Bipolar Disorder

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

This topic discusses bipolar disorder in adults. If you are concerned that your child or teen may have bipolar disorder, see the topic Bipolar Disorder in Childhood and Adolescence.

What is bipolar disorder?

Bipolar disorder is an illness that causes extreme mood changes that switch from manic episodes of very high energy to the extreme lows of depression. It is also called manic-depressive disorder.

This illness can cause behavior so extreme that you cannot function at work, in family or social situations, or in relationships with others. Some people with bipolar disorder become suicidal.

Having this disorder can make you feel helpless and hopeless. But you are not alone. Talking with others who suffer from it may help you learn that there is hope for a better life. And treatment can help you get back in control.

Family members often feel helpless when a loved one is depressed or manic. If your loved one has bipolar disorder, you may want to get counseling for yourself. Therapy can also help a child who has a bipolar parent.

What causes bipolar disorder?

The cause of bipolar disorder is not completely understood. We know that it runs in families. It may also be affected by your living environment or family situation. One possible cause is an imbalance of chemicals in the brain.

What are the symptoms?

The symptoms depend on your mood swings. In a manic episode, you may feel very happy, energetic, or on edge. You may feel like you need very little sleep. You may feel overly self-confident. Some people spend a lot of money or get involved in dangerous activities when they are manic.

After a manic episode, you may return to normal, or your mood may swing in the opposite direction to feelings of sadness, depression, and hopelessness. When you are depressed, you may have trouble thinking and making decisions. You may have memory problems. You may lose interest in things you once enjoyed. You may also have thoughts about killing yourself.

The mood swings of bipolar disorder can be mild or extreme. They may come on slowly over several days or weeks or suddenly over a few minutes or hours. The mood swings may last for a few hours or for several months.

How is bipolar disorder diagnosed?

Bipolar disorder is hard to diagnose. There are no lab tests for it. Instead your doctor or therapist will ask detailed questions about what kind of symptoms you have and how long they last. To be diagnosed as bipolar, you must have had a manic episode lasting at least a week (less if you had to be hospitalized). During this time, you must have had three or more symptoms of mania, such as needing less sleep, being more talkative, behaving wildly or irresponsibly in activities that could have serious outcomes, or feeling as if your thoughts are racing.

Your urine and blood may be tested to rule out other problems that could be causing your symptoms.

How is it treated?

The sooner bipolar disorder is identified and treated, the better your chances of getting it under control. One of the most important parts of dealing with a manic episode is recognizing the early warning signs so that you can start treatment early with medicine that is especially for manic phases.

A variety of medicines are used to treat bipolar disorder. You may need to try several before you find the right combination that works for you.

• Most people with bipolar disorder need to take a medicine called a mood stabilizer every day.
• Medicines called antipsychotics can help get a manic phase under control.
• Antidepressants are used carefully for episodes of depression, because they cause some people to move into a manic phase.

People often have to try several different medicines before finding what works for them. Regular checkups are important so that your doctor can tell if your treatment is working.

Counseling for you and your family is also an important treatment. It can help you cope with some of the work and relationship issues that your illness may cause.

Charting your mood is one way you can start to see your patterns and symptoms. Keep a notebook of your feelings and what brought them on. If you learn what triggers your mood swings, you may be able to avoid them sometimes.

People often stop taking their medicines during a manic phase because they feel good. But this is a mistake. You must take your medicines regularly, even if you are feeling better.

Who is affected by bipolar disorder?

Over 3 million Americans—about 1% of the population, or 1 in every 100 people—have bipolar disorder, with similar rates in other countries.¹ Bipolar disorder occurs equally among males and females. It often begins between the ages of 15 and 24.²

Frequently Asked Questions

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	Managing a manic episode

The cause of bipolar disorder is not well understood, although evidence suggests that the disorder runs in families.³ Your living environment and family situation may also play a role in the disorder. Episodes of depression and mania may be caused by a problem with certain brain chemicals called neurotransmitters.

Antidepressant medications can trigger a manic episode in a person who has bipolar disorder. This may occur, however, before someone is diagnosed with bipolar disorder, while he or she is seeking treatment for an episode of depression.

Sleep deprivation or substance abuse, including caffeine, can cause a person with bipolar disorder to have a manic episode.

Bipolar disorder causes extreme mood swings, from feeling overly energetic (mania) to feeling very sad or having low energy (depression).³

Mania may cause a person to:

• Feel extremely happy or very irritable.
• Have a very high opinion of himself or herself (inflated self-esteem).
• Not need as much sleep as usual (feel rested after 3 hours of sleep).
• Talk more than usual.
• Be more active than usual.
• Have difficulty concentrating because of having too many thoughts at once (racing thoughts).
• Be easily distracted by sights and sounds.
• Act impulsively or do reckless things, such as go on shopping sprees, drive recklessly, get into foolish business ventures, or have frequent, indiscriminate, or unsafe sex.

Depression may cause a person to:

• Feel sad or anxious for a significant time.
• Feel hopeless or pessimistic.
• Have slowed thoughts and speech because of low energy.
• Have difficulty concentrating, remembering, and making decisions.
• Have changes in eating and sleeping habits leading to too much or too little eating or sleeping.
• Have decreased interest in usual activities, including sex.
• Have suicidal thoughts.
• Not enjoy things he or she normally would.

Types of bipolar disorder

• Bipolar I. Considered the classic form of the illness, bipolar I causes recurrent episodes of mania and depression. The depression may last for a short time or for months. You may then go back to feeling normal for a time, or you may go right into a manic episode.
• Bipolar II. If you have bipolar II, you will experience depression just as in bipolar I. But the episodes of mania are less severe (hypomania). People with bipolar II have more depressive episodes than hypomanic episodes.
• Rapid-cycling bipolar disorder. If you have rapid-cycling bipolar disorder, you will experience at least four episodes of depression, mania, or both within a 12-month period. You may go directly from an episode of depression to an episode of mania, or you may have a short time lapse between the two extreme moods. The mood swings are the same as with other types of bipolar, but the frequency of mood swings distinguishes rapid-cycling bipolar disorder from the other subtypes.

Some people may have bipolar disorder with mixed symptoms, in which episodes of depression and mania occur together. Symptoms include sadness, euphoria, and irritability. Other symptoms can include agitation, lack of sleep, appetite changes, and possibly, thoughts of suicide. This makes the disorder challenging to treat and very frustrating for you and for those around you. It can also lead to hospitalization if your daily functioning becomes impaired.

In addition to changes in mood, some people with bipolar disorder also have symptoms of anxiety, panic attacks, or symptoms of psychosis.

Symptoms of bipolar disorder in children can be very different than those of adults and can be confused with other childhood mental disorders, such as depression or attention deficit hyperactivity disorder (ADHD). Bipolar disorder in children significantly interferes with a child's ability to function in school, with friends, and at home.

Some other conditions with symptoms similar to bipolar disorder include depression, schizophrenia, and attention deficit hyperactivity disorder (ADHD).

People with bipolar disorder—men more often than women—may have substance abuse problems, especially during manic episodes.⁴ Abusing alcohol or drugs may affect treatment and interfere with taking medications as prescribed. Other disorders that may occur along with bipolar disorder include:⁵

• Obsessive-compulsive disorder.
• Panic attacks or panic disorder.

These illnesses need to be treated along with the bipolar disorder.

With bipolar disorder, you alternate between episodes of depression and mania. In between, you may return completely to normal or have some remaining symptoms. The extreme mood changes may come on suddenly or appear more slowly.

During a manic episode, you may be abnormally happy, energetic, or very irritable for a week or more. Initially, you may feel incredibly productive or creative. You may feel powerful and seductive and think there is nothing you can't accomplish. But as a manic episode progresses, you may behave wildly and irresponsibly, spending a lot of money, getting involved in dangerous activities, and sleeping very little. You may also have a hard time functioning in your job and relationships.

After a manic episode, you may return to normal, or your mood may swing in the opposite direction and you may feel useless, hopeless, and extremely sad. When you are depressed, you may have trouble concentrating, remembering, and making decisions; you may have changes in your eating and sleeping habits; and you may lose interest in things you once enjoyed. Some people become suicidal or harm themselves during episodes of depression. Some feel as if they can't move, care, or think.

Men tend to have more manic episodes, while women have more episodes of depression.⁶

Initially, stress may trigger depression or mania. But, as the illness progresses, mood swings may not be caused by any specific event. Without treatment, your bipolar disorder may get worse, causing you to move more often between mania and depression.

Bipolar disorder can be passed down through families. If anyone in your family has been diagnosed with bipolar disorder, your risk of developing it is higher.

If you have bipolar disorder, changes in sleep or daily routines can increase your risk for a manic episode. Antidepressant medications can trigger a manic episode in someone who has bipolar disorder.⁷ This may occur, however, before someone is diagnosed with bipolar disorder, while he or she is seeking treatment for an episode of depression.

A stressful event may trigger an episode of mania or depression.

Your risk of either a depressive or manic episode is increased if you do not take your medications as prescribed by your doctor. It is common for people to stop taking their medications during a manic phase when they feel good. Even if you are feeling better, you must take your medications regularly to control bipolar disorder.

Alcohol or drug use or abuse puts you at a high risk for having a relapse of mood disturbances.⁵

If you have bipolar disorder, call 911 or other emergency services if you:

• Think you cannot stop from harming yourself or someone else.
• Hear voices that are new or more upsetting than normal.
• Want to commit suicide, or you know someone who has mentioned wanting to commit suicide.

Warning signs of suicide include:

• Use of illegal drugs or drinking alcohol heavily.
• Talking, writing, or drawing about death, including writing suicide notes and speaking of items that can cause physical harm, such as pills, guns, or knives.
• Spending long periods of time alone.
• Giving away possessions.
• Acting aggressive or suddenly appearing calm.

Watchful Waiting

Watchful waiting may be enough if a mood episode has just started and you are taking proper medications. If your mood episode has not improved within 2 weeks, call your doctor.

If you have a loved one who is experiencing a manic episode and is behaving irrationally, help the person seek treatment.

Who To See

Bipolar disorder is complex and hard to diagnose because it has many phases and symptoms. Sometimes it is misdiagnosed as only depression (unipolar depression) because people are more likely to seek treatment during a period of depression.

After you are diagnosed with bipolar disorder, it is important to keep a long-term relationship with your doctor or therapist to make sure that your treatment is consistent and that your medications can be adjusted as needed.

Although other health professionals can diagnose bipolar disorder, you will probably be referred to a psychiatrist who specializes in treating such disorders and can prescribe medications and provide counseling. Other health professionals who can diagnose bipolar disorder include:

• Family doctors (general practitioners).
• Internists.
• Psychiatric nurse practitioners.

Counseling can help you deal with mood changes and the impact bipolar disorder can have on your work and family relationships. In addition to psychiatrists, health professionals who can provide counseling include:

• Psychologists.
• Social workers.
• Licensed professional counselors.

Family member support

If a loved one has bipolar disorder, it may be helpful for you to get counseling to deal with its impact on your own life. Manic episodes can be particularly difficult. Consult a psychiatrist, psychologist, social worker, or licensed professional counselor for your own therapy.

Therapy can also be helpful for a child who has a bipolar parent. The parent's mood swings may negatively affect the child, causing tearfulness, anger, depression, or rebellious behavior.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

There are no lab tests for bipolar disorder. Instead, your doctor will ask detailed questions about your symptoms, including how long they last and how often you have them. He or she will discuss your family history and may do a mental health assessment.

A mental health assessment tests your emotional functioning and your ability to think, reason, and remember. It includes an interview with a health professional, a physical exam, and written or verbal tests. During the interview, the health professional assesses your appearance, mood, behavior, thinking, reasoning, memory, ability to express yourself, and ability to maintain personal relationships.

Blood and urine tests, such as a test of your thyroid, may be done to make sure another problem is not causing your symptoms. A toxicology screen examines blood, urine, or hair for the presence of drugs.

Early Detection

The earlier bipolar disorder is diagnosed and treated, the better your chances of getting the illness under control and improving the quality of your life. Early detection and treatment can help reduce your risk of complications, such as alcohol and drug abuse or suicide.⁸

About 10% to 15% of people with bipolar disorder will die from suicide.³ Up to 60% of those with bipolar disorder develop drug and alcohol abuse problems, which interfere with successful treatment of the disorder.⁸

Although there is no cure for bipolar disorder, it can be effectively treated with a combination of medications and counseling. It is important to take your medications exactly as prescribed, even when you feel well. Your doctor may have to try different combinations of medications to find what's right for you.

Initial treatment

The first treatment for bipolar disorder often happens in the "acute" phase, when a person may have his or her first manic episode. In the acute phase, you may be suicidal or psychotic or using such poor judgment that you are in danger of harming yourself. Your doctor may decide you should be hospitalized for your own safety, especially if he or she believes you are suicidal. Medications that may be used for initial treatment include:

• Mood stabilizers, such as lithium carbonate (Eskalith, Lithane, and Lithobid, for example). Experts believe lithium may affect certain brain chemicals (neurotransmitters) that cause mood changes, but how the medication works is not completely understood. Anticonvulsants, such as valproate sodium (Depakene Syrup), divalproex (Depakote), and carbamazepine (Tegretol and Equetro) are also mood stabilizers. Valproate and divalproex are used to treat manic episodes. The anticonvulsant lamotrigine (Lamictal) was approved for the long-term maintenance treatment of bipolar I disorder and may be helpful for depression. Anticonvulsants can be helpful in hard-to-treat bipolar episodes. A mood stabilizer and an antipsychotic are often used as the first medications for acute manic episodes.
• Antipsychotics, such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole, and haloperidol (Haldol). Antipsychotics improve manic episodes. They may be used in combination with mood stabilizers and anticonvulsants.
• Benzodiazepines, such as diazepam (Valium). These may be used instead of antipsychotics or as an additional medication during a manic phase.

Managing a manic episode

Ongoing treatment

Ongoing treatment for bipolar disorder includes counseling and adjusting medications with the goal of preventing manic and depressive episodes. It may take months for your symptoms to go away and for you to be able to function normally.

Mood stabilizers are generally used long-term, and other medications are prescribed for episodes of mania or depression that happen even though you are taking the mood stabilizers. If you've had three or more manic episodes, you may benefit by taking medications for the rest of your life. Counseling may help you deal with troubled relationships and enable you to function at work.

Antidepressants, such as fluoxetine (Prozac, for example), are used very carefully to treat depression because they can trigger a manic episode. Experts now recommend that antidepressants only be used for short periods of time during severe episodes of depression and that they be combined with mood stabilizers.⁹

Managing a manic episode

Treatment if the condition gets worse

In some cases, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals.

If you also have anxiety symptoms, such as worrying and not sleeping, panic attacks, or symptoms of psychosis, you may need additional medications.

Managing a manic episode

What To Think About

When you and your doctor are discussing your medications, think about whether your lifestyle allows you to take medications on time every day. A medication you only take once a day may work best for you if you have a hard time remembering to take your medications.

The side effects of the medications should also be considered. You may be able to tolerate some side effects better than others. Discuss the side effects of each medication with your doctor as you consider your treatment options.

The use of antidepressants alone has been linked to an increase in manic episodes.⁷ Antidepressant treatment needs to be monitored closely and always used in combination with other drugs, such as mood stabilizers or antipsychotics, to avoid causing a manic episode.⁹

Bipolar disorder cannot be prevented, but often the mood swings can be controlled with medications.

About 1 in 3 people will remain completely free of symptoms of bipolar disorder by taking mood stabilizer medications, such as carbamazepine or lithium, for life.⁵

Other ways to help prevent a depressive or manic mood episode include:

• Eating a balanced diet.
• Exercising daily.
• Avoiding extensive travel into other time zones.
• Getting approximately the same number of hours of sleep every night.
• Avoiding alcohol and illegal drugs.
• Reducing stress at work and at home.
• Seeking treatment as soon as you notice symptoms of a depressive or manic episode coming on.

Changes in your sleep patterns can sometimes trigger a manic or depressive episode. If you plan extensive travel into other time zones, you may want to call your doctor before you leave to discuss whether you should make any changes in your medications and what to do if you have a manic or depressive episode while you are away.

Home treatment is important in bipolar disorder. In addition to taking your medications every day as prescribed, you can help control mood swings by:

• Getting enough exercise. Try moderate activity for at least 30 minutes a day, every day, if possible. Moderate activity is activity equal to a brisk walk. For more information, see the topic Fitness.
• Getting enough sleep. Keep your room dark and quiet, and try to go to bed at the same time every night.
• Eating a healthy, balanced diet. A balanced diet includes foods from different food groups , such as whole grains, dairy, fruits and vegetables, and protein. Eat a variety of foods within each group (for example, eat different fruits from the fruit group instead of only apples). A varied diet helps you get all the nutrients you need, since no single food provides every nutrient. Eat a little of everything but nothing in excess. All foods can fit in a healthy diet if you eat everything in moderation. For more information, see the topic Healthy Eating.
• Control the amount of stress in your life. Manage your time and commitments, establish a strong system of social support and effective coping strategies, and lead a healthy lifestyle. Techniques to relieve stress include physical activity and exercise, breathing exercises, muscle relaxation, and massage. For more information, see the topic Stress Management.
• Avoid alcohol and illegal drugs.
• Learn to recognize the early warning signs of your manic and depressive episodes.
• Ask for help from friends and family when needed. You may need help with daily activities if you are depressed, or you may need support to control high energy levels if you are experiencing mania. For more information, see:

Managing a manic episode.

Family members often feel helpless when a loved one is depressed or manic. Family members and friends can help by:

• Encouraging the person to take his or her medications regularly, even when feeling good.
• Learning the warning signs for suicide, which include:
  • Drinking alcohol heavily or taking illegal drugs.
  • Talking, writing, or drawing about death, including writing suicide notes.
  • Talking about things that can cause harm, such as pills, guns, or knives.
  • Spending long periods of time alone.
  • Giving away possessions.
  • Acting aggressive or suddenly appearing calm.
• Recognizing a lapse into a manic or depressive episode and helping the person cope and get treatment.
• Allowing your loved one to take enough time to feel better and get back into daily activities.
• Learning the difference between hypomania and when he or she is just having a good day. Hypomania is an elevated or irritable mood that is clearly different from a regular nondepressed mood and can last for a week or more.
• Encouraging your loved one to go to counseling and to join a support group, and joining one yourself if needed.

To learn more about how you can help your loved one through mood swings, see:

• Helping a depressed person.
• Helping a person during a manic episode.

Medications, when taken regularly as prescribed, can help control bipolar mood swings. Although your family doctor can prescribe medications to treat bipolar disorder, you will probably be referred to a psychiatrist, who is trained specifically to treat mental disorders.

Mood stabilizers, such as lithium, are usually prescribed first to treat mania and to prevent the return of both manic and depressive episodes. You may need to take a mood stabilizer for several years, or even for the rest of your life, to manage the illness. Your doctor may prescribe additional medications—typically antipsychotics—to better control your symptoms.

Your doctor will vary the amounts and combinations of your medications according to your symptoms, which type of bipolar disorder you have (bipolar I or II, rapid-cycling, or bipolar with mixed symptoms), and how you respond to the medications.

Medication Choices

Several medications are used to treat bipolar disorder. It may take time and several attempts at using different medications to find the treatment that works best for you. The most common medications used to treat bipolar disorder are:

• Mood stabilizers, such as lithium carbonate (Eskalith, Lithane, and Lithobid, for example). Experts believe lithium may affect certain brain chemicals (neurotransmitters) that cause mood changes, but how the medication works is not completely understood. A mood stabilizer and an antipsychotic are recommended as the first medications for acute manic episodes. Anticonvulsants, such as valproate sodium (Depakene Syrup), divalproex (Depakote), and carbamazepine (Tegretol and Equetro) are also considered mood stabilizers. Valproate and divalproex are used to treat manic episodes. The anticonvulsant lamotrigine (Lamictal) was approved for the long-term maintenance treatment of bipolar I disorder and may be helpful for depression. Anticonvulsants can be helpful in hard-to-treat bipolar episodes.
• Antipsychotics, such as olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), quetiapine (Seroquel), and aripiprazole. Antipsychotics improve manic episodes. Olanzapine may be used in combination with mood stabilizers and anticonvulsants.
• Benzodiazepines, such as diazepam (Valium). These may be used instead of antipsychotics or as an additional medication during a manic phase.

What To Think About

Antidepressants, such as fluoxetine (Prozac, for example), are used very carefully to treat depression because they can trigger a manic episode. Experts now recommend that antidepressants only be used for short periods of time during severe episodes of depression and that they be combined with mood stabilizers.⁹

If you are prescribed lithium carbonate, valproate, or carbamazepine, you will need regular blood tests to monitor the amount of medicine in your blood. Too much lithium in your bloodstream may lead to serious high lithium carbonate side effects. Your doctor may want you to have blood tests while on medication to check whether the medication is affecting your liver, kidneys, and thyroid gland or to measure the amount of blood cells in your body.

During your doctor's appointment, ask about:

• The side effects of each medication.
• How often you will need to take the medications.
• How the medications may interact with other medications you are taking.
• Whether it's important that you take the medications at the same time every day.

The U.S. Food and Drug Administration (FDA) advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. It is most important to watch for these behaviors in children, who may be less able to control their impulsivity as much as adults and therefore may be at greater risk for suicidal impulses. The FDA has not recommended that people stop using antidepressants, but simply to monitor those taking the medications and, if concerns arise, to contact a health professional.

There is no known surgery at this time to treat bipolar disorder.

Almost all people who have bipolar disorder need medication. But counseling is also important to help you cope with work and relationship struggles related to your illness.

Other Treatment Choices

Types of counseling used to treat bipolar disorder include:

• Cognitive-behavioral therapy, a type of counseling aimed at teaching you how to become healthier by modifying certain thought and behavior patterns. It is based on the theory that thought and behavior can affect a person's symptoms and be an obstacle to recovery.
• Interpersonal therapy, which focuses on social and personal relationships and related problems by discussing grief and loss, role disputes in relationships, and relationship transitions.
• Problem solving, a brief, focused form of cognitive therapy used to treat depression. It focuses on specific problems and how you can solve them.
• Family therapy, a type of counseling used to help families deal with a stressful situation or a life-changing event. In family therapy, each person can express any concerns and fears about how the problem affects the person with bipolar disorder and the family as a whole.

In some cases, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals.

Complementary therapy

Omega-3 fatty acids have been getting some attention as a possible complementary treatment for bipolar disorder. However, more research is needed to prove the effectiveness of omega-3 fatty acids in treating this condition.^{10, 11}

What To Think About

Managing a manic episode

Establish a long-term relationship with a counselor you like. The counselor will help you recognize personality changes that indicate when you are moving into a mood episode. Getting early treatment can reduce the length of the mood episode.

Bipolar disorder also affects family members. They need to understand the disorder and how to help you cope.

Online Resources

Organizations

• Bipolar Disorder in Childhood and Adolescence
• Borderline Personality Disorder
• Depression
• Depression in Childhood and Adolescence
• Postpartum Depression

Citations

1. Sells SR, Loosen PT (2000). Bipolar di