Bipolar Disorder

Cause

The cause of bipolar disorder is not well understood. But experts believe many factors may be involved. It tends to run in families. You are at greater risk of having bipolar disorder if a close family member has it.

Antidepressant medicines can trigger a manic episode in a person who has bipolar disorder. But this may occur before the person is diagnosed, while he or she is seeking treatment for an episode of depression.

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

Symptoms

Bipolar disorder causes extreme mood swings, from feeling overly energetic (mania) to feeling very sad or having low energy (depression).^{footnote 2}

Mania may make you:

• Feel extremely happy or very irritable.
• Not need as much sleep as usual. (You may feel rested after 3 hours of sleep.)
• Talk more than usual.
• Be more active than usual.
• Have trouble concentrating because of having too many thoughts at the same time (racing thoughts).
• Act impulsively or do reckless things, such as go on shopping sprees, drive recklessly, or get into foolish business ventures. Or you may have frequent, indiscriminate, or unsafe sex.

Depression may make you:

• Feel sad or anxious for a significant period of time.
• Have slowed thoughts and speech because of low energy.
• Have trouble concentrating, remembering, and making decisions.
• Have changes in eating and sleeping habits. You may eat or sleep too much or too little.
• Have less interest in your usual activities, including sex.
• Have suicidal thoughts.

Types of bipolar disorder

• Bipolar I. This is the classic form of the illness. It causes episodes of mania and depression that keep coming back. 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 high.
• Bipolar II. With this form, you will have depression just as in bipolar I. But the manic highs are less severe (hypomania). People with bipolar II have more depressive lows than hypomanic highs.

Some people may have bipolar disorder with mixed symptoms. Their highs and lows of mania and depression occur together. 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.

If you have rapid-cycling bipolar disorder, you may have at least four episodes of depression, mania, or both within a 12-month period. You may go directly from a low to a high. Or you may have a short time lapse between the two extreme moods.

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

What Happens

With bipolar disorder, you go back and forth between highs and lows of mania and depression. 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 go from feeling abnormally happy and productive to behaving irresponsibly and sleeping very little. After this manic high, your mood may return to normal. Or it may swing in the opposite direction. You may feel useless and extremely sad. And you may lose interest in things you've enjoyed in the past.

Men tend to have more manic highs, and women tend to have more lows of depression.^{footnote 3}

At first, 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. This can cause you to move more often between mania and depression.

Other health problems

People with bipolar disorder—men more often than women—may have substance use disorder, especially during manic episodes.^{footnote 4} A substance use disorder may affect treatment and interfere with taking medicines as prescribed. Other disorders that may occur along with this disorder include:^{footnote 5}

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

These illnesses need to be treated along with bipolar disorder.

What Increases Your Risk

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

Some things can increase your risk of a manic episode or depression. These include:

• Changes in sleep or daily routines.
• Antidepressant medicine. This can happen if you haven't been diagnosed with bipolar disorder and are seeking treatment for depression.
• Stressful events.
• Quitting your medicine for bipolar disorder. Even if you're feeling better, it's important to take your medicines as prescribed.

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

When To Call

Call 911 or other emergency services immediately if:

• You or someone you know is thinking seriously of suicide or has recently tried suicide. Serious signs include these thoughts:
  • You have decided how to kill yourself, such as with a weapon or medicines.
  • You have set a time and place to do it.
  • You think there is no other way to solve the problem or end the pain.
• You feel you can't stop from hurting yourself or someone else.

If you or someone you know talks about suicide, self-harm, or feeling hopeless, get help right away. Call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or text HOME to 741741 to access the Crisis Text Line. Consider saving these numbers in your phone.

Call a doctor now if:

• You hear voices.
• You have been thinking about death or suicide a lot, but you don't have a plan for suicide.
• You are worried that your feelings of depression or thoughts of suicide aren't going away.

Seek care soon if:

• You have symptoms of depression or mania, such as:
  • Feeling sad or hopeless.
  • Not enjoying anything.
  • Having trouble with sleep or feeling that you don't need much sleep.
  • Feeling guilty.
  • Feeling anxious or worried.
  • Feeling extremely happy or very grouchy.
  • Talking too fast or more than usual.
  • Being more active than usual.
  • Having trouble concentrating because of having too many thoughts at the same time (racing thoughts).
  • Acting impulsively or doing reckless things. You may spend a lot of money, drive recklessly, or get into foolish business ventures. Or you may have frequent, indiscriminate, or unsafe sex.
• You have been treated for depression for more than 3 weeks, but you aren't getting better.

Exams and Tests

To find out if you have bipolar disorder, your doctor will ask detailed questions about your symptoms. You will be asked how long your symptoms last and how often you have them. Your doctor will ask about your family history and may do a mental health assessment.

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

The earlier the disease is confirmed, the sooner you can get treatment, feel better, and improve the quality of your life. This can also reduce your risk of other health problems, such as substance use disorder.

Treatment Overview

Bipolar disorder is treated with a combination of medicines and counseling. It's important to take your medicines exactly as prescribed, even when you feel well. Your doctor may have you try different combinations of medicines to find what's right for you.

Your family doctor can prescribe medicines to treat bipolar disorder. But you will probably be referred to a psychiatrist, who is trained specifically to treat mental disorders.

Many people don't get help for bipolar disorder. You may not seek treatment because you think the symptoms aren't bad enough or that you can work things out on your own. But treatment can help you manage the highs and lows.

Your treatment plan

Treatment often starts with helping you through an "acute" phase or manic episode. You may be suicidal or psychotic or using such poor judgment that you are in danger of harming yourself. Your doctor may decide that you should be hospitalized for your own safety, especially if he or she thinks you are suicidal.

Medicines

Medicines that may be used include mood stabilizers and antipsychotics. Over time, these medicines will be adjusted 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 maintain a normal routine of work and activity. To learn more, see Medications.

Counseling

Counseling is also an important part of treatment. It can help you cope with problems that may come up in your work or relationships because of bipolar disorder. To learn more, see Other Treatment.

Self-care

You can also do some things on your own to help manage your symptoms and maintain a normal routine. Joining a support group to talk with others who have bipolar disorder can help. To learn more, see Home Treatment.

Prevention

Bipolar disorder cannot be prevented. But often the mood swings can be controlled with medicines. And there are many things you can do for yourself to help manage highs and lows. To learn more, see Home Treatment.

Self-Care

Home treatment is important in bipolar disorder. There are many things you can do to help control mood swings. You don't have to do them all at once. Try to do one thing, such as eating a healthy diet, then add another when you can.

Watch what you eat

Try to eat 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 from 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. No single food provides every nutrient.

Keep good habits

• Take your medicine every day as prescribed.
• Get enough exercise. Try moderate activity for at least 30 minutes a day, every day, if possible. A brisk walk is an example of moderate activity.
• Avoid alcohol and illegal drugs.
• Limit caffeine and nicotine.

Reduce stress, get rest

• Try to control the amount of stress in your life. Techniques to relieve stress include physical activity and exercise, breathing exercises, muscle relaxation, and counseling and support groups.
• Get enough sleep. Keep your room dark and quiet, and try to go to bed at the same time every night. If you plan to travel into other time zones, ask your doctor if you should make any changes in your medicines. And ask what to do if you have a manic or depressive episode while you are away.

Ask for help

• 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 have a manic high.

• Bipolar Disorder: Preventing Manic Episodes

How family and friends can help

Family members often feel helpless when a loved one is depressed or manic. But you can help.

• Encourage the person to take prescribed medicines regularly, even when he or she is feeling good.
• If family therapy is available, it is important for everyone in the family to attend the sessions.
• Recognize a lapse into a manic or depressive episode. Help the person cope and get treatment.
• Allow your loved one to take enough time to feel better and get back into daily activities.
• Learn the difference between hypomania and when your loved one is just having a good day. Hypomania is an elevated or irritable mood that is clearly different from a regular nondepressed mood. It can last for a week or more.

Know the signs

• Learn the warning signs for suicide. They include:
  • Drinking alcohol heavily or taking illegal drugs.
  • Talking, writing, or drawing about death, such as 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.

Get help for you

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 hard. Talk with a psychiatrist, a psychologist, a social worker, or a licensed professional counselor for your own therapy.

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

Medicines

Medicines, when taken as prescribed, can help control bipolar mood swings. Your doctor will vary the amounts and combinations of your medicines according to your symptoms, which type of bipolar disorder you have, and how you respond to the medicines.

About 1 out of 3 people will be completely free of symptoms of bipolar disorder by taking mood stabilizer medicine, such as carbamazepine or lithium, for life.^{footnote 5}

Taking medicines during pregnancy for bipolar disorder may increase the risk of birth defects. If you are pregnant or thinking of becoming pregnant, talk to your doctor. You may need to keep taking medicine if your bipolar disorder is severe. Your doctor can help weigh the risks of treatment against the risk of harm to your pregnancy.

Medicine choices

Several medicines are used to treat bipolar disorder. It may take time to find the treatment that works best for you. The most common medicines used are:

• Mood stabilizers, such as lithium (Lithobid). Experts believe that lithium may affect certain brain chemicals (neurotransmitters) that cause mood changes. A mood stabilizer and an antipsychotic are recommended as the first medicines for acute manic episodes.
• Anticonvulsants, such as carbamazepine (such as Equetro and Tegretol), divalproex (Depakote), and valproate (Depakene). They are also considered mood stabilizers. Divalproex and valproate are used to treat manic episodes. The anticonvulsant lamotrigine (Lamictal) may be helpful for bipolar depression.
• Antipsychotics, such as aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon). Antipsychotics improve manic episodes. Olanzapine may be used in combination with other medicines.
• Benzodiazepines, such as diazepam (Valium). These may be used instead of antipsychotics or as an additional medicine during a manic phase.

Medicines and your lifestyle

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

During your doctor's appointment, ask about:

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

Monitoring medicines

You'll need to check in with your doctor regularly when taking medicines for bipolar disorder.

If you are prescribed carbamazepine, lithium, or valproate, 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 side effects. Blood tests can also help show how medicines are affecting your liver, kidneys, and thyroid gland or to measure the number of blood cells in your body.

The use of antidepressants alone has been linked to an increase in manic episodes. Antidepressant treatment needs to be monitored closely to avoid causing a manic episode.

FDA advisories

The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant and anticonvulsant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide, such as threatening to harm himself or herself and being preoccupied with death or suicide. This is especially important at the beginning of treatment or when doses are changed.

Other Treatment

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

Counseling choices

• Cognitive-behavioral therapy is 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 can slow or prevent recovery.
• Interpersonal therapy focuses on social and personal relationships and related problems. You and your counselor discuss grief and loss, role disputes in relationships, and relationship transitions.
• Problem solving is a brief, focused form of cognitive therapy used to treat depression. It focuses on specific problems and how you can solve them.
• Family therapy is 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 who has bipolar disorder and the family as a whole.

No matter which type of counseling you choose, establish a long-term relationship with a counselor you like. The counselor will help you recognize personality changes that show when you are moving into a mood swing. Getting early treatment can reduce the length of the high or low. See some tips for finding a counselor or therapist.

ECT therapy

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.

Alternative therapy

A few studies suggest that adding omega-3 fatty acids to medicine (such as lithium) can help reduce the depressive symptoms of bipolar disorder in some people. Omega-3 fatty acids don't seem to have an effect on the manic symptoms of bipolar disorder. And omega-3 fatty acids alone are not a good treatment for bipolar disorder. They are not a replacement for medicine or other therapy used to treat bipolar disorder.^{footnote 6, footnote 7}