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BIPOLAR DISORDER

Bipolar disorders are brain disorders that cause changes in a person’s mood, energy and ability to function. Bipolar disorder is a category that includes three different conditions — bipolar I, bipolar II and cyclothymic disorder. People with bipolar disorders have extreme and intense emotional states that occur at distinct times, called mood episodes. These mood episodes are categorized as manic, hypomanic or depressive. People with bipolar disorders generally have periods of normal mood as well. Bipolar disorders can be treated, and people with these illnesses can lead full and productive lives. Diagnostic and Statistical Manual of Mental Disorders, (DSM-5) American Psychiatric Publishing, 2013

The Center for Disease Control (CDC) characterizes Bi-Polar Disorder as:

Bipolar disorder (formerly known as “manic-depressive disorder”) is another major mood disorder in which the individual most commonly experiences episodes of depression and episodes of mania.1 Mania is characterized by clearly elevated, unrestrained, or irritable mood which may manifest in an exaggerated assessment of self-importance or grandiosity, sleeplessness, racing thoughts, pressured speech, and the tendency to engage in activities which appear pleasurable, but have a high potential for adverse consequences.2 As is true for depression, medications and some forms of psychotherapy are effective in the treatment of bipolar disorder (Andreasen & Black, 2006).

What is bipolar disorder? Bipolar disorder is a mental illness that was previously referred to as manic depression. It affects the normal functioning of the brain so that the person experiences extreme moods – mania and depression.

People may also experience psychosis in the manic and/or depressed phase. A variety of types of bipolar disorder exists. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), the following are the distinct types:

Bipolar I Disorder

Symptoms of Bipolar I Disorder
Bipolar I disorder can cause dramatic mood swings. During a manic episode, people with bipolar I disorder may feel high and on top of the world, or uncomfortably irritable and “revved up.“ During a depressive episode they may feel sad and hopeless. There are often periods of normal moods in between these episodes. Bipolar I disorder is diagnosed when a person has a manic episode. Bipolar 1 disorder – characterized by one or more major manic or mixed episodes, usually accompanied by major depressive episodes

Bipolar II disorder involves a person having at least one major depressive episode and at least one hypomanic episode (see above). People return to usual function between episodes. People with bipolar II often first seek treatment because of depressive symptoms, which can be severe.

People with bipolar II often have other co-occurring mental illnesses such as an anxiety disorder or substance use disorder.

Treatment
Treatments for bipolar II are similar to those for bipolar I — medication and psychotherapy. Medications most commonly used are mood stabilizers and antidepressants, depending on the specific symptoms. If depression symptoms are severe and medication is not working, ECT (see above) may be used. Each person is different and each treatment is individualized.

A manic episode is a period of at least one week when a person is very high spirited or irritable in an extreme way most of the day for most days, has more energy than usual and experiences at least three of the following, showing a change in behavior:

  • Exaggerated self-esteem or grandiosity
  • Less need for sleep
  • Talking more than usual, talking loudly and quickly
  • Easily distracted
  • Doing many activities at once, scheduling more events in a day than can be accomplished
  • Increased risky behavior (e.g., reckless driving, spending sprees)
  • Uncontrollable racing thoughts or quickly changing ideas or topics

The changes are significant and clear to friends and family. Symptoms are severe enough to cause problems with work, family or social activities and responsibilities. Symptoms of a manic episode may require a person to get hospital care to stay safe. The average age for a first manic episode is 18, but it can start anytime from early childhood to later adulthood.

A hypomanic episode is similar to a manic episode (above) but the symptoms are less severe and need only last four days in a row. Hypomanic symptoms do not lead to the major problems that mania often causes and do not require hospitalization.

Cyclothymic disorder is a milder form of bipolar disorder involving many mood swings, with hypomania and depressive symptoms that occur often and fairly constantly. People with cyclothymia experience emotional ups and downs, but with less severe symptoms than bipolar I or II.

Cyclothymic disorder symptoms include the following:

  • For at least two years, many periods of hypomanic and depressive symptoms (see above), but the symptoms do not meet the criteria for hypomanic or depressive episode.
  • During the two-year period, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months.

Treatment
Treatment for cyclothymic disorder can involve medication and talk therapy. For many people, talk therapy can help with the stresses of ongoing high and low moods. People with cyclothymia may start and stop treatment over time.

• Cyclothymic disorder – characterized by at least two years of numerous periods of hypomanic symptoms (that do not meet criteria for a manic episode) and numerous periods of depressive symptoms (that do not meet criteria for a major depressive episode)

• Bipolar disorder not otherwise specified – where bipolar features exist but do not meet any of the criteria for any of the specific diagnoses above. DSM (IV) further divides these distinct types into many subcategories.

A major depressive episode is a period of two weeks in which a person has at least five of the following (including one of the first two):

  • Intense sadness or despair; feeling helpless, hopeless or worthless
  • Loss of interest in activities once enjoyed
  • Feeling worthless or guilty
  • Sleep problems — sleeping too little or too much
  • Feeling restless or agitated (e.g., pacing or hand-wringing), or slowed speech or movements
  • Changes in appetite (increase or decrease)
  • Loss of energy, fatigue
  • Difficulty concentrating, remembering making decisions
  • Frequent thoughts of death or suicide

Bipolar disorder can disrupt a person’s life and relationships with others, particularly with spouses and family members, and cause difficulty in working or going to school. People with bipolar I often have other mental disorders such as attention-deficit/hyperactivity disorder (ADHD), an anxiety disorder or substance use disorder. The risk of suicide is significantly higher among people with bipolar disorder than among the general population.

The National Comorbidity Study reported a lifetime prevalence of nearly 4% for bipolar disorder. Bipolar disorder is more common in women than men, with a ratio of approximately 3:2. The median age of onset for bipolar disorder is 25 years,8 with men having an earlier age of onset than women.8

  • In an insured population, 7.5% of all claimants with behavioral health care coverage filed a claim, of which 3.0% had bipolar disorder.9 Persons with bipolar disorder incurred $568 in annual out-of-pocket expenses—more than double the expenses incurred by all claimants. Annual insurance payments were greater for medical services for persons with bipolar disorder than for patients with other behavioral healthcare diagnoses.9
  • The inpatient hospitalization rate of bipolar patients (39.1%) was greater than the 4.5% characterizing all other patients with behavioral health care diagnoses.
  • Bipolar disorder has been deemed the most expensive behavioral health care diagnosis,9 costing more than twice as much as depression per affected individual.10 Total costs largely arise from indirect costs and are attributable to lost productivity, in turn arising from absenteeism and presenteeism.10
  • For every dollar allocated to outpatient care for persons with bipolar disorder, $1.80 is spent on inpatient care, suggesting early intervention and improved prevention management could decrease the financial impact of this illness.9

Bipolar disorder can run in families. In fact, 80-90 percent of individuals with bipolar disorder have a relative with either depression or bipolar disorder. However, environmental factors can also contribute to bipolar disorder — extreme stress, sleep disruption and drugs and alcohol may trigger episodes in vulnerable patients.

Management of acute episodes of mania or depression depends on the degree of risk associated with the behaviors and mood. People will be hospitalized if their mania causes them to engage in life threatening, risk-taking behaviors and if their depression causes suicidal ideation or similar. A biopsychosocial approach that includes attending to the biological need (chemical imbalance), as well as the psychological and social aspects of life is the most effective method in the treatment of, and recovery from, bipolar disorder.

Treatment and Management

Bipolar disorder is very treatable. Medication alone or a combination of talk therapy (psychotherapy) and medication are often used to manage the disorder over time. Each person is different and each treatment is individualized. Different people respond to treatment in different ways. People with bipolar disorder may need to try different medications and therapy before finding what works for them.

Medications known as “mood stabilizers” are the most commonly prescribed type of medication for bipolar disorder. Anticonvulsant medications are also sometimes used. In psychotherapy, the individual can work with a psychiatrist or other mental health professional to work out problems, better understand the illness and rebuild relationships. A psychiatrist is also able to prescribe medications as part of a treatment plan. Because bipolar disorder is a recurrent illness, meaning that it can come back, ongoing preventive treatment is recommended. In most cases, bipolar disorder is much better controlled if treatment is continuous.

In some cases, when medication and psychotherapy have not helped, a treatment known as electroconvulsive therapy (ECT) may be used. ECT uses a brief electrical current applied to the scalp while the patient is under anesthesia. The procedure takes about 10-15 minutes and patients typically receive ECT two to three times a week for a total of six to 12 treatments.

Since bipolar disorder can cause serious disruptions and create an intensely stressful family situation, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies to help them cope, to be an active part of the treatment and to gain support for themselves.

References

  1. Campbell RJ, Campbell’s psychiatric dictionary. (9th ed.). New York, Oxford, 2009.
  2. Andreasen NC, Black DW. Introductory textbook of psychiatry. (4th ed.). Arlington, VA:American Psychiatric Publishing, Inc., 2006.

More detail on mental health/mental illnesses may be found at: http://www.nimh.nih.gov/health/index.shtml or www.samhsa.gov/

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