Bipolar disorder, formerly called manic-depressive illness, is a condition where a person experiences extreme mood swings with at least one manic episode, with the following symptoms (American Psychiatric Association, 2000):

A period of abnormally elevated, expansive or irritable mood, lasting at least one week (or any duration if hospitalisation is required);

During the period of mood disturbance, three (or more) of the following symptoms are present:

increased self-esteem or grandiosity;
decreased need for sleep (e.g. feels rested after only 3 hours of sleep);
more talkative than usual or pressure to keep talking;
flight of ideas or subjective experience that thoughts are racing;
distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli);
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation;
excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained shopping sprees, sexual indiscretions, or risky business investments).

People with bipolar disorder, also often experience episodes of depression, characterised by at least 2 weeks of depressed/low mood or loss of interest with at least four of the following symptoms experienced nearly every day (American Psychiatric Association, 2000):

change in appetite or significant change in weight (an increase or decrease);
sleep problems;
psychomotor agitation or retardation (e.g. moving slower than usual);
fatigue or loss of energy;
feelings of worthlessness or excessive or inappropriate guilt;
difficulty thinking or concentrating, or indecisiveness; and/or
recurrent thoughts of death, thoughts about suicide or attempted suicide;

The patterns of mood swings that occur in people with bipolar disorder can vary. Some experience depressive episodes after each manic episode with a period of 'wellness' in between. Others experience persistent symptoms that do not meet the criteria for a full-blown episode (i.e. hypomania or dysthymia) but can significantly interfere with their functioning. For some, they can experience a rapid cycling between each mood state, referred to as a mixed episode. Some people only have a few episodes in their lifetime, whereas others may experience a number each year.

How is bipolar disorder different from normal mood swings?

Changes or fluctuations in mood are common. However, people with bipolar disorder, experience mood swings for no apparent reason. The extent of the mood swings is also much greater than that seen in normal daily fluctuations of mood, generally lasting for weeks at a time, as opposed to a few hours. The mood swings in bipolar disorder often cause serious distress or impairment in social, occupational or important areas of functioning.

Who is affected by bipolar disorder?

According to the American Psychiatric Association (2000):

About 1 in 100 people meet the criteria for bipolar disorder in their lifetime.
Bipolar disorder occurs in all cultures. However, it can be experienced and communicated differently in different cultures (e.g. in some cultures mania and depression are experienced mainly as somatic symptoms, such as headaches, or a lot of energy).
Both males and females are equally affected by bipolar disorder. The first episode in males is likely to be a manic episode while females more commonly first experience a depressed episode. Also, it is more common for females to experience a hypomanic episode.
Bipolar disorder can be diagnosed anytime between adolescence and after 50 years of age. The average age of onset is 20.
People with bipolar disorder often experience anxiety or substance misuse. Up to 93% of people with bipolar disorder experience anxiety at some stage in their life (Goodwin & Sachs, 2004).

What effect can bipolar disorder have on a person’s life?

Bipolar disorder can have a significant impact on a person’s quality of life. It can interfere with interpersonal relationships, family life, work, and social activities.

It is important that people with bipolar disorder try to maintain a regular routine, particularly in relation to their sleep, as disruptions to routine or high levels of stress can trigger an episode of depression or mania. Hence, it may be necessary to make adjustments to social, work or family life to keep a regular routine and to ensure stress levels are maintained at a manageable level.

How might bipolar disorder change over time?

Bipolar disorder is a recurrent disorder; 90% of people who experience an episode have future episodes (American Psychiatric Association, 2000).
Bipolar disorder may begin with a depressive episode or a manic episode, or a combination of depressive and manic episodes, known as a mixed episode.
Symptoms of depression often develop over a few days to weeks, while symptoms of mania usually begin suddenly, with a rapid escalation of symptoms over a few days.
Manic episodes usually last from a few weeks to several months and are briefer and end more abruptly than depressive episodes.
In approximately 50-60% of cases, a depressive episode either precedes or follows a manic episode (American Psychiatric Association, 2000).
The interval between episodes tends to decrease with increase in age.
On average, a person with bipolar disorder has an episode of illness about every two years, but this varies greatly from person to person.
Approximately 20-30% of people with bipolar disorder have residual symptoms between episodes (American Psychiatric Association, 2000).
The majority of people who experience bipolar disorder can expect to gain control over their symptoms following appropriate treatment and management.

What causes bipolar disorder?

Bipolar disorder is primarily caused by biological factors, namely genes and brain chemicals:

Family history/genes: Bipolar disorder is, in part, inherited. The chance that a relative of someone with bipolar disorder will develop bipolar disorder is between 3-15% depending on the degree of relatedness. No single 'bipolar disorder gene' has been identified and in fact, several are thought to be present and to play interacting roles. There is no test that can be done to estimate the precise likelihood that a person will develop the condition.
Brain chemicals: A large body of research indicates that individuals with bipolar disorder have distinct abnormalities in the regulation of a number of relevant neurochemicals in the brain. These abnormalities persist even when symptoms are not present (i.e. the disorder is in remission). This is an area of ongoing research and it is likely that future discoveries in this area will continue to improve our understanding of the causes of bipolar disorder.

Treatment of bipolar disorder

Although treatment will vary from one individual to another depending on the individual's needs, there are two main phases common to all treatment plans:

The acute phase of treatment can last from 6 weeks to 6 months. It is the period in which the symptoms of an acute episode of mania or depression are eliminated or brought under control, restoring a normal level of functioning to the person's life. During the acute phase, short-term treatments are offered, with the intention of discontinuing the treatment on recovery from the symptoms.
The maintenance phase is the period in which relapse prevention strategies are put into place. During this period, the goal is to remain free of the symptoms experienced during the acute episode, by using appropriate medication, education and support. During the maintenance phase, a long-term treatment plan is offered.

The precise treatment approach used will differ for each person, and will also differ depending on the types of mental health professionals providing the treatment (e.g. general practitioners, psychiatrists, psychologists, social workers or counsellors). Such professionals often work in teams so that all necessary treatment approaches can be made available and be well integrated. These treatment approaches can include a combination of medications, electroconvulsive therapy and psychological treatments.

Short-term treatment used during the acute phase

Medication: Medications used in the treatment of acute mania, mixed states or depression include:
Mood stabilisers: Lithium carbonate, valproate and carbamazepine are effective in stabilising the mood during the acute phase. They do not cause the switching to the opposite mood state and prevent the occurrence of another episode.
Antipsychotics: Antipsychotics are used to treat acute mania or depression with psychotic features. Antipsychotics are also used in combination with mood stabilisers to treat acute mania.
Antidepressants: Antidepressants are an effective treatment for acute depression. However, there is an increased risk of mania and therefore antidepressants are best used in combination with an agent that reduces the risk of mania (such as lithium, valproate or an antipsychotic).
Benzodiazepines: Lorazepam and clonazepam are used in treating insomnia and agitation, often experienced with acute mania. Benzodiazepines, however, should be stopped once their desired effect on sleep has been achieved.
Electroconvulsive therapy (ECT): ECT is used in severe acute mania or depression; when an acute episode has not responded to medication; or when the acute episode occurs during pregnancy and drug treatment may need to be avoided.

For more detailed information on ECT and the medications discussed above and their side effects, please talk with your doctor or refer to the medication pamphlets provided by your doctor.

Long-term treatment used during the maintenance phase

Medication: The following mood stabilisers are often used in combination:
Lithium which is effective in preventing relapse of mania, but less effective in preventing onset of depression.
Valproate has a reputation for greater tolerability than lithium; however, it is not possible to say whether it is more effective in preventing depression or mania and is not as widely researched as lithium.
Carbamazepine has been shown to be inferior to lithium in preventing relapse and therefore is used less often.
Lamotrigine is now regarded as an excellent choice for preventing depression. It is commonly used by people with bipolar disorder, where depression predominates.

All medications for bipolar disorder must be taken on a daily basis, as prescribed. Many people are tempted to stop taking medication, particularly during the maintenance phase, due to negative side effects or because symptoms no longer seem to be present. Many of the side effects for bipolar disorder are temporary or ease with time. However, if you find that you are concerned about the side effects, you are strongly encouraged to talk with your doctor.

ALWAYS CONSULT YOUR DOCTOR IF YOU WISH TO ADJUST OR STOP YOUR MEDICATION.

Psychological therapies: Psychological treatments are usually offered by a clinical psychologist and provide support, education, guidance and strategies to individuals with bipolar disorder and their family members. Psychological treatments complement medical treatments offered by psychiatrists, and have been found to help stabilise behaviour and mood, reduce hospitalisation, and enhance general functioning (Craighead, Miklowitz, Vajk & Frank, 1998). Psychological treatments may also assist in dealing with some of the stressors associated with the diagnosis of bipolar disorder. The following psychological treatments, when used in combination with medication, help in reduce the recurrence of manic and depressive episodes:
Cognitive behavioural therapy (CBT): CBT helps reduce distressing emotions, symptoms and life-problems by considering the way a person thinks, feels, and behaves. CBT is time limited (8-16 sessions); collaborative, with the therapist and client working together; and has a ‘here and now’ focus. The main goals of CBT are to reduce distressing emotions and symptoms, so that life regains balance and quality of life is improved. CBT will also equip people with skills and strategies that reduce the chance of them re-experiencing difficulties. If difficulties do recur, the strategies learnt will help people to manage these so that these problems are experienced with less intensity, and resolved more quickly. CBT can help people to feel better about themselves and teach them skills to cope more easily and effectively with day-to-day situations and stresses.
Interpersonal and social rhythm therapy (IPSRT): IPSRT is a treatment designed specifically for people with bipolar disorder. IPSRT addresses difficulties in interpersonal relationships and helps to regulate daily routines. It has been found that when used in conjunction with medication, IPSRT reduces the risk of a relapse (Frank, Swartz, & Kupfer, 2000). Furthermore, IPSRT is helpful in improving medication compliance. IPSRT helps in controlling bipolar disorder by scheduling regular activities, teaching relaxation strategies, and teaching skills to manage interpersonal relationships more successfully, which will lead to a reduction in levels of stress, and further regulate activity levels and sleep patterns.

How long will treatment last for?

Treatment for an acute episode can last for up to 6 months. However, like any other chronic medical condition, such as heart disease or diabetes, successful long-term management of bipolar disorder requires ongoing treatment with a combination of medications and psychosocial therapy.

Expectations for the future

Bipolar disorder is an unpredictable recurrent disorder. However, through compliance with treatment the episodes can either be prevented, or their severity and frequency can be reduced. With appropriate ongoing treatment, a person with bipolar disorder can lead a very stable, productive and successful life.

What can I do to help myself?

If you experience symptoms of bipolar disorder, consult your doctor or mental health professional in order to be appropriately assessed and for suitable treatment to be administered. Please refer to the end of this brochure for contact details of relevant professionals at Sentiens.
Follow the treatment as prescribed. Take your medication regularly, on the good days as well as the bad days, in order to prevent further episodes and relapse.
If you are unsure about your treatment or its side effects, please ask your doctor or mental health professional. Good communication with your doctor about side effects can help to ensure that you don’t stop taking your medication prematurely and your doctor will be able to make adjustments to your medication to reduce the side effects.
Learn to recognise your early signs of depression and mania. Regularly monitor your symptoms, and work with your treating doctor or mental health professional to put in appropriate strategies when required.
Ask trusted family and friends for support when you need it.
Maintain a regular routine for eating and sleeping.
It is also important to remember that the use of drugs, alcohol and some other prescribed medications may cause the bipolar medication to become ineffective or increase the side effects. All substances and medications being taken should be reported to your doctor.

References

Alderton, D. (2005). The treatment of bipolar disorder. [Medication Brochure]. Perth: Sentiens.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: American Psychiatric Association.

Barnes, C. (2003). Bipolar affective disorder: Electroconvulsive therapy. [Brochure]. Perth: Sentiens.

Craighead, W. E., Miklowitz, D. J., Vajk F. C., & Frank, E. (1998). Psychological treatments for bipolar disorder. In P. E. Nathan & J. M. Gorman (Eds.) A guide to treatments that work (pp. 240- 248). New York: Oxford University Press.

Exeter-Kent, H. (2003). Bipolar affective disorder: Cognitive behavioural therapy approach for depression. [Brochure]. Perth: Sentiens.

Feeney, F. (2005). Interpersonal and social rhythm therapy. [Brochure]. Perth: Sentiens.

Frank, E., Swartz, H. A., & Kupfer, D. J. (2000). Interpersonal and social rhythm therapy: Managing the chaos of bipolar disorder. Biological Psychiatry, 48, 593-604.

Goodwin, G. & Sachs, G. (2004). Bipolar disorder. Oxford: Health Press.

Keck, P. E. & McElroy, S. L. (1998). Pharmacological treatment of bipolar disorders. In P. E. Nathan & J. M. Gorman (Eds.) A guide to treatments that work (pp. 249- 269). New York: Oxford University Press.

Mukherjee, S., Sackheim, H. A., & Schnur, D. B. (1994). Electroconvulsive therapy of acute manic episodes: A review of 50 years’ experience. American Journal of Psychiatry, 151(2), 169-176.

Nathan, P.E., & Gorman, J.M. (Eds.). (1998). A guide to treatments that work. New York: Oxford University Press.

National Institute of Mental Health, (2001), Bipolar disorder, from www.nimh.nih.gov

Nemeroff, C.B. & Schatzberg, A.F. (1999). Recognition and treatment of psychiatric disorders: A psychopharmacology handbook for primary care. Washington DC, USA: American Psychiatric Press.

World Health Organisation. (1997). Management of Mental Disorders. Darlinghurst: WHO Collaborating Centre for Mental Health and Substance Abuse.

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Bipolar Disorder