Bipolar Disorder

Bipolar disorder (previously known as manic depression or manic depressive illness) is a psychiatric disorder marked by extreme shifts in mood from severe depression to mania (a highly activated state). The cyclical mood fluctuations that characterize this disorder can be devastating for the individual and family members and often result in significant impairment in social, interpersonal, and occupational functioning. Bipolar disorder is a serious illness that requires ongoing psychiatric and psychological treatment. Untreated individuals with bipolar disorder have a significantly higher lifetime rate of attempted suicide (25%) and completed suicide (10%-15%).

Common Symptoms of Bipolar Disorder

The most severe form of the disorder, bipolar I disorder, is characterized by one or more manic or mixed (simultaneously manic and depressed) episodes of sufficient severity to cause marked impairment in social and occupational functioning, often resulting in a psychiatric hospitalization. Typically, people with bipolar I disorder experience extreme fluctuations in mood ranging from severe depression to mania. During manic episodes people experience euphoric, elevated, or irritable moods in which they may become highly energized, have an inflated sense of self-esteem, experience a reduced need for sleep, become very talkative, have racing thoughts, take on multiple projects at once, and become easily distracted.

People in a more severe state of mania may lose their normal sense of judgment and may undertake risky behaviors with the potential for painful negative consequences. In the most severe stages of acute mania individuals will become disorganized in their behavior and thought processes. These individuals may appear bizarre to others, and they may experience strange or unusual ideas.

Bipolar II disorder is distinguished from bipolar I disorder by the presence of a milder form of mania called hypomania. Hypomanic episodes are characterized by a shorter duration (4 days versus 7 days) than manic episodes and less severe impairment in social and occupational functioning. Hypomanic episodes do not terminate in grossly disorganized behavior or psychotic features that typically require hospitalization. While bipolar II disorder is often thought of as a “milder form” of the disorder, individuals with this disorder have a high risk of suicide and a severe depressive course just as devastating as that experienced in bipolar I disorder. Individuals with bipolar II disorder may have significant interpersonal and occupational problems due to ongoing fluctuations in mood.

Individuals with bipolar I and bipolar II disorders also experience significant periods of depression. These periods are characterized by a depressed mood and loss of interest or pleasure as well as the following symptoms: significant weight loss or decrease or increase in appetite; sleeping too much or too little; and being agitated, slowed down, or feeling fatigued. During depressed periods, individuals often report feelings of worthlessness, excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, or suicidal thoughts or plans. A significantly elevated risk of suicide occurs during the depressed phase of bipolar and bipolar II.

The mildest form of bipolar disorder is cyclothymic disorder, a chronic fluctuating mood disorder characterized by numerous periods of hypomanic and depressive symptoms over at least 2 years. Individuals with cyclothymic disorder are at increased risk to develop bipolar I or bipolar II disorder.

Age of Onset

The typical age of onset of bipolar disorder is at 20 years of age in both men and women. However, 50% of individuals experience an earlier onset (some as early as late childhood). About 10% of individuals experience a late-life (post-50) onset. Women are more at risk for depression (about 2 times the rate for men), but for bipolar disorder the gender ratio of male to female is about equal. There are no known differences in the rate of bipolar disorder in different ethnic groups or cultures.

In about 60% of cases, the disorder presents initially as a severe depression, but individuals may also experience an initial severe episode of mania. The symptoms of a severe bipolar I manic episode may include extreme agitation, disorganization, and psychotic features (hearing voices or believing in strange ideas). For the individual and family members, the onset of these symptoms can be extremely confusing and profoundly disturbing, especially if the young person has never before exhibited any significant problems. Diagnosis may be complicated because these symptoms overlap with signs of drug abuse and schizophrenia, an illness also characterized chiefly by hearing voices (auditory hallucinations) and having strange ideas (delusions).

Prevalence of Bipolar Disorder

The prevalence of bipolar I disorder is estimated to be between 1% and 1.2%, significantly lower than that of depression. However, taking into account both bipolar II (less severe mania) and other “less than manic” forms of the disorder, the overall prevalence rate of bipolar disorder may be closer to 4% to 5%.

Etiology of Bipolar Disorder

Bipolar disorder is one of the psychiatric disorders known to have a very strong biological and genetic basis, substantially more so than depression. The probability of developing the disorder when a close biological relative has bipolar disorder is about 15% to 20% (i.e., 15-20 times the population risk). The probability is in the 50% to 70% range when both parents have the disorder. Environmental factors also play a significant role in the timing of the initial onset, the course of the disorder (as described below), and the prognosis of the disorder.

Course and Prognosis

There is a great deal of variability in the course of bipolar disorder. About 90% of individuals who have an initial episode of mania have a second episode. In a high percentage of cases, manic episodes occur directly after a period of depression. Individuals may experience significant periods of wellness between episodes of mania and depression or, in many cases, may experience unremitting periods of continuing low-level depression. Approximately one third have residual symptoms that interfere with their social, interpersonal, and occupational functioning. Ongoing treatment, especially adherence to medication, greatly enhances quality of life and overall outcomes for these individuals.

Assessment of Bipolar Disorder

The current prevailing scientific view of bipolar disorder conceives of the illness dimensionally rather than categorically. That is, bipolar disorder may be viewed as a part of a spectrum of disorders ranging from depression through cyclothymic disorder to bipolar I disorder. This view has important implications for the assessment and treatment of the disorder in that the clinician must be alert to “less than manic” forms of the illness. Careful assessment before prescribing medication is important because people with bipolar disorder experience significant periods of depression as well as distinct periods of elevated mood. About 60% of people who present initially with mainly depressive symptoms may go on to experience a manic or hypomanic episode. People who receive an antidepressant may experience a medication-induced manic or hypomanic episode. While the severe symptoms associated with bipolar I disorder are easily recognized, milder forms of the illness can be easily overlooked with significantly negative consequences.

Assessment must always include a careful screening for past indications of either hypomania or mania with or without a history of depression. Longitudinal assessments rather than one-time assessments are preferred because of the episodic nature of the illness. Finally, because of the heritability of the illness, assessment should include a careful family history.

Treatment of Bipolar Disorder

Biological Treatment

Treatment of bipolar disorder is complex and often involves several different classes of medication, including antidepressants, anticonvulsants, antipsychotics, and mood stabilizers. Lithium continues to be the gold standard for treatment, due to research that has been conducted confirming its long-term effectiveness.

Treatment can be divided into acute and maintenance phases. For acute mania or mixed states, a first-line treatment would be lithium, valproate, carbamazepine, haloperidol, aripiprazole, olanzapine, risperidone, or quetiapine. Any of these first-line treatments may be combined with adjunctive treatments that are intended to reduce symptoms of agitation, insomnia, or anxiety. For acute bipolar depression, a first-line treatment would be lamotrigine, olanzapine, or quetiapine. For individuals with rapid cycling (more than four mood episodes in 12 months), lamotrigine is the first-line choice. For maintenance with a mood stabilizer, lithium, valproate, lamotrigine, or aripiprazole may be considered. There is some debate as to the relative risk versus benefit of continuing treatment with antidepressants, which may in some cases exacerbate the illness.

Because of rapid changes in knowledge and practice in this area, the reader is cautioned that this discussion of biological treatment is not intended to substitute for professional medical consultation and advice.

Even the best pharmacological treatment rates are completely effective in less than 50% of patients. Significant problems with adherence to treatment (i.e., taking medication consistently as prescribed) greatly limit the overall effectiveness of medication-only approaches.

Psychotherapy or Psychosocial Treatment

Some people are able to remain relatively stable on a long-term medication regimen. However, adjunctive psychotherapeutic treatment should be considered for individuals experiencing continuing episodes or significant periods of mood instability marked by breakthroughs of depression, mania, or hypomania. This is especially important if marked suicidal ideation, severe hopelessness, or mood instability is causing significant problems in an individual’s living and quality of life.

Treatments that have demonstrated specific evidence of effectiveness include cognitive and cognitive-behavioral therapy, developed by Albert Ellis, Aaron Beck, and others, interpersonal and social rhythm therapy (IPSRT), developed by Ellen Frank; and family-focused treatment (FFT), developed by David Miklowitz. Effective treatments appear to share several common characteristics, including education about the disorder, emphasizing medication adherence, helping patients maintain lifestyle regularity, helping patients recognize early warning signs of illness, and helping patients develop specific coping plans in order to anticipate and minimize the impact of future episodes.


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