Bipolar disorder

What is bipolar disorder?

People who have bipolar disorder experience periods (or ‘episodes’) of mania and periods (or ‘episodes’) of depression (bipolar disorder used to be called ‘manic depression’). The majority of people with bipolar disorder have recurrent episodes but in between episodes, most people don’t experience any symptoms.

During episodes of both mania and depression, people may temporarily experience the symptoms of psychosis – they may have unusual experiences such hearing voices, or have delusional beliefs, for example. However, not everyone experiences psychosis, and psychotic symptoms are not necessary for a diagnosis of bipolar disorder to be given.

In most cases, people with bipolar disorder experience both episodes of mania and episodes of depression. Episodes of depression tend to be more common than episodes of mania.

Episodes of mania and depression may alternate with one another, but sometimes people have a mixture of the symptoms of mania and the symptoms of depression at the same time. This is called a ‘mixed’ episode.

The frequency of episodes varies quite considerably: some people might have one episode a year, while others have more frequent episodes. When people have four or more episodes of any kind within a year, mental health professionals say they have ‘rapid cycling’ bipolar disorder.

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Bipolar 2 disorder and hypomania

People may be given a diagnosis of bipolar 1 disorder or bipolar 2 disorder. People who have bipolar 2 disorder have episodes of depression and episodes involving less severe symptoms of mania. This is called ‘hypomania’ and is less likely to interfere dramatically with their lives. When people experience episodes of hypomania, they do not experience the symptoms of psychosis.

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Who gets bipolar disorder?

About one person in every 100 people has bipolar 1 disorder at some time in their life. The first episode usually occurs before the age of 30. Research indicates that about one person in every 200 people experiences bipolar 2 disorder.

Researchers still don’t know the precise causes of bipolar disorder, but there is strong evidence from twin and family studies to indicate that genes may have quite a large part to play.

Scientists know from research studies that first-degree relatives (children or brothers and sisters) of someone who has bipolar disorder are much more likely to develop bipolar disorder themselves than people who have no bipolar in the family.

First-degree relatives of someone who has bipolar disorder also have a much higher risk of developing depression.

Scientists think there may be 'shared' genes that put people at greater risk for developing a number of different mental health problems and brain conditions, including bipolar disorder, depression and schizophrenia.

Recent studies have suggested there are also a number of specific genes involved in bipolar disorder, but each of these ‘risk genes’ on their own have quite small effects. Researchers think that people need to inherit many ‘risk genes’ – but even if they do inherit a lot of them, they won't necessarily go on to experience bipolar disorder because there are other factors that contribute to its development. These include negative life experiences such as childhood maltreatment.

Scientists also think that the stress hormone cortisol, and the system in the brain that activates it (called the HPA – hypothalamic-pituitary-adrenal – axis) may have something to do with the development of both depression and bipolar disorder.

Researchers have found higher than normal cortisol levels in people with depression (especially people who have psychotic depression), which might mean the HPA axis isn’t working properly. Some studies have also found abnormalities in this system in people with bipolar disorder. If cortisol levels are high all the time, this has an effect on mood and memory.

There have also been studies that have found abnormalities in the system that regulates thyroid hormones in people with bipolar disorder. The system is called the HPT – hypothalamic-pituitary-thyroid – axis. Thyroid hormones can affect mood and behaviour. Researchers have found that a significant number of people with rapid cycling bipolar disorder have hypothyroidism – an under-active thyroid gland.

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Mania

During the early stages of a manic episode, people can be very happy, productive and creative. They have less need for sleep and don’t feel tired.

In its mild form, mania is not necessarily a problem and some people say it is enjoyable. However, the energetic and high mood can get out of control. Even if the person feels physically exhausted, they may have no desire to rest. They can become overactive, irritable and restless, finding it hard to be still and difficult to concentrate. They may feel over-confident, believing they can do anything, and come up with extravagant ideas and wild or grandiose plans.

They may lose judgement, take risks and become impulsive. These risks can lead to decisions that they later regret – bouts of spending that cause financial problems, for example. Their libido may rise and they may become promiscuous. They may talk or shout quickly and loudly. They may be difficult to understand because their thoughts and ideas are coming thick and fast. They may drink more alcohol or use more street drugs than normal.

During a manic episode, people may experience symptoms of psychosis – delusions, hallucinations and confused thoughts. In some cases, people don’t see that they are unwell, or accept that they might benefit from treatment.

An episode of mania can last for a few days or for a few months. Afterwards, people are often completely worn out and may feel ashamed of, and humiliated by, their behaviour.

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Depression

The depression experienced by people with bipolar disorder is similar to major or severe depression – what mental health professionals call ‘unipolar’ depression. An episode of depression can last for several months.

Typically, people lose interest in their daily lives. They feel low in mood, get very tired, lose weight, have disrupted sleep patterns (especially waking unusually early and being unable to fall asleep again), and have low self-esteem. They may experience delusions – feeling they are totally to blame for bad events in the world, for example – or hallucinations.

People often think about harming themselves and a significant number of people who have bipolar disorder attempt to take their own lives during episodes of depression.

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Diagnosis

Sometimes it may be difficult to diagnose bipolar disorder, especially after a first episode.

If the first episode is depression, mental health professionals cannot predict whether someone has unipolar depression (which is more common) or will go on to develop bipolar disorder. If someone is experiencing mania, this may be caused by other conditions, or by prescribed medication, or by street drugs such as cocaine or ecstasy. Doctors will need to rule out these other possible causes.

An online survey of people who have bipolar disorder and their families (carried out by Bipolar UK, Bipolar Scotland and the Royal College of Psychiatrists in 2012) showed that many people were not diagnosed for more than 13 years after they had first started experiencing symptoms. 15 per cent of more than 700 people surveyed had been diagnosed promptly but 85 per cent had difficulty getting the right diagnosis – most were initially diagnosed with depression.

If someone is feeling depressed, or very excited and out of control, and the GP suspects bipolar disorder, she or he should refer the individual to a mental health specialist. The National Institute for Health and Care Excellence (NICE) 2014 guidance about bipolar disorder says assessment, diagnosis (and treatment) of bipolar disorder should be carried out by specially trained mental health professionals.

NICE says GPs should refer people to an early intervention service, a specialist bipolar disorder service or a community-based mental health team (specialist services for bipolar disorder are rare in the NHS).

There are two systems of classification to help mental health professionals make a diagnosis.

The first is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

The second is the International Classification of Disease (ICD), published by the World Health Organisation.

The definition of bipolar disorder is similar in each one. However, the current version of the ICD does not include bipolar 2 disorder. Only the DSM talks about bipolar 2 disorder, where people experience episodes of depression and less severe mania symptoms called hypomania. It also includes ‘cylothymia’ which is when someone has episodes of hypomania and less severe episodes of depression.

When making a diagnosis, mental health professionals should ask about symptoms, find out if someone has experienced previous episodes of depression or mania, and whether any family members have had bipolar disorder.

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Treatment and care

There are three types of treatment for bipolar disorder: medication, talking therapies and electroconvulsive therapy (ECT).

Different sorts of drugs are prescribed for episodes of mania and episodes of depression. In addition, many people need to take medication on a regular basis, even between episodes when they are well, to help prevent relapse. Medication prescribed for long-term treatment is called 'prophylactic' medication.

Medication used for bipolar disorder includes antipsychotics, mood stabilisers and anticonvulsants.

NICE says in its 2014 guideline that people who have bipolar disorder should not be given the anticonvulsants gabapentin and topiramate. In the past, these drugs have been prescribed off licence to treat bipolar disorder, but NICE says there is no strong evidence to show they are effective.

Talking therapies designed for bipolar disorder, or cognitive behaviour therapy and/or family therapy can help stabilise people’s mood and help them recognise signs that they are becoming unwell so they can try to prevent new episodes.

Electroconvulsive therapy (ECT) is occasionally offered to people who have bipolar disorder if medication is not working, and/or if someone has very severe symptoms, including the symptoms of psychosis.

If someone’s behaviour is very extreme and destructive, and if they are considered a danger to themselves or to others, they may be admitted to hospital for treatment against their will, under the Mental Health Act (see Mental Health Act page) .

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Treatment for episodes of mania and hypomania

Antipsychotics and ‘mood stabilisers’ (such as lithium or valproate) may be prescribed for mania and hypomania (see Medication for bipolar disorder page). Valproate should not be prescribed for women who are, or who may become pregnant, as it could harm the baby.

The National Institute of Health and Care Excellence (NICE) says in its 2014 guideline about bipolar disorder that one of four antipsychotics should be prescribed: haloperidol, olanzapine, quetiapine or risperidone.

If the first drug doesn't work, mental health professionals should suggest trying one of the other three antipsychotics.

No more than one antipsychotic should be prescribed at a time, except for a short period changing from one medication to another.

If an antipsychotic is not effective, doctors may recommend lithium at the same time as an antipsychotic. Lithium is the most effective mood stabiliser but too much can be harmful. The effective dose of lithium will vary from one person to another, so people who are prescribed this drug need to have regular blood tests. These tests ensure the concentration of lithium in the bloodstream is in the correct range and help doctors work out the appropriate dose for each individual.

If lithium doesn't work, valproate may be offered (though not to women who are, or may become pregnant).

Mental health professionals should not prescribe lamotrigine to treat mania or hypomania (although they may prescribe this drug for episodes of depression).

At the end of an episode of mania or hypomania, mental health professionals may suggest continuing the medication for three to six months.

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Treatment for episodes of depression

The National Institute of Health and Care Excellence (NICE) says that in the first instance, people should be offered talking therapies recommended for depression (such as CBT, interpersonal therapy or behavioural couples therapy), or talking therapies designed especially for bipolar disorder.

However, if the depression is severe and making life very difficult, doctors may offer medication to take at the same time. The choice of drugs should depend on an individual's preference and past medical history.

NICE's 2014 guidance about bipolar disorder says doctors should prescribe either the antidepressant fluoxetine to be taken together with the antipsychotic olanzapine; or the antipsychotic quetiapine to be taken on its own; or olanzapine to be taken on its own. NICE does not recommend people be prescribed antidepressants by themselves: there is a risk that they can work 'too well' and cause the mood to switch from depression to mania.

If fluoxetine, olanzapine or quetiapine don't work, doctors may suggest the anticonvulsant lamotrigine.

At the end of an episode of depression, mental health professionals may suggest your relative keeps taking the medication, or/and continues with the talking therapy, for three to six months afterwards.

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Long-term treatment and care

The National Institute for Health and Care Excellence (NICE) recommends that in the long-term, people who have bipolar disorder are offered medication and talking therapies to help them stay well.

The responsibility for your relative's long-term care may be transferred to his or her GP. If this happens, members of the specialist mental health team should work with the GP to agree a care plan, detailing medication, recovery goals, what to do in a crisis and a review date.

The 2014 NICE guideline about bipolar disorder says lithium usually works better than any other type of medication for long-term treatment. Doctors will ask your relative if he or she wants to continue on the medication they were prescribed during an episode of the illness, or whether they want to change to lithium. However, lithium doesn't work for some people, and your relative may therefore be offered valproate, olanzapine or quetiapine as a drug to take in the long term (valproate should not be offered to women who are, or who may become, pregnant).

Your relative should also be offered a talking therapy to help prevent relapse. Therapies designed for bipolar disorder focus on self-management skills – how to spot early warning signs of relapse and how to stay well. Specialist talking therapy for bipolar disorder is not available everywhere and the government's Improving Access to Psychological Therapies (IAPT) programme is currently trialling these sort of specialist services to try to make them more widely available.

If your relative is in close contact with, or lives with, family members, he or she should also be offered family therapy.

If your relative is well and decides to stop taking long-term medication, they should discuss this with their doctor first of all – and reduce the medication gradually over at least four weeks. Your relative should also discuss with doctors how to recognise when they are becoming unwell again, and what to do if that happens. NICE recommends health professionals suggest people plan what to do in a crisis by making an advance statement containing their treatment preferences, or by making a lasting power of attorney to name who can make decisions on their behalf when they are unwell.

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Physical health

The medication used to treat bipolar disorder can seriously affect people’s physical health – one of the side effects may be weight gain, for example, which can contribute to other physical health problems.

The National Institute for Health and Care Excellence (NICE) 2014 guideline about bipolar disorder stresses that it is important for people to try to stay healthy to avoid diabetes and other physical health problems.

Before starting any medication, people should be given a physical check-up. Health professionals should check weight, pulse and blood pressure, and may do blood and urine chest to check for diabetes and cholesterol levels, and an electrocardiogram (ECG) to check the heart.

When someone starts antipsychotic medication for the first time, doctors should check their weight once a week for the first six weeks. Doctors should also check pulse and blood pressure each time the dose is changed, and measure blood sugar, cholesterol and weight after three months of taking the medication.

Mental health professionals should offer advice about healthy eating and exercise, and treatment and support in line with NICE guidance on obesity, preventing type 2 diabetes, high blood pressure and other physical health problems, if appropriate.

Everyone who has a diagnosis of bipolar disorder should have a general health check with their GP at least once a year. This should include checking weight, blood sugar and cholesterol levels.

Doctors should explain that drinking alcohol, smoking or taking drugs while taking medication for bipolar disorder can stop the medication from working properly and make symptoms worse.

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Pregnancy and birth

Women who have been given a diagnosis of bipolar disorder might experience a relapse of the illness almost immediately after the birth of their first child. This is called puerperal, or postpartum, psychosis. Women who experience puerperal psychosis after the birth of their first child will almost inevitably experience it again following the birth of a second child, and after subsequent births (see New mothers (puerperal psychosis) page).

It is very important for women to tell doctors if they become pregnant, or if they are trying for baby. Women should discuss the possibility of experiencing puerperal psychosis with their psychiatrist and obstetrician: ideally, they should talk to their psychiatrist before they become pregnant. Valproate should not be taken during pregnancy as it may harm the developing baby. Women may therefore need to change medication during pregnancy and their psychiatrist will advise on alternative drugs.

It is also important to plan support and care after the birth. The risk of puerperal psychosis is highest straight after birth, so health professionals may arrange for women to stay for a few days longer on an obstetric ward, for example, where support from a hospital-based psychiatrist is available at all hours.

In many parts of the country, there are dedicated perinatal psychiatry teams who can give expert advice about preventative measures and can help coordinate care of women who are at risk of developing puerperal psychosis.

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Other diagnoses

Many people who have bipolar disorder experience other mental health problems at the same time. Mental health professionals call these ‘comorbid’ problems.

Up to 60 per cent of people who have bipolar disorder experience anxiety, and about 40 per cent use drugs and/or alcohol in a way that is detrimental to their health.

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Living with bipolar disorder

Manic episodes can be very disruptive to everyday life and can also be dangerous and detrimental – they can lead to dangerous driving, financial problems, high-risk sexual behaviour, legal challenges or loss of a job, for example. The National Institute for Health and Care Excellence (NICE) 2014 guidance about bipolar disorder says mental health professionals should advise people not to make any important decisions while they are experiencing an episode of mania.

People can often identify changes in their mood or behaviour that might indicate the start of another episode. Knowing what these warning signs are, of whether there are any triggers for relapse, can be helpful to the individual who is unwell, and also to their family members and friends.

NICE highlights the important role of family members and other carers, and states that the symptoms of bipolar disorder can be very stressful for them, and that relationships can be put under great pressure.

NICE says mental health professionals should give family members information about bipolar disorder, its symptoms and treatments that are offered, and should be available to help and advise carers in times of crisis. Mental health professionals should talk to families about how they can be involved in care and treatment, and make sure they are offered an assessment of their own needs. The education and support offered to family members may be given as part of family therapy, if this is available.

 

 


This page was last updated 12 November 2014
Links on this page last checked: 12 November 2014
Next links check due: April 2015