By Chris Woolston, M.S.
We all have times when we feel euphoric or despondent. A death in the family can cause profound sadness. Winning a sports competition can lead to elation. But some people have dramatic shifts in mood that can take them by surprise. Through no fault of their own, their brains can shift from deep depression to unsettling highs.
This condition used to be called manic depression, but now it's known as bipolar disorder -- a name that captures the swing from one opposite to another. About 5.7 million Americans age 18 and older suffer from bipolar disorder. With the right treatment, many can lead stable, fulfilling lives. But bipolar disorder is still widely misunderstood, under-recognized and under-treated, frequently with tragic results.
What are the symptoms of bipolar disorder?
Bipolar disorder comes in different forms. Symptoms can range from merely troubling to severe or even life-threatening. Some people go through dramatic mood swings that can shift rapidly in a single day, or week, or several times a year -- a condition called rapid cycling bipolar disorder. Others may have sporadic episodes of euphoric highs or devastating lows in between long periods of relative calm. On average, people with bipolar disorder have their first episode of mania or depression in their late teens or early 20s; the median age of onset is 25.
Bipolar disorder is different from regular depression in one important way: People with bipolar disorder have had at least one bout of mania, the extreme "high" that's truly the polar opposite of depression. In fact, a person who has gone through mania may be diagnosed with bipolar disorder even if he or she has never really been seriously depressed.
Some of the symptoms of mania may not seem like anything you'd want to "fix." A person may feel euphoric and perhaps bursting with confidence. But even these positive feelings have a downside. People in a manic state also tend to be reckless and aggressive. They may drive too fast, spend too freely, pick fights, or in rare cases -- even commit serious crimes: When you feel invincible, you're not likely to think about consequences. Other symptoms of mania include rapid speech, less need for sleep, trouble concentrating, racing thoughts, and extreme agitation. In some ways, mania could appear similar to the behavior of people taking methamphetamine or other stimulants.
Coming down from a manic state, a person with the illness can be devastated or ashamed by his or her actions. Following a manic episode, the poet Robert Lowell wrote an apology to the poet T.S. Eliot for numerous phone calls. "When the 'enthusiasm' is coming on me, it is accompanied by a feverish reaching to my friends. After it's over, I wince and wither." Others, particularly those unaware they have an illness, may not realize that the condition is abnormal.
When someone with bipolar disorder becomes depressed, he'll feel much like anyone else with serious depression. Possible signs include feelings of sadness and hopelessness along with guilt, anxiety, fatigue, irritability, and trouble eating or sleeping.
When depression hits, it can sap a person's energy, motivation, and the will to live. Roughly 15 percent of people with bipolar disorder eventually commit suicide, and about 80 percent seriously think about it or attempt it. One tragic example: In 2008, 19-year-old Abraham Biggs, a bipolar college student, overdosed on drugs in front of a live Internet audience.
Some people experience severe depression and mania at the same time. Such a blend is called mixed state bipolar disorder and can also cause a person to think about death, harming himself, or attempting suicide. Of 242 adolescents seeking help at a medical clinic for major depression, for example, 100 were found to be bipolar. Eighty-two percent of those teens who were bipolar were in a mixed state. A great majority of them also had thoughts of suicide.
Can children have bipolar illness?
The signs can be hard to spot, and there is some controversy about the reliability of diagnosing bipolar disorder in children, according to a 2007 study in the Archives of General Psychiatry. Between 1994 and 2003, the diagnosis of bipolar disorder in youth increased 40-fold, while in adults, there was only a twofold increase in diagnosis. However, the same study noted that often young people diagnosed with bipolar disorder are reclassified as having depression, so there is room for misdiagnosis.
Symptoms such as mania and irritability may be diagnosed as bipolar disorder, but they're also symptoms of other childhood psychiatric disorders, such as Attention Deficit Hyperactivity Disorder. Researchers also noted that about half of adolescent inpatients who had been previously diagnosed with bipolar disorder, were reclassified as having depression. Researchers also speculate that the huge increase in diagnoses among children could be because the criteria for diagnosing the illness in children are not specific enough. But they do agree on one thing: More studies are needed to better understand the illness in young people.
Children are especially likely to have the condition if both their parents have it. Bipolar kids often go through their moods swings very quickly, sometimes several times in one day. Although they may have episodes of elation, they are more likely to be extremely irritable, aggressive, and prone to room-wrecking tantrums. Even an expert may have trouble understanding the source of such behavior. But whether the child has bipolar disease or something else, he clearly needs help, and the sooner the better.
What causes bipolar disorder?
Nobody knows exactly what causes bipolar disorder. Chemical imbalances in the brain definitely play a role, but it's hard to say where those imbalances get their start. The condition runs in families, and most experts believe that people are born with a tendency to be bipolar. But family history isn't everything. It's possible for one identical twin to be bipolar while the other twin isn't. Experts believe that outside forces -- including traumatic life events, serious losses, or drug abuse -- can push some people over the edge. There's no connection between a person's risk for bipolar disease and gender, race, or income.
How is bipolar disorder diagnosed?
Doctors can order physicals and blood tests to check on overall health, but the only way to diagnose bipolar disorder is to get a full account of a person's symptoms and family history. People who are being evaluated for the disorder should expect to answer many questions about their feelings, behaviors, and overall state of mind.
How is bipolar disorder treated?
Medications that change the chemistry of the brain are the cornerstone of treatment for bipolar disorder. The first drugs of choice for treating mania are usually "mood stabilizers" containing the element lithium. Examples include Eskalith and Lithobid, both of which contain lithium carbonate. Although lithium is a main line of treatment, it's a tricky drug to take correctly. If the dose isn't exactly right, the drug may not work. Up to 75 percent of patients will experience side effects such as swelling, weight gain, nausea, vomiting, and tremors. Lithium generally shouldn't be taken by people with kidney or heart disease. Lithium use can also cause trouble with the thyroid, so patients thyroid levels should be monitored regularly. If your doctor prescribes a lithium medication, take it exactly as described and talk to your doctor about side effects, any possible drug interactions, and long-term health risks.
Doctors sometimes prescribe antidepressant medications to help lift the moods of depressed bipolar patients, but there's a real risk that the drugs will work "too well" and turn depression into mania. This risk can be reduced by combining antidepressants with lithium. However, one large study funded by the National Institute for Mental Health (NIMH) found that combining a mood stabilizer with lithium or other mood stabilizers was not more effective than using a mood stabilizer alone.
People with rapidly cycling bipolar disorder may get better with the help of anti-seizure medications including valproic acid (Depakene), divalproex (Depakote) and lamotrigine (Lamictal). These medications can raise the risk of suicidal thoughts and behaviors, however, so patients should be monitored for these risks, according to the NIMH.
Sometimes physicians try antipsychotic medications such as olanzapine (Zyprexa) if other medications don't seem to help. These medications can cause a range of side effects, including blurred vision, and patients should not drive until they adjust to the medication. They may also cause significant weight gain, a risk factor for diabetes. For this reason, the National Institute for Mental Health recommends that a person's weight, blood sugar levels, and cholesterol levels should be monitored regularly by a doctor if he or she is taking antipsychotics. In rare cases, the medications can also cause tardive dyskinesia (TD), a condition that causes involuntary mouth movements; it may go away partially or completely when the medication is stopped.
Often treatment of bipolar disorder is a matter of trial and error until the doctor and patient find the drug that works best. This can be challenging if the person is resisting treatment or doesn't take the medicines every day. Some bipolar patients reject their medicines when they are in their manic phase because they don't want anything to take away their feeling of euphoria.
In addition to medication, many people with bipolar disease benefit from regular counseling, including cognitive behavioral therapy. A 2007 study reported in the Archives of General Psychiatry found that intensive psychotherapy was more effective than brief therapy for the illness: patients who received it were more likely to get well and stay well.
Support groups may help, too. To find a group near you, visit the website of the Depression and Bipolar Support Alliance at www.dbsalliance.org. Family interventions have shown some promise as an adjunct therapy, but there is not yet enough evidence that this approach is effective.
In the hardest-to-treat cases, in which medications and counseling aren't enough to control the condition, a doctor might recommend electroconvulsive therapy, commonly called "shock therapy." This may strike people as inhumane, but the treatment has changed a lot over the decades. Patients receive a small, carefully targeted electrical current through the brain that causes a brief seizure. For unknown reasons, the seizures seem to help boost mood and calm the mind. Studies suggest that it may be especially helpful for people with severe depression or with "mixed" bipolar disease. Nonetheless, it's considered a treatment of last resort -- and only for certain types of patients.
Patients can expect to get three treatments a week for two to four weeks. Electroconvulsive therapy is thought to be more powerful and effective than antidepressant drugs, but it's an expensive, complicated approach. Patients have to go under a short-acting general anesthesia for each treatment -- and there can be side effects, including headaches, tiredness, and gaps in memory about things that happened before the treatment.
What can people with bipolar disorder do to help themselves?
If you suffer from bipolar disorder, make sure to keep all of your doctor appointments, and don't skip your medications. That's easy to do when you're feeling fine, but it can be a real struggle if you are feeling very high or very low. If you have unpleasant or worrisome side effects from the medication, consult your doctor right away; he or she may be able to adjust the medication or find an alternative.
It's good to have a support person handy or some system you can rely on to take your medications on time -- even for those times when you may not feel like it. If you start feeling manic or depressed, feel an episode of mania or depression coming on, be sure to tell your doctor and other people you trust who can help you in your daily life. You should avoid drinking and illegal drugs -- they'll cloud your thinking or trigger an episode, and may interact badly with the medication you're taking to control your moods.
The Mayo Clinic suggests that regular exercise and sufficient sleep can help with depression and help stabilize your moods; yoga, meditation, massage and acupuncture may also help relieve depression and/or anxiety, though there is little research on these complementary methods and bipolar illness. Research suggests that omega-3 fatty acids (found in fish and fish oil supplements) can be helpful for the depressive part of bipolar disorder, though more clinical trials are needed to determine whether its helpful for mania, according to a group for evidence-based medicine known as the Cochrane Collaboration.
You may find a bipolar support group helpful. Organizations like the Depression and Bipolar Support Alliance, and the National Alliance for the Mentally Ill have ongoing support groups all over the country. Perhaps most importantly, reach out for help if you start thinking about suicide. Call a family member, a doctor, or a suicide hotline. Or just get yourself to the emergency room -- whatever it takes to escape that suicidal desire and live for another day. With so many treatment options for bipolar disorder, there's a good chance that an adjustment to your medication will change the way you feel for the better.
National Institute of Mental Health. Bipolar Disorder. 2010. http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-publication.shtml
Mayo Clinic. Bipolar disorder. 2010. http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=treatments-and-drugs
Montgomery, P et al. Omega-3 fatty acids for bipolar disorder. The Cochrane Database of Systematic Reviews, 2009.
Justo, Luis, et al. Family Intervention of Bipolar Disorder. The Cochrane Database of Systematic Reviews. January 2009.
Moreno, Carmen, Lage, Gonzalo, et al, "National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth," Archives of General Pschiatry, 64 (no9), Sep. 2007, pp.1032-1039
Depression and bipolar support alliance. Bipolar disorder. 2010
National Alliance on Mental Illness. Bipolar disorder. 2007.
Merikangas K et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Archives of General Psychiatry. May 2007. 64(5): 543-552. http://archpsyc.ama-assn.org/cgi/content/full/64/5/543
University of Michigan Depression Center. Electroconvulsive Therapy (ECT). http://www.depressioncenter.org/treatments/ected.asp
Newman CF. Reducing the risk of suicide in patients with bipolar disorder: interventions and safeguards. Cognitive and Behavioral Practice. Vol 12 No 1 p.76-88. Winter 2005.
Last Updated: March 11, 2013
May 22: Surgery for Sleep Apnea?
Does removing the tonsils and adenoids help children with sleep apnea?