Episodes of mood swings from depression to mania may occur rarely or multiple times a year. Each bout usually lasts several days. Between episodes, some people have long periods of emotional stability. Others may frequently have mood swings from depression to mania or both depression and mania at the same time.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, healthcare professionals use medicines and talk therapy, also known as psychotherapy, to treat bipolar disorder.

Symptoms

There are several types of bipolar and related disorders:

• Bipolar I disorder. You've had at least one manic episode that may come before or after hypomanic or major depressive episodes. In some cases, mania may cause a break from reality. This is called psychosis.
• Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode. But you've never had a manic episode.
• Cyclothymia. You've had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms. These symptoms are less severe than major depression.
• Other types. These types include bipolar and related disorders caused by certain drugs or alcohol, or due to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

These types may include mania, or hypomania, which is less extreme than mania, and depression. Symptoms can cause changes in mood and behavior that can't be predicted. This can lead to a lot of distress and cause you to have a hard time in life.

Bipolar II disorder is not a milder form of bipolar I disorder. It's a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, people with bipolar II disorder can be depressed for longer periods of time.

Bipolar disorder can start at any age, but usually it's diagnosed in the teenage years or early 20s. Symptoms can differ from person to person, and symptoms may vary over time.

Mania and hypomania

Mania and hypomania are different, but they have the same symptoms. Mania is more severe than hypomania. It causes more noticeable problems at work, school and social activities, as well as getting along with others. Mania also may cause a break from reality, known as psychosis. You many need to stay in a hospital for treatment.

Manic and hypomanic episodes include three or more of these symptoms:

• Being much more active, energetic or agitated than usual.
• Feeling a distorted sense of well-being or too self-confident.
• Needing much less sleep than usual.
• Being unusually talkative and talking fast.
• Having racing thoughts or jumping quickly from one topic to another.
• Being easy to distract.
• Making poor decisions. For example, you may go on buying sprees, take sexual risks or make foolish investments.

Major depressive episode

A major depressive episode includes symptoms that are severe enough to cause you to have a hard time doing day-to-day activities. These activities include going to work or school, as well as taking part in social activities and getting along with others.

An episode includes five or more of these symptoms:

• Having a depressed mood. You may feel sad, empty, hopeless or tearful. Children and teens who are depressed can seem irritable, angry or hostile.
• Having a marked loss of interest or feeling no pleasure in all or most activities.
• Losing a lot of weight when not dieting or overeating and gaining weight. When children don't gain weight as expected, this can be a sign of depression.
• Sleeping too little or too much.
• Feeling restless or acting slower than usual.
• Being very tired or losing energy.
• Feeling worthless, feeling too guilty or feeling guilty when it's not necessary.
• Having a hard time thinking or concentrating, or not being able to make decisions.
• Thinking about, planning or attempting suicide.

Other features of bipolar disorder

Symptoms of bipolar disorders, including depressive episodes, may include other features, such as:

• Anxious distress, when you're feeling symptoms of anxiety and fear that you're losing control.
• Melancholy, when you feel very sad and have a deep loss of pleasure.
• Psychosis, when your thoughts or emotions disconnect from reality.

The timing of symptoms may be described as:

• Mixed, when you have symptoms of depression and mania or hypomania at the same time.
• Rapid cycling, when you have four mood episodes in the past year where you switch between mania and hypomania and major depression.

Also, bipolar symptoms may happen when you're pregnant. Or symptoms can change with the seasons.

Symptoms in children and teens

Symptoms of bipolar disorder can be hard to identify in children and teens. It's often hard to tell whether these symptoms are the usual ups and downs or due to stress or trauma, or if they're signs of a mental health problem other than bipolar disorder.

Children and teens may have distinct major depressive or manic or hypomanic episodes. But the pattern can vary from adults with bipolar disorder. Moods can shift fast during episodes. Some children may have periods without mood symptoms between episodes.

The most noticeable signs of bipolar disorder in children and teenagers may be severe mood swings that aren't like their usual mood swings.

When to see a doctor

Despite their mood extremes, people with bipolar disorder often don't know how much being emotionally unstable disrupts their lives and the lives of their loved ones. As a result, they don't get the treatment they need.

If you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. But an emotional crash always follows this euphoria. This crash can leave you depressed and worn out. It could cause you to have problems getting along with others. It also could leave you in financial or legal trouble.

If you have any symptoms of depression or mania, see your healthcare or mental health professional. Bipolar disorder doesn't get better on its own. A mental health professional with experience in bipolar disorder can help you get your symptoms under control.

When to get emergency help

Thoughts about suicide and acting on these thoughts are common for people with bipolar disorder. If you're thinking about hurting yourself, or if you have a loved one who is in danger of suicide or attempting suicide, get help. You can let a family member or friend know, contact a suicide hotline, call 911 or your local emergency number, or go to the emergency department. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential. The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 1-888-628-9454 (toll-free).

Causes

While it's not known what causes bipolar disorder, these factors may be involved:

• Biological differences. People with bipolar disorder appear to have physical changes in their brains. The importance of these changes is still uncertain, but more research may help identify why these changes happen.
• Genetics. Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may cause bipolar disorder.

Risk factors

Factors that may raise the risk of getting bipolar disorder or cause the first episode include:

• Having a first-degree relative, such as a parent or sibling, with bipolar disorder.
• Periods of high stress, such as the death of a loved one or another traumatic event.
• Drug or alcohol misuse.

Complications

Left untreated, bipolar disorder can lead to serious problems that affect every area of your life, including:

• Problems related to drug and alcohol misuse.
• Suicide or suicide attempts.
• Legal or financial problems.
• Trouble getting along with others.
• Poor work or school performance.

Conditions that occur at the same time

Sometimes what seems to be bipolar disorder might really be another disorder. Or, the symptoms of bipolar disorder might overlap with other disorders, and you also may have another health condition that needs to be treated along with bipolar disorder. Some conditions can make bipolar disorder symptoms worse or make treatment less successful.

Examples include:

• Anxiety disorders.
• Eating disorders.
• Attention-deficit/hyperactivity disorder (ADHD).
• Post-traumatic stress disorder (PTSD).
• Alcohol or drug misuse.
• Borderline personality traits or disorders.
• Physical health problems, such as heart disease, thyroid issues, headaches or obesity.

Prevention

There's no sure way to prevent bipolar disorder. But getting treated as soon as you notice a mental health disorder can help stop bipolar disorder or other mental health conditions from getting worse.

If you've been diagnosed with bipolar disorder, here are some ways you can stop minor symptoms from becoming full-blown episodes of mania or depression:

• Pay attention to warning signs. Talking with your care team about symptoms early on can stop episodes from getting worse. You may have found a pattern to your bipolar episodes and what causes them. Call your healthcare professional or mental health professional if you feel you're starting to have an episode of depression or mania. Ask your family members or friends to watch for warning signs.
• Get enough sleep. Sleep disruptions often cause bipolar instability.
• Stay away from drugs and alcohol. Drinking alcohol or taking street drugs can make your symptoms worse and make them more likely to come back.
• Take your medicines as directed. You may be tempted to stop treatment, but don't. Stopping your medicine or lowering your dose on your own may cause withdrawal effects. Also, your symptoms may get worse or return.

Diagnosis

To find out if you have bipolar disorder, your evaluation may include:

• Physical exam. Your healthcare professional may do a physical exam and lab tests to find any medical problems that could be causing your symptoms.
• Mental health assessment. Your healthcare professional may refer you to a psychiatrist, who will talk to you about your thoughts, feelings and behavior patterns. You also may answer a series of questions. With your permission, family members or close friends may be asked to provide information about your symptoms.
• Mood charting. You may be asked to keep a daily record of your moods, sleep patterns or other factors that could help make the right diagnosis and get you the right treatment.

Diagnosis in children

Although children and teenagers with bipolar disorder are diagnosed with bipolar disorder based on the same criteria used for adults, symptoms in children and teens often have different patterns. These patterns may not fit neatly into diagnostic categories.

Also, children who have bipolar disorder are often diagnosed with other mental health conditions, such as ADHD or behavior problems. This can complicate a diagnosis. These children may need to see a child psychiatrist with experience in bipolar disorder.

Treatment

Treatment is best guided by a medical doctor who diagnoses and treats mental health conditions (psychiatrist) who is skilled in treating bipolar and related disorders. Your care team also may include a psychologist, social worker or psychiatric nurse.

Bipolar disorder is a lifelong condition, with treatment directed to manage symptoms.

Depending on your needs, treatment may include:

• Medicines. Often, you'll need to start taking medicines right away to balance your moods.
• Ongoing treatment. You need to take your medicine for the rest of your life — even when you feel better. If you don't keep taking your medicine, your symptoms could come back, or minor mood changes could turn into full-blown mania or depression.
• Intensive outpatient programs or a program involving a partial stay in a hospital. These programs provide intensive support and counseling that lasts a few hours per day for several weeks to help you get symptoms under control.
• Treatment for alcohol or drug misuse. If you have problems with alcohol or drugs, you'll also need treatment for this misuse. Without this treatment, it can be very hard to manage bipolar disorder.
• A hospital stay. Your healthcare professional may recommend that you stay in a hospital if you're behaving dangerously or thinking about suicide, or you've become detached from reality. Getting mental health treatment at a hospital can keep you calm and safe and stabilize your mood. This is true whether you're having a manic or major depressive episode.

The main treatments for bipolar disorder include medicines and talk therapy, also known as psychotherapy, to control symptoms. Treatment also may include education and support groups.

Medicines

Several medicines are used to treat bipolar disorder. The types and doses of medicines prescribed are based on your symptoms. Usually you'll need a mood stabilizer or an antipsychotic medicine that functions as a mood stabilizer.

Medicines may include:

• Mood stabilizers. Mood-stabilizing medicines help control manic or hypomanic episodes. They also may help depressive bouts. Examples include lithium (Lithobid), valproic acid, divalproex sodium (Depakote, Depakote ER), carbamazepine (Tegretol, Tegretol XR, Equetro, others) and lamotrigine (Lamictal).
• Antipsychotics. Antipsychotic medicines have mood-stabilizing properties, and many have been approved by the U.S. Food and Drug Administration for manic or hypomanic episodes or maintenance treatment. Antipsychotics may be used by themselves or with mood stabilizers. Examples of antipsychotic drugs are olanzapine (Zyprexa, Lybalvi, others), risperidone (Risperdal), quetiapine (Seroquel, Seroquel XR), aripiprazole (Abilify, Aristada, others), ziprasidone (Geodon), lurasidone (Latuda), asenapine (Saphris), lumateperone (Caplyta) and cariprazine (Vraylar).
• Antidepressants. Your healthcare professional may cautiously add an antidepressant to manage depression. But an antidepressant sometimes can cause a manic or hypomanic episode. Antidepressants should be prescribed along with a mood stabilizer or antipsychotic medicine.
• Antidepressant-antipsychotic combination. The medicine Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine. It's approved to treat bipolar depression.
• Antianxiety medicines. Benzodiazepines may ease anxiety and make you sleep better. But they're usually used on a short-term basis as they can be misused when taken for a long time.

Finding the right medicine

Finding the right medicine for you likely will take some trial and error. If one doesn't work well for you, there may be others to try. Sometimes, two or three medicines are used at the same time. This process requires patience, as some medicines need weeks to months to take full effect. Periodic or routine blood monitoring may be needed for certain medicines.

Generally, your healthcare professional changes only one medicine at a time. This is done to find out which medicines make your symptoms better with the least bothersome side effects. Your healthcare professional also may need to change your medicines as your symptoms change.

Side effects

You may have side effects with medicines. Some side effects may get better as your healthcare professional adjusts the dose and your body gets used to the medicines. Talk to your healthcare professional or mental health professional to find a medication that can be effective and has minimal side effects.

Don't make changes or stop taking your medicines. If you stop your medicine, you may have withdrawal effects or your symptoms may get worse or return. You may become very depressed, think about suicide, or go into a manic or hypomanic episode. If you think you need to make a change, call your healthcare professional.

Medicines and pregnancy

A few medicines for bipolar disorder can be linked to birth defects. These medicines may pass through breast milk to the baby. Every medicine is different, so you should talk with your prescriber. Valproic acid and divalproex sodium have a specific warning that they are to be avoided when pregnant. Carbamazepine, a mood stabilizer, may make certain birth control medicines less effective.

If possible, talk with your healthcare professional about treatment options before you become pregnant. If you're taking medicine to treat your bipolar disorder and think you may be pregnant, talk to your healthcare professional right away.

Talk therapy

Talk therapy, also called psychotherapy, is a vital part of bipolar disorder treatment. This treatment can be provided in individual, family or group settings.

Several types of therapy may help, including:

• Interpersonal and social rhythm therapy. This therapy focuses on stabilizing daily rhythms, including sleeping, waking and eating. A consistent routine helps manage moods. A daily routine for sleep, diet and exercise may help people with bipolar disorder.
• Cognitive behavioral therapy (CBT). This therapy focuses on identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive beliefs and behaviors. CBT can help find what triggers your bipolar episodes. You also learn effective ways to manage stress and cope with upsetting situations.
• Psychoeducation. Learning about bipolar disorder, also known as psychoeducation, can help you and your loved ones know more about the condition. Knowing what's going on can help you get the best support, find issues, make a plan to stop symptoms from returning and stick with treatment.
• Family-focused therapy. Family support and communication can help you stay with your treatment plan. It also can help you and your loved ones see and manage warning signs of mood swings.

Other treatment options

Depending on your needs, your health professional may add other treatments to your depression therapy, such as:

• Electroconvulsive therapy, also known as ECT. During ECT, electrical currents pass through the brain, causing a brief seizure. ECT seems to change brain chemistry, which can reverse symptoms of certain mental illnesses. ECT may be an option to treat bipolar disorder if you don't get better with medicines, can't take antidepressants for health reasons such as pregnancy or are at high risk of attempting suicide.
• Repetitive transcranial magnetic stimulation, also known as rTMS. During a series of rTMS treatment sessions, magnetic waves stimulate the brain to reduce depression. This treatment is being studied as an option for people with bipolar disorder who haven't responded to antidepressants. It is not as powerful as ECT.
• Ketamine. Ketamine also is being studied as a possible treatment for bipolar depression. Limited research suggests that ketamine could be a promising short-term treatment that's generally well tolerated. It's been shown to ease symptoms of depression and reduce thoughts of suicide — all within two weeks. But the effects of ketamine include dissociative symptoms during the treatment. Patients may feel groggy, spacey, out of it, or disconnected with reality and surroundings. But some patients also report thinking more clearly and feeling more connected with others. More studies are needed to determine the role of ketamine in the long-term treatment of bipolar disorder and create guidelines for its use.

Treatment in children and teenagers

Generally, healthcare professionals decide on treatments for children and teenagers on a case-by-case basis, depending on symptoms, medicine side effects and other issues.

Generally, treatment includes:

• Medicines. There's less research on the safety and effectiveness of bipolar medicines in children than in adults, so healthcare professionals often decide on treatment based on adult research. Children and teens with bipolar disorder often are prescribed the same types of medicines as adults. That's because children have taken part in fewer studies. But children can respond differently to medicines than adults. Some children may need to try more than one medicine for the best results.
• Talk therapy. Initial and long-term therapy can help keep symptoms from returning. Talk therapy, also known as psychotherapy, can help children and teens manage their routines, cope better, handle learning difficulties, make social problems better, and make family bonds and communication stronger. If needed, talk therapy can treat alcohol or drug misuse problems common in older children and teens with bipolar disorder.
• Psychoeducation. Psychoeducation can include learning the symptoms of bipolar disorder and how they differ from behavior related to your child's age, the situation and appropriate cultural behavior. Knowing more about bipolar disorder also can help you support your child.
• Support. Teachers and school counselors can help find services. They and family and friends can encourage success.

Lifestyle and home remedies

You'll probably need to make lifestyle changes to stop cycles of behavior that make your bipolar disorder worse. Here are some steps to take:

• Quit drinking or using street drugs. One of the biggest concerns with bipolar disorder is the negative results of risk-taking behavior and drug or alcohol misuse. Get help if you have trouble quitting on your own.
• Form healthy relationships. Surround yourself with people who are a positive influence. Friends and family members can provide support and help you watch for warning signs of mood shifts.
• Create a healthy routine. Having a regular routine for sleeping, eating and physical activity can help balance your moods. Eat a healthy diet. If you take lithium, talk with your healthcare professional about how much fluid and salt you should take in. If you have trouble sleeping, talk to your healthcare professional or mental health professional about what you can do.
• Check first before taking other medicines. Call your healthcare professional or mental health professional before you take medicines that another health professional prescribes or any supplements or medicines available without a prescription. For example, when taking lithium (Lithobid), you should avoid regularly using ibuprofen (Advil, Motrin IB, others). Sometimes other medicines cause depression or mania. Or these medicines may not work well with the medicines you take for bipolar disorder.
• Think about keeping a mood chart. Keeping a record of your daily moods, treatments, sleep, activities and feelings may help identify triggers, effective treatment options and when treatment needs to be changed.

Alternative medicine

There isn't much research on alternative or complementary medicine — sometimes called integrative medicine — and bipolar disorder. Most studies are on major depression, so it isn't clear how these nontraditional approaches work for bipolar disorder.

If you choose to use alternative or complementary medicine in addition to the treatment your healthcare professional recommends, take some precautions first:

• Don't stop taking your prescribed medicines or skip therapy sessions. Alternative or complementary medicine does not replace regular medical care to treat bipolar disorder.
• Be honest with your healthcare professional and mental health professional. Tell them which alternative or complementary treatments you use or would like to try.
• Beware of potential dangers. Alternative and complementary products aren't regulated like prescription drugs. Just because it's natural doesn't mean it's safe. Before using alternative or complementary medicine, talk to your healthcare professional or mental health professional about the risks, including how these treatments might cause problems with the medicines you already take.

Coping and support

Coping with bipolar disorder can be hard. Here are some ways to help:

• Learn about bipolar disorder. Learning about your condition can motivate you to stick to your treatment plan and know when your mood changes. Help your family and friends learn about what you're going through.
• Focus on your goals. Learning to manage bipolar disorder can take time. Stay motivated by keeping your goals in mind and reminding yourself that you can work to fix damaged relationships and other problems your mood swings cause.
• Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share what's going on with you.
• Find healthy outlets. Explore healthy ways to focus your energy, such as hobbies, exercise and recreational activities.
• Learn ways to relax and manage stress. Yoga, massage, deep breathing, meditation or other relaxation techniques can help.

Preparing for an appointment

You may start by seeing your primary care professional or a psychiatrist. You may want to take a family member or friend along to your appointment, if possible, for support and to help remember information.

What you can do

Before your appointment, make a list of:

• Any symptoms you've had, including any that may seem unrelated to the appointment.
• Key personal information, including any major stresses or recent life changes.
• All medicines, vitamins, herbs or other supplements you're taking, and the doses.
• Questions to ask your healthcare professional.

Questions to ask your healthcare professional may include:

• Do I have bipolar disorder?
• Are there any other possible causes for my symptoms?
• What kinds of tests will I need?
• Which treatments do you recommend?
• What side effects can treatment cause?
• What are the alternatives to the treatment that you suggest?
• I have other health conditions. How can I best manage these conditions together?
• Should I see a psychiatrist or another mental health professional?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can have?
• What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your healthcare professional likely will ask you several questions:

• When did you or your loved ones first begin noticing your symptoms?
• How often do your moods change?
• Do you think about suicide when you're feeling down?
• Do your symptoms get in the way of daily life or how well you get along with others?
• Do you have any blood relatives with bipolar disorder or depression?
• What other mental or physical health conditions do you have?
• Do you drink alcohol, smoke or chew tobacco, or use street drugs?
• How much do you sleep at night? Does the amount of sleep you get change over time?
• Do you sometimes take risks that you wouldn't usually take, such as take part in unsafe sex or make financial decisions that are unwise or impulsive?
• What, if anything, seems to make your symptoms better or worse?

Your healthcare professional or mental health professional will ask more questions based on your responses, symptoms and needs. Getting ready for these questions will help you make the most of your time at your appointment.