Bipolar disorder

Overview

Stuck at the extremes

Bipolar affective disorder, also called manic depression, is a devastating illness marked by alternating periods of euphoria and depression. Instead of feeling in charge of their moods, people with bipolar disorder feel victimized by them.

This widely misunderstood condition's stereotype focuses on major mood swings, ranging from deep depression to extremely energetic and unrealistic, "crazy" behavior. Wild mood swings that a person cannot control may happen (and could lead to hospitalization), but bipolar disorder is often much more subtle. Everyone has mood swings, so it's often difficult to distinguish between people who are simply "moody" and those who are truly bipolar.

Bipolar disorder usually begins with a period of depression, typically lasting three to six months. The manic phase that follows is usually shorter — several days to months. In the first few days of a manic episode, the person not only feels wonderful but often attracts others because of his or her enthusiastic mood and expansive behavior. If the mood escalates, however, its inappropriateness becomes apparent and the person's actions become more erratic and destructive, possibly alienating even close friends and family.

Detailed Description

A manic episode of bipolar affective disorder is marked by hyperactivity paired with extreme euphoria, out of proportion to any event worth celebrating. While the person exhibits extreme, even self-destructive behavior, he or she feels better than ever and may have no sense that his or her behavior is inappropriate. Those in the throes of a manic episode will typically talk excessively, stay up all night, and have bursts of energy, though they accomplish little because they cannot focus on any task for long. They have racing thoughts and grandiose delusions, frequently using poor judgment. In the throes of mania, patients may spend a great deal of money, become sexually reckless, and break laws.

As mania progresses, patients become increasingly irritable, hostile, angry, and even delusional. The last stage of a manic episode is also the most destructive. Patients are filled with panic and terror. Sleep is impossible. Physical activities dissolve to a state of frenzy, and hallucinations may occur. Not all manic-depressives reach this final stage.

The "down" phase of bipolar affective disorder can have all the features of major depression, such as "blue" mood, disturbed sleep, lack of pleasure and interest in activities, disturbed appetite, weight change, and trouble concentrating.

There are four types of bipolar affective disorder:

• Bipolar affective disorder, type I consists of alternating episodes of major depression and full-blown psychotic mania in which the person is incapacitated by physical frenzy and hallucinations
• Bipolar affective disorder, type II is marked by alternating episodes of depression and hypomania (a milder form of mania in which the person has an inappropriately elevated mood, but whose behavior doesn't impair his or her ability to work or have relationships)
• Bipolar affective disorder, not otherwise specified consists of major depressions and episodes that almost but don't quite reach criteria for hypomania
• Cyclothymic disorder is characterized by hypomania and mild depression alternating together over the course of a few days

How Common Is Bipolar Affective Disorder?

Nearly 2% of the U.S. population has the disorder — more than 5.4 million people. It usually emerges during the teens, 20s, and 30s; however, it can arise at any age. Men and women are equally affected, on average at age 30.

What You Can Expect

Untreated, a manic episode may last several months. Like depressive episodes, mania may pass without treatment. However, the toll on the person and his or her family may be intolerable. Fortunately, bipolar affective disorder is treatable with drug therapy, as well as psychotherapy. With proper care, doctors may bring a manic episode under control within a few weeks.

Conventional Treatment

Goals of Treatment

Currently there is no cure for bipolar affective disorder, although research about its treatments and causes continues. Doctors seek to recognize and treat the condition early; to carefully manage antidepressant drugs so patients don't switch from a depressive state to a manic state; and to keep patients free of manic and depressive episodes.

Treatment Overview

Current drug therapies are effective in about 70% of people with bipolar affective disorder, and electroconvulsive therapy may also successfully treat the illness. Psychotherapy can augment drug treatment, but is not effective alone. Your treatment probably won't require a hospital stay; you'll be treated in your doctor's office and go home the same day. However, an initial episode may require hospitalization and powerful antipsychotic and mood-stabilizing drugs until the episode is under control. A long-term maintenance program includes regular assessment of mood, blood lithium levels, and well-being.

Drug Therapy

Drugs most commonly prescribed
Depakene
Depakote
Tegretol
Second choices
In the depressive phase of bipolar disorder, antidepressant drug therapy may be needed. However, these drugs could potentially shift a person with bipolar disorder into mania. In these cases, it is important to ensure that the person is already using a mood stabilizer. Drugs for the depressive phase may include the following:
Selective serotonin reuptake inhibitors (SSRIs)
Paxil http://www.nmihi.com/p/paroxetine.html
Prozac
Trycyclic antidepressants (TCAs)
Pamelor
Others:
Desyrel
Effexor http://www.nmihi.com/u/venlafaxine.html
Remeron
Zyban http://www.nmihi.com/b/bupropion.html
Antipsychotic medications
With severe mania, antipsychotic medications may be used. This class of medications includes:
Zyprexa
Risperdal
Clozaril
Loxitane (loxapine)

Psychotherapy

Psychotherapy is effective largely because it helps keep the person aware of his or her illness, the likelihood of it happening again, and the need to continue with drug therapy. People with bipolar disorder sometimes deny an emerging manic episode because its initial euphoria is seductive. A good therapist will help the patient recognize warning signs such as a change in sleep, and acknowledge mania before it can accelerate into dangerous activity.

Electroconvulsive therapy (ECT)

ECT, previously known as "shock treatment," is reserved for severe, unresponsive, life-threatening manic states. Doctors place electrodes on the patient's head and deliver a mild shock, inducing a brain seizure. Doctors give the treatment under general anesthesia, in five to seven treatments, one treatment every other day. It may cause temporary memory loss, but it can deliver almost immediate relief from a severe manic episode. Why ECT works is still a mystery.

Healthcare Professionals Who May Be Involved in Treatment

These health providers help treat bipolar disorder:

• Family physician
• General internists
• Pediatricians
• Geriatricians
• Gynecologists
• Obstetricians
• Neurologists
• Neuropsychiatrists
• Psychiatrists
• Clinical psychologists
• Pharmacists
• Physician assistants
• Nurse practitioners
• Psychiatric nurse specialists
• Medical social workers

Activity & Diet Recommendations

If you have bipolar disorder, you must learn to recognize an emerging manic episode and report it to your doctor. You can also keep a daily checklist to help objectively monitor your sleep, work, spending, and sexual habits. If a pattern of potentially destructive behavior emerges, you should contact your therapist.

If your appetite is suppressed during a depressive phase, make sure you get enough calories, protein, and vitamins.

Monitoring Manic Depression

Since this is a cyclical disease that fluctuates from one extreme to the other, a physician must carefully monitor symptoms to most effectively treat them. In addition, lithium and other drug therapies may require monitoring via blood tests. Therefore, periodic visits to a physician will be necessary.

Possible Complications

The side effects of lithium include decreased thyroid function, nausea, diarrhea, tremor, and other neurological or psychological symptoms. Depakote causes mild elevations of liver enzymes. Carbamazepine can cause blood cell changes. If bipolar affective disorder is untreated, it could eventually lead to suicide.

Quality of Life

Although the behavior of a person with bipolar disorder in a manic state is out of his or her control, it can be intolerable nonetheless for friends, family, and co-workers. People with bipolar disorder often divorce, lose their jobs, and suffer financial and legal problems. As seductive as the euphoria of the manic phase of the disease may be, people with bipolar disorder need to accept their diagnoses and rigorously follow their prescribed course of treatment.

Considerations for Women

Pregnancy

Research is ongoing about the potential harm lithium may cause to a fetus, but doctors don't usually prescribe it during pregnancy. However, there are also potential risks to you if you stop using lithium. There are also risks to the fetus from Depakote and Carbamazepine. You should carefully discuss all potential risks with your doctor.

In addition, right after delivery the mother is at high risk for relapse of bipolar affective disorder.

Nursing mothers

Breastfeeding is not advised for women taking lithium. Much of the lithium in the bloodstream can be passed through the breast milk, with toxic effects for the baby.

Considerations for Older People

Ten percent of all mood disorders affecting older people are diagnosed as bipolar affective disorder. The manic state of the disease is less likely to appear as euphoria or excitement; it tends to appear as agitation, irritability, and disturbed sleep instead.