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What is bipolar disorder?

Those with bipolar disorder will have episodes (or periods) of mania and episodes (or periods) of depression – this is the illness that used to be named ‘manic depression’. The majority of those with the disorder have recurrent manic and depressive periods but in between these times, they won’t experience symptoms at all.

During both depression and mania, people can have temporary experiences of psychosis symptoms. For example, they might have delusions or hear voices. Not everyone does experience psychosis, however, and symptoms of psychosis don’t have to be present for a formal bipolar disorder diagnosis to be given.

In the majority of cases, those with bipolar disorder will experience both types of episode: mania and depression but episodes of depression are usually more common than manic episodes. The two will often alternate but it is possible to have symptoms of depression and the same time as symptoms of mania, which is given the name ‘mixed episode’.

Episode frequency has considerable variety among sufferers. Some can have only one bipolar episode in a year while some will have them more frequently. When someone has four episodes or more a year (of any kind), they are said to have bipolar disorder that is ‘rapid cycling’ according to mental health professionals.

Bipolar 2 disorder and hypomania

There are sub-types of bipolar disorder: bipolar 1 and bipolar 2. Those with bipolar 2 disorder will have depressive episodes like bipolar 1 disorder but their manic episodes are less severe. This condition is much less likely to cause dramatic interferences in their lives and is called ‘hypomania’. When people have hypomania episodes they don’t have symptoms of psychosis.

Who gets bipolar disorder?

Around 1% of people will have bipolar 1 disorder at some moment in their life with the first episode normally occurring prior to age 30. There is research indicating that bipolar 2 disorder affects 1 in every 200 people.

There is very little known about the precise cause of bipolar disorder but studies that have taken place in twins and families indicate a genetic influence. Researchers have found that first-degree relatives i.e. brothers, sisters, parents and children are much more likely to have bipolar disorder if someone has bipolar disorder when compared to families without the disorder present. Also, a person’s first-degree relatives are at a greater risk of getting depression if the person has bipolar disorder.

There is a belief amongst scientists around the concept of ‘shared’ genes that mean people have a higher risk of developing different mental health or brain problems. These include depression, schizophrenia and bipolar disorder.

Studies recently have suggested that there exist specific genes that are involved in bipolar disorder but that each of these genes individually will only have small effects. Research suggests that a person will need to inherit a number of the ‘risk genes’ to develop bipolar disorder but this doesn’t mean that everyone who inherits a large amount of these will develop bipolar disorder. This is because there are a number of factors at play when developing the condition, including life experiences that are negative or traumatic, such as childhood abuse.

Research also suggests that cortisol, the stress hormone, as well as the HPA axis (the hypothalamic pituitary adrenal axis – a system in the brain) might be involved in a person developing bipolar disorder and depression.

There has been research that has discovered higher levels of cortisol in those with depression (and especially psychotic depression). This could mean that the HPA axis is malfunctioning. Studies also found some abnormalities in the HPA system when people have bipolar disorder. When a person’s levels of cortisol are elevated all the time, their memory and mood will be affected.

Studies have also shown abnormalities in the HPT system (hypothalamic pituitary thyroid axis) when people have bipolar disorder. This is the system that regulates the thyroid hormones. The thyroid hormones regulate a person’s behaviour and mood. Research has shown that a large proportion of people with bipolar disorder that is ‘rapid cycling’ also have an under-active thyroid gland i.e. hypothyroidism.

Mania

In its early stages, an episode of mania means people feel productive, creative and very happy. They won’t feel tired and will need less sleep. When this mania is mild, it won’t really be a problem and some people actually enjoy it. However, when it is not mild, people get out of control because of their energy and high mood. Despite being exhausted physically, the person won’t want to rest and will become irritable, overactive and restless. Sitting still will be hard, as will concentrating. People also feel over-confident and believe that they are able to do anything they want. They will invent ideas that are wild, extravagant or grandiose.

During a manic episode, people lose judgement, become impulsive and take risks. These can manifest into problems later on like financial problems if they have spent a lot of money. People can also experience a rise in libido, sometimes resulting in promiscuity. They may also talk quickly or shout and could be difficult to understand as their ideas and thoughts come out thick and fast. There is also an increase in alcohol consumption or use of recreational drugs amongst people having a manic episode.

Manic episodes can also come with psychosis symptoms such as hallucinations, delusions or confused thoughts. In many cases, people won’t know what they are unwell and won’t accept that they might need treatment.

A manic episode can last from a few days to a few months. After it is common for people to feel exhausted and they might also feel humiliated or ashamed of their behaviour during the manic episode.

Depression

When people with bipolar disorder experience depression it is usually similar to severe depression. Mental health professionals refer to this as ‘unipolar’ depression. These episodes might last several months.

During these depressive episodes, people will lose interest in their lives and will get tired easily. They will have low mood, unintentionally lose weight and have problems sleeping. Usually, the sleep problems mean they wake up really early and can’t go back to sleep. They will also suffer from low self-esteem. Depressive episodes can also come with delusions or hallucinations – a person might believe that they are to blame for the bad things that are happening in the world. It is true that people with bipolar disorder can readily think about self-harm during these depressive periods and a number of people do attempt to take their own life when going through an episode of depression.

Diagnosis

Bipolar disorder is often difficult to diagnose, particularly after the first episode. If a person has a depressive episode first, nobody can predict whether or not this is unipolar depression (much more common) or whether it will develop into bipolar disorder. If a person is experiencing a manic episode, it could be that it is caused by another condition or by medication that has been prescribed or recreational drugs like ecstasy or cocaine. Doctors, therefore, have to make sure they rule out other causes.

There was an online survey in 2012 carried out by the Royal College of Psychiatrists, Bipolar UK and Bipolar Scotland that showed that many diagnoses didn’t occur until over 13 years from the first onset of symptoms. There were over 700 survey participants and 15% of these were diagnosed quickly, with 85% having trouble to get the correct diagnosis, the majority of these were given a diagnosis of depression initially.

There is guidance for GPs to refer people they suspect to have bipolar disorder to a specialist of mental health. NICE (National Institute of Health and Care Excellence) issued guidance in 2014 saying that bipolar disorder (its assessment, diagnosis and treatment) should be dealt with my mental health professionals with special training. GPs should be referring people to early intervention services, specialist bipolar disorder services or community-based mental health teams. There are rarely specialist services just for bipolar disorder in the NHS).

Mental health specialists make a diagnosis by referring to two classification systems. The first is the DSM. This is the Diagnostic and Statistical Manual of Mental Disorders and is an American Psychiatric Association publication. The second is the ICD. This is the International Classification of Disease and is a publication by the WHO (World Health Organisation).

Both publications define bipolar disorder in a similar way. The latest ICD publication, however, does not mention bipolar 2 disorder. The DSM does mention bipolar disorder 2 as a condition whereby the person experiences depressive episodes with mania symptoms that are less severe (hypomania). The DSM also mentions cyclothymia. This is when somebody has hypomanic episodes with depressive episodes that are also less severe.

When mental health professionals make a diagnosis, they ask about symptoms and find out about previous experiences of manic or depressive episodes. They will also ask about family members having bipolar disorder.

Treatment and care

Bipolar disorder has three main treatment types. These include talking therapies, medication and ECT (electroconvulsive therapy).

There are lots of different drug types that are prescribed for episodes of depression and episodes of mania. Also, there are many people that will need to have medication regularly, even in between when patients are well in order to prevent a relapse. When medication is prescribed in the long-term, we call it ‘prophylactic’ medication.

Bipolar disorder medication includes mood stabilisers, antipsychotics and anticonvulsants.

In its 2014 guidelines, NICE says that those with bipolar disorder shouldn’t take topiramate or gabapentin because they say that the evidence of these working for the treatment of bipolar disorder is not strong.

Talking therapies for people with bipolar disorder or CBT (cognitive behavioural therapy) and family therapy does help to stabilise a person’s mood and will help them to recognise when they are becoming unwell so that they are able to take precautions to prevent a new episode occurring.

ECT (Electroconvulsive therapy) is offered occasionally to those with bipolar disorder if their medication doesn’t work or if someone has symptoms that are very severe, including psychosis symptoms.

If someone displays symptoms that are destructive or very extreme and if they are a danger to others or themselves, it could be that they are admitted against their will to hospital to be treated under the Mental Health Act.

Treatment for episodes of mania and hypomania

Mood stabilisers and antipsychotics (like valproate or lithium) might be prescribed for hypomania and mania. Valproate shouldn’t be prescribed to pregnant women or those who might get pregnant as it could cause harm to the baby.

NICE (the National Institute of Health and Care Excellent) guidelines from 2014 stat that 4 different antipsychotic medications can be prescribed. These include risperidone, quetiapine, olanzapine and haloperidol.

Mental health professionals should try each drug, in turn, to see if it works. There should be only one antipsychotic prescribed at one time unless it is for a short period when changing from one drug to another.

Doctors might also recommend lithium to be taken alongside an antipsychotic if the antipsychotic alone is not working. Lithium is a very effective as a mood stabiliser but it can be harmful in high doses. The dose that works for one person will be different to another so those who take lithium require blood tests regularly to ensure their bloodstream has a lithium concentration in the correct range. These tests also help the specialists to figure out an appropriate dose for their patients. If lithium does not work, doctors may offer valproate (but not to women who could be or who are pregnant).

Lamotrigine should not be prescribed to treat hypomania or mania despite being used for depression.

When a person comes to the end of a manic or hypomanic episode, they might be recommended to continue their medication for between three and six months.

Treatment for episodes of depression

Nice (the National Institute of Health and Care Excellence) says that CBT and other talking therapies should be offered in the first instance of depression. This could also be behavioural couples’ therapy, interpersonal therapy or talking therapies that are designed with bipolar disorder in mind.

If depression is on the severe side, however, and is making a person’s life very difficult, a doctor might offer medication for them to take alongside the talking therapies. The drug prescribed should depend on the individual and their medical history in the past.

The 2014 guidance by NICE on bipolar disorder states that doctors should be prescribing either fluoxetine (an antidepressant) alongside olanzapine (the antipsychotic) or quetiapine (the antipsychotic) on its own or olanzapine on its own. The NICE guidance doesn’t recommend antidepressants being prescribed alone as there is a risk of them working ‘too well’ and causing the depression to switch to mania.

If quetiapine, olanzapine or fluoxetine don’t work, lamotrigine, an anticonvulsant, might be suggested by doctors.

When a depressive episode comes to an end, mental health workers might suggest a person keeps on taking their medication or continues with their talking therapy for between three and six months afterwards.

Long-term treatment and care

NICE (the National Institute for Health and Care Excellent) recommends that people who have bipolar disorder continue to be offered talking therapies and medication in the long term in order to help them to stay well.

The responsibility of a person’s care in the long term could be transferred to their GP. When this happens, the GP will work alongside the specialist mental health team to agree a plan that details recovery goals, details medication, details what should happen in a crisis and decide on a date for a review.

The guidelines about bipolar disorder from NICE in 2014 say that lithium works much better than other medications in the long term. Doctors will ask the patient if they would like to continue taking their prescribed medication from during the episode or whether they would like to switch to lithium. Lithium, however, won’t work for some and the patient might then be offered quetiapine, olanzapine or valproate (unless the patient is a pregnant woman or a woman who could be pregnant).

Talking therapy will also be offered in order to prevent a relapse occurring. Talking therapies that are designed for bipolar disorder will focus on self-management skills. This includes knowing how to spot the early warning signs of relapsing as well as how to stay well in the long term. This specialist bipolar talking therapy isn’t available in all locations and IAPT (Improving Access to Psychological Therapies) a programme from the government is trialling specialist services in order to make them available more widely.

If the patient lives with family or is in close contact with members of their family, they should also have the opportunity to have family therapy.

If the patient is well and makes the decision to stop taking their medication in the long term, they need to discuss it with their doctor and then reduce their medication bit by bit over a period of 4 weeks at least. The patient should also discuss with their doctor how to recognise signs of relapse and what they should do if they do. Health professionals recommend that people prepare a plan of what should happen in a crisis and should make a statement detailing their preferences for treatment. They could also make a long-term power of attorney where they can name a person to make decisions for them if they become unwell.

Physical health

Bipolar medication can affect a person’s physical health. One side effect is weight gain. This can contribute to other physical health problems for the patient.

In their 2014 guidance, NICE (the National Institute for Health and Care Excellent) stresses the importance of patients trying to stay healthy in order to avoid other physical health problems, including diabetes.

Before people start a new medication, they should have a physical health check where their weight, heart rate and blood pressure are taken. They might also have blood and urine tests to check levels of cholesterol and to check for diabetes. They might also have an ECG (electrocardiogram) to check their heart.

When a person begins an antipsychotic drug, doctors need to check their weight weekly for six weeks. They will also need to check blood pressure and heart rate every time the dose gets changed. After three months on the drug, the patient should have their weight, cholesterol and blood sugar checked again.

Patients should be offered advice about exercise and healthy eating as well as support and treatment in line with the guidance by NICE on preventing Type 2 diabetes, obesity and high blood pressure, where appropriate.

Every person with a bipolar disorder diagnosis is required to have a health check with their family doctor annually. This needs to check their blood sugar, cholesterol levels and their weight.

Doctors need to explain how drinking alcohol, taking drugs and smoking while taking bipolar disorder medication can prevent the drugs from working as they should and may even worsen symptoms.

Pregnancy and birth

Women with a bipolar disorder diagnosis sometimes have a relapse immediately after giving birth to their first baby. This is called postpartum or puerperal psychosis. Women who have postpartum psychosis with their first baby are very likely to have it again when a subsequent child is born.

It is vital that women inform doctors when they become pregnant or if they are trying to conceive. Women should also discuss the chances of having postpartum psychosis with the obstetrician and psychiatrist. Ideally, a woman will talk to their psychiatrist before she gets pregnant.

The drug valproate shouldn’t be taken by women in pregnancy because it can cause harm to their developing baby. It might be necessary, therefore, for women to change their medication during their pregnancy. Their psychiatrist will be able to give advice on alternative drug treatments.

It will also be necessary to plan for care and support in the postpartum period. The highest risk of postpartum psychosis is immediately after birth so medical professionals should arrange for a woman to have a longer stay in hospital after birth in a hospital where there is a psychiatrist available round the clock.

Around the UK, there are many perinatal psychiatry teams who give expert advice about measures that can be taken to try to prevent postpartum psychosis. They can also coordinate women’s care when they are at risk of developing postpartum psychosis.

Other diagnoses

A lot of people with bipolar disorder will have other problems with their mental health at the same time. These are referred to as ‘comorbidities’.

As much as 60% of those with bipolar disorder will experience anxiety and as much as 40% will use alcohol and/or drugs detrimentally to their health.

Living with bipolar disorder

Episodes of mania can be extremely disruptive to a person’s life and can also be detrimental and dangerous. For example, mania can lead to financial problems, dangerous driving, job loss, legal challenges and promiscuity. NICE (the National Institute for Health and Care Excellence) recommends in their 2014 guidance that mental health professionals should give people with bipolar disorder advice about not making important decisions when they are having a manic episode.

It is possible for many people to identify behaviour or mood changes that could indicate the onset of another episode. Knowledge of the warning signs can be helpful to the person as well as to their immediate family members and their friends. Carers and family members have an important role to play and it can also be stressful for them when they see their family members with bipolar disorder symptoms. Relationships with family members can be put under a lot of stress and pressure.

Family members should be given information about the disorder by mental health professionals which should describe its symptoms and the treatments that are offered. They should be available to advise and help when a crisis happens too. Mental health workers need to talk to a patient’s family about their involvement in the care and treatment of the patient and should also offer to assess their needs as a family. This support and education for family members can be provided during family therapy, where available.