Bipolar Disorder: Symptoms, Diagnosis and Treatment
Medically reviewed on Nov 13, 2017 by L. Anderson, PharmD.
What Is Bipolar Disorder?
Bipolar disorder, previously known as manic depression, is a serious mental health disorder characterized by periods of excitability or euphoria (mania) alternating with periods of severe depression. These periods of mood swings may last week or months. It can interfere with work, school, family life and relationships. If left untreated, bipolar disorder has a high risk of suicide. However, medication treatment, psychological counseling, group support, and patient education can provide good outcomes in bipolar disorder. It is a lifelong illness that requires ongoing treatment.
Who Gets Bipolar Disorder?
Bipolar disorder affects men and women equally and usually appears between the ages of 15 and 30. People older than 65 years of age are not usually first diagnosed with bipolar disorder.
During manic periods, a person with bipolar disorder may be overly impulsive and energetic, with an exaggerated sense of self. The depressive phase brings overwhelming feelings of anxiety, low self-worth, and suicidal thoughts or actions.
Bipolar disorder affects approximately 5.7 million American adults, or about 2.6 percent of the U.S. adult population age 18 and older in a given year. Roughly 1 to 3 percent of people worldwide have bipolar disorder.
Risk Factors for Bipolar Disorder
Bipolar disorder is a result of disturbances in the areas of the brain that regulate mood. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder, and may have genetic component. It may result in an imbalance of chemicals in the brain, and medications can help to reset these imbalances.
Factors that can lead to, trigger, or worsen a bipolar event include:
- drug or alcohol abuse
- periods of high stress, such as a death of a loved one
- other traumatic event
Types of Bipolar Disorder
The primary types of bipolar disorder include:
Bipolar I Disorder: People with bipolar I disorder have had at least one fully manic episode lasting at least 7 days (or requiring hospitalization) with periods of major depression usually lasting at least 2 weeks. Hypomania usually also occurs during their course. Periods of psychosis (losing touch with reality) can occur in the manic phase. A severe manic episode may involve suicidal, violent behavior, aggressiveness, psychosis (delusions or hallucinations), and putting others at risk of harm.
Symptoms may be mixed, as well, with manic and depressive symptoms occurring at the same time. Bipolar I disorder may also be referred to as manic depression.
Bipolar II Disorder: People with bipolar disorder II seldom experience full-fledged mania. Instead they experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of major depressive disorder. Up to 15% of patients may eventually be diagnosed with bipolar I disorder due to having a fill manic episode. Patients with bipolar II disorder may be incorrectly diagnosed with just major depression because the hypomania period is often not easily recognized, or patients only seek help in the depressive phase.
Cyclothymic Disorder (Cyclothymia): A form of bipolar disorder called cyclothymia involves many periods of more mild hypomania and depression, with less-severe mood swings. These symptoms occur over a period of at least 2 years, when patients have symptoms at least 50% of the time and are not symptom-free for any longer than 2 months. As with bipolar II disorder, people with cyclothymia may also be misdiagnosed as having depression alone.
Symptoms of Bipolar Disorder
Mania or Hypomania
Typically at least 3 of the following symptoms must be present for the diagnosis of mania or hypomania. The manic phase may last from days to months and can include the following symptoms:
Elevated mood, euphoria
- Racing thoughts
- Hyperactivity, excessive talking
- Increased energy
- Lack of self-control
- Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
- Over-involvement in activities
Reckless behavior, impulsive, "super-powers"
- Spending sprees
- Binge eating, drinking, and/or drug use
- Sexual promiscuity
- Impaired judgment
- Tendency to be easily distracted
- Little need for sleep
- Easily agitated or irritated, anger
- Poor temper control
These symptoms of mania are seen with bipolar I disorder. In people with bipolar II disorder, hypomanic episodes involve similar symptoms that are less intense; however, bipolar II disorder is NOT defined as a milder form of bipolar I disorder.
The depressed phase of both bipolar I disorder and bipolar II disorder involves symptoms similar to major depressive disorder, and includes at least 5 of these symptoms:
- Persistent sadness, feeling empty, low self-esteem, tearfulness (in children and teenagers, depression may appear as anger or irritability)
- Fatigue or lethargy
- Excessive sleepiness
- Inability to sleep
- Loss of appetite and weight loss
- Overeating and weight gain
- In children, unexpected weight loss may be a sign of depression
- Feelings of worthlessness, hopelessness and/or guilt
- Difficulty concentrating, remembering, or making decisions
- Withdrawal from all, or almost all activities or friends that were once enjoyed
- Thinking about or planning suicide (suicidal ideation) or attempting suicide
There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances in either the manic or the depressive phase and this can worsen the symptoms. Over 60% of people with bipolar disorder abuse alcohol or drugs.
The "mood swings" in bipolar disorder that vary between mania and depression can be very abrupt and disabling. There may be an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state. A diagnosis may also be described as rapid-cycling pattern, occurring as 4 or more episodes (mania, hypomania, or major depressive disorder) during a 12-month period.
A seasonal pattern occurs when one type of mood is prevalent at a particular time of the year (i.e., depression in winter) for the 2 previous years. The remission of the seasonal pattern also occurs the same time each year (i.e., spring). Depression is more common in winter, and the hypomanic episodes tend to occur more frequently in spring and summer.
Use of recreational drugs may be responsible for some of the symptoms of bipolar disorder. Drug abuse may itself be a symptom of bipolar disorder. You should avoid the use of alcohol and illicit drugs if you have a diagnosis of bipolar disorder.
In order to make a diagnosis of bipolar disorder, your physician will consider a number of factors. He or she may do some or all of the following:
- Observe your behavior and mood.
- Obtain your medical history, including any medical problems you have and any medications you take.
- Ask about your recent mood swings and how long you've experienced them; you may be asked to fill out a psychological self-assessment questionnaire.
- Ask about your family medical history, particularly whether anyone in your family has or had bipolar disorder.
- Perform a thorough examination to identify or rule out physical causes of the symptoms you are experiencing.
- Request laboratory tests to check for thyroid problems or drug levels, and review basic blood tests lab results.
- Speak with your family members to discuss their observations about your behavior.
- You may be asked to keep a daily chart of mood and sleep patterns.
- With severe symptoms, hospitalization may be required.
Treatment of Bipolar Disorder
Medication treatment is the backbone of therapy for bipolar disorder. It is recommended in all phases of the condition, and is effective in many people to gain control of their mood swings. Adding psychotherapy (talk therapy) is also usually recommended.
The goals of bipolar disorder treatment are:
- to reduce symptoms
- prevent new mood episodes
- lower the risk of self-harm and suicide
- allow the patient to integrate back into family, work, and social functioning
Common drug classes used to treat bipolar disorder are the mood stabilizers including anti-seizure medications, the atypical antipsychotics, and combinations of these medications. Successful drug therapy used in the initial treatment of the acute mood disorder is usually recommended to be continued as maintenance therapy if well-tolerated. Lithium is the most effective long‑term treatment for bipolar disorder, according to multiple studies including 2017 updated NICE guidelines.
Some patients may require a combination of medications for treatment, both in the short-term and long-term, if single therapy is not fully effective. Relapses can occur frequently in bipolar disorder. It may be necessary to try several medications to find the one that best treats symptoms with the lowest risk for side effects.
The choice of medication depends upon choice based on effectiveness and safety, a patient's past response to medications and side effects, other current medical illnesses and medications, and cost issues for patients. If female, child-bearing potential may play a role in the choice of therapy.
Drug interactions can be a common problem with bipolar disorder therapy, and drug interaction screens should be employed with initial treatment and with any drug changes. Patients should report all drug therapy, including OTCs and herbal supplements, to their doctor and pharmacist.
Treatment will typically allow patients to regain restful sleep patterns. Getting enough sleep helps keep a stable mood in some patients.
Mood Stabilizers Used in Bipolar Disorder
|Generic Name||Brand Name(s)|
|carbamazepine, carbamazepine ER||Equetro, Tegretol, Epitol|
|divalproex sodium, valproic acid, valproate sodium||Depakote, Depakote ER, Depakene|
Bipolar disorder is often treated with mood-stabilizing medications such as lithium, divalproex sodium (valproate), and carbamazepine. Most mood stabilizers are anticonvulsants (antiepileptic), with the exception of lithium. These are effective for treating both the manic and depressive phases, as well as preventing future symptoms. Anticonvulsants are linked with an increased risk for birth defects or developmental delays in pregnancy, and alternative treatments may be needed if women of child-bearing potential.
Lithium, while an older drug, is still considered one of the most widely studies and effective mood stabilizers and has been shown to decrease the risk of self-harm and suicide. It can be used as monotherapy or in combination with a mood stabilizer or antipsychotic. Important points to consider with lithium treatment:
- Lithium can lead to side effects such as frequent urination, nausea, diarrhea, tremor, thirst, changes in memory and thinking, and weight gain. Take lithium with food to help decrease the nausea.
- It requires blood tests to monitor drug levels and dose, usually every 6 to 12 months once stable.
- Patients should need good kidney function while taking lithium, or they may need a lower dose. Kidney function will be monitored during treatment. Avoid dehydration.
- Thyroid function and heart function may be adversely affected with long-term treatment.
- Women of child-bearing potential should avoid use of lithium due to possible fetal harm.
- Lithium is available in many different forms - tablets, capsules, and liquid - and is usually given 2 or 3 times a day. It is available in a cost-saving generic form.
- When taking lithium, always check with your doctor or pharmacist for drug interactions before starting any new medication.
Divalproex and lamotrigine are common anticonvulsant mood stabilizers used for treatment. In some patients, especially those with mixed symptoms of mania and depression or those with rapid-cycling bipolar disorder, divalproex may work better than lithium.
Valproate and lamotrigine use in women of child-bearing potential also have a risk of birth defects, and other options should usually be considered.
Oxcarbazepine (Trileptal) is another anticonvulsant used to treat bipolar disorder, similar to carbamazepine, although not specifically FDA-approved for this condition. However, oxcarbazepine has a safer side effect profile than carbamazepine.
Side effects associated with mood stabilizers can very from drug to drug; check for specific side effects here. Side effects that might be seen with lithium or anticonvulsants may include:
- Rash, some may be severe
- Excess thirst or urination
- Dry mouth
- Nausea and vomiting
- Weight gain
- Hair loss
- Slurred speech
- Irregular heartbeat
- Changes in vision (blurred vision, double vision)
- Hallucinations (seeing things or hearing voices that do not exist)
- Loss of coordination
- Changes in liver tests
Atypical Antipsychotics Used in Bipolar Disorder
|Generic Name||Brand Name(s)|
|olanzapine||Zyprexa, Zyprexa Zydis|
|quetiapine||Seroquel, Seroquel XR|
|risperidone||Risperdal, Risperdal Consta, Risperdal M-Tab|
Antipsychotic drugs can help a person who has lost touch with reality. They are often used initially during an acute phase of mania. Studies have also shown that atypical antipsychotics are helpful with maintenance treatment, and can be combined with a mood stabilizer for longer term therapy.
However, metabolic side effects with atypical antipsychotic agents, such as weight gain, elevated blood sugar and lipids, and type 2 diabetes, can be troublesome. It is important to consider the risk versus benefit of using an antipsychotic, based upon the individual's cardiovascular health risks. Ziprasidone, asenapine, lurasidone, and aripiprazole may have a lower risk of weight gain and type 2 diabetes, although clinicians should monitor for this side effect with all antipsychotics.
The occurrence of extrapyramidal side effects (EPS) or movement disorders, and the risk for serious tardive dyskinesia is much lower with the atypical antipsychotics than with conventional, first generation antipsychotics.
Side effects associated with atypical antipsychotics may include:
- dry mouth
- blurred vision
- weight gain, elevated risk for type 2 diabetes
- elevated cholesterol
- orthostatic hypotension (decreased blood pressure upon standing)
- dizziness, fainting
- movement disorders (lower incidence)
- irregular heart rhythms
- elevated prolactin levels
- skin reactions
Clozapine (Clozaril) is an older atypical antipsychotic and may be effective in patients who do not respond to treatment with other therapies (refractory) for bipolar disorder. Regular blood testing is required due to a risk of agranulocytosis, a dangerous lowering of white blood cells that may increase the risk for infection. Clozapine can lead to agranulocytosis in roughly 1% of patients; for this reason, clozapine is not commonly used in bipolar disorder.
Older, first generation antipsychotics like haloperidol (Haldol), chlorpromazine (Thorazine) or perphenazine (Trilafon) are also rarely used due to a higher incidence of severe movement disorders like tardive dyskinesia, which involves writhing movements of the body, lips smacking, and tongue protrusion.
Antidepressant Use in Bipolar Disorder
Use of antidepressants in bipolar disorder is controversial; antidepressants may trigger mania or rapid cycling in people with bipolar disorder. However, antidepressant drugs may be useful during the depressive phase in certain patients provided the antidepressants are used with a mood stabilizer or atypical antipsychotic. Patients who present acutely in a full manic or hypomanic episode should have antidepressants discontinued. Antidepressants are not recommended to be used alone in any phase of bipolar disorder.
Keep in mind that people with bipolar II disorder may be misdiagnosed with depression only because they do not experience full-fledged mania or only present to their doctor in the depressive phase. If these patients take antidepressants without mood stabilizers, it can trigger a manic episode.
Benzodiazepine Use in Bipolar Disorder
Benzodiazepine therapy may be needed in some acute manic episodes as adjunct therapy. In bipolar disorder, benzodiazepines would typically only be used short-term, if needed.
Commonly used benzodiazepines include:
- alprazolam (Xanax)
- clonazepam (Klonopin)
- lorazepam (Ativan)
- diazepam (Valium)
They may be used short-term to help with manic symptoms like agitation, insomnia, or anxiety while the mood stabilizer treatment takes effect.
Psychotherapy (Talk Therapy)
Psychotherapy may be a useful option when you reach the maintenance phase of treatment. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones. Your doctor will recommend different options for talk therapy, an important part of your medical treatment. Types of psychotherapy used in bipolar disorder include:
- Cognitive behavioral therapy: the goal is to change your negative pattern of thinking so you can view and respond to challenging situations more clearly
- Family-focused therapy: education about your illness with your family to allow for greater support
- Interpersonal and social rhythm therapy: used to treat the disruption in sleep patterns and social activity that is related to bipolar disorder
- Psychoeducation: activities to deliver education around bipolar disorder so you can take a more active role in your treatment
Electroconvulsive Therapy (ECT)
Electroconvulsive therapy (ECT) may be used to treat bipolar disorder, and has been found to be very effective. ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia. It is not used until medications have repeatedly failed or there some reason a patient cannot take drug therapy. For example, patients with severe mania during pregnancy may need ECT.
Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications.
Abrupt Discontinuation of Treatment
Patients should not abruptly stop taking their bipolar disorder medication. Doing so may worsen symptoms and lead to withdrawal effects. Patients should talk to their doctor before stopping any medical treatment. In addition, patients should tell their doctor about all over-the-counter (OTC) and supplements they use, as there can be drug interactions or other concerns.
Substance Abuse with Bipolar Disoder
Substance abuse can be a frequent concern in patients with bipolar disorder. Abusing drugs and alcohol can worsen symptoms and prevent therapy from working effectively. If you use illicit drugs or alcohol, talk to your doctor about getting help and treatment for this condition.
Call Your Doctor If:
- You are experiencing severe symptoms of depression or mania
- You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms
- You are experiencing serious side effects of medcation
- You are female being treated for bipolar disorder and find you are now pregnant
For Immediate Help:
- If you are in crisis, having thoughts of death or suicide, or considering suicide at this moment, tell someone right away who can help you.
- If you doctor is not available, go to the nearest hospital or call 911.
- Call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is free, available to anyone, and confidential.
- Mental Health Medications. National Institutes of Mental Health (NIMH). Oct. 2016. Accessed Nov. 14, 2017 at https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149867
- Antipsychotic medication and weight gain. British Association for Psychopharmacology. Accessed Nov. 14, 2017 at https://www.bap.org.uk/articles/antipsychotic-medication-and-weight-gain/
- United Kingdom National Institute for Health and Care Excellence (NICE). Bipolar disorder: The assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. Pharmacological Interventions. NICE Clinical Guideline 185, September 2014. Accessed Nov. 16, 2017 at http://www.nice.org.uk/guidance/cg185
- Post RM, Keck P, Solomon D. Bipolar disorder in adults: Choosing maintenance treatment. Up To Date. Updated Nov. 2, 2017. Accessed Nov. 16, 2017 at https://www.uptodate.com/