Bipolar Disorder

What is bipolar disorder?

Bipolar disorder, or manic depression, is a serious brain disorder that causes extreme shifts in mood, energy, and functioning. It affects 2.3 million adult Americans, which is about1.2 percent of the population, and can run in families. The disorder affects men and women equally. Bipolar disorder is characterized by episodes of mania and depression that can last from days to months. Bipolar disorder is a chronic and generally life-long condition with recurring episodes that often begin in adolescence or early adulthood, and occasionally even in children. It generally requires lifelong treatment, and recovery between episodes is often poor. Generally, those who suffer from bipolar disorder have symptoms of both mania and depression (sometimes at the same time).

What are the symptoms of mania?

Mania is the word that describes the activated phase of bipolar disorder. The symptoms of mania may include:

· either an elated, happy mood or an irritable, angry, unpleasant mood

· increased activity or energy

· more thoughts and faster thinking than normal

· increased talking, more rapid speech than normal

· ambitious, often grandiose, plans

· poor judgement

· increased sexual interest and activity

· decreased sleep and decreased need for sleep

What are the symptoms of depression?

Depression is the other phase of bipolar disorder. The symptoms of depression may include:

· depressed or apathetic mood

· decreased activity and energy

· restlessness and irritability

· fewer thoughts than usual and slowed thinking

· less talking and slowed speech

· less interest or participation in, and less enjoyment of activities normally enjoyed

· decreased sexual interest and activity

· hopeless and helpless feelings

· feelings of guilt and worthlessness

· pessimistic outlook

· thoughts of suicide

· change in appetite (either eating more or eating less)

· change in sleep patterns (either sleeping more or sleeping less)

What is a "mixed" state?

A mixed state is when symptoms of mania and depression occur at the same time. During a mixed state depressed mood accompanies manic activation.

What is rapid cycling?

Sometimes individuals may experience an increased frequency of episodes. When four or more episodes of illness occur within a 12-month period, the individual is said to have bipolar disorder with rapid cycling. Rapid cycling is more common in women.

What are the causes of bipolar disorder?

While the exact cause of bipolar disorder is not known, most researchers believe it is the result of a chemical imbalance in the certain parts of the brain. Other evidence suggests that the disorder results from impairments of the function of intracellular signaling pathways (the "machinery" inside nerve cells) within specific areas of the brain. Scientists have found evidence of a genetic predisposition to the illness. An active area of research involves trying to understand what those genes are that lend susceptibility to developing the disorder. Bipolar disorder tends to run in families, and close relatives of someone with bipolar disorder are more likely to be affected by the disorder. Sometimes serious life events such as a serious loss, chronic illness, illicit or prescription drug use or financial problems, can trigger an episode in some individuals with a predisposition to the disorder. There are other possible "triggers" of bipolar episodes: the treatment of depression with an antidepressant medication may trigger a switch into mania, sleep deprivation may trigger mania, or hypothyroidism may produce depression or mood instability. It is important to note that bipolar episodes can and often do occur without any obvious trigger.

How is bipolar disorder treated?

While there is no cure for bipolar disorder, it is a treatable and manageable illness. After an accurate diagnosis, most people can be successfully treated. Medication is an essential part of successful treatment for people with bipolar disorder. Maintenance treatment with a mood stabilizer substantially reduces the number and severity of episodes for most people, although episodes of mania or depression may occur and require a specific additional treatment. In addition, psychosocial therapies including, cognitive-behavioral therapy, interpersonal therapy, family therapy, and psychoeducation are important to help people understand the illness and to develop skills to cope with the stresses that can trigger episodes. Changes in medications or doses may be necessary, as well as changes in treatment plans during different stages of the illness.

Medications used to treat mania. Medications commonly used to treat manic episodes of bipolar disorder are called mood stabilizers, and they include lithium (Eskalith or Lithobid) and divalproex sodium (Depakote).

· Lithium has long been used as a first line treatment for acute mania in people with bipolar disorder. Lithium is effective for preventing episodes of mania from occurring and for treating an episode after it has begun. However, for some individuals, lithium is ineffective and for others, lithium has a variety of side effects that may make it an undesirable treatment option.

· Depakote is an anticonvulsant that has been used to treat epilepsy since 1983, but it was approved as a treatment for manic episodes of bipolar disorder in 1995. Depakote seems to be as effective as lithium for treating mania and it has fewer side effects, although it may not be appropriate for people with a history of liver problems.

· Other anticonvulsant medications have also been used to treat mania, including lamotrigine (Lamictal) which was recently approved by the Food and Drug Administration for treatment of bipolar disoder.  These include carbamazepine (Tegretol) and topiramate (Topamax). However, these two medications have not been officially approved by the FDA for the treatment of bipolar disorder and have their own side effects.

· Mania may also be treated acutely with antipsychotic medications. This class of medications includes Olanzapine (Zyprexa), which is FDA approved for the treatment of acute mania.

Medications used to treat depression. During depressive episodes, people with bipolar disorder may need additional treatment with an antidepressant medication. Because of the risk of triggering mania, doctors often prescribe an antidepressant only after the individual is already receiving a therapeutic dose of lithium or an anticonvulsant mood stabilizer. Research suggests that mood stabilizers can protect against antidepressant-induced switches into mania. Antidepressant medications relieve depression, elevate mood, and activate behavior, but it often takes three to four weeks to respond. Sometimes a variety of different antidepressants and doses will be tried before finding the medication that works best for a particular individual.

· There are several different types of antidepressants used to treat depression including tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), or newer antidepressants that function in different ways. Recent data suggests that the anticonvulsant lamotrigine (Lamictal) may possess antidepressant effects in bipolar disorder. Once again, it is important to emphasize that treatment of depression in bipolar disorder without a mood stabilizing medication may result in "cycling" into a manic episode.

· Consumers and their families must be cautious during the early stages of treatment when energy levels and the ability to take action return before mood improves. At this time - when decisions are easier to make, but depression is still severe - the risk of suicide may temporarily increase.

What are the side effects of the medications used to treat bipolar disorder?

All medications have side effects. Different medications produce different side effects, and people differ in the amount and severity of side effects they experience. Side effects can often be treated by changing the dose of the medication, switching to a different medication, or treating the side effect directly with an additional medication.

Side effects of medications used to treat mania.

· Side effects of lithium include hand tremors, excessive thirst, excessive urination, and memory problems. Side effects often become less troublesome after a few weeks as the body adjusts to the medication. Particularly bothersome tremors can be treated with additional medication. Low thyroid function can be treated with thyroid supplements. In very few people, long-term lithium treatment can interfere with kidney function.

· Common side effects of anticonvulsant mood stabilizers include nausea, drowsiness, dizziness, and tremors. Some people taking anticonvulsant mood stabilizers may develop liver problems or problems with white blood cell count and blood platelets, which can be severe. Therefore, blood tests to monitor liver function and blood cells may be an important part of treatment with some of these medications.

Side effects of medications used to treat depression. About half of the people taking antidepressant medications have mild side effects during the first few weeks of treatment.

· Common side effects of tricyclic antidepressants (TCAs) include dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness, drowsiness, skin rash, or weight gain or loss.

· Individuals taking monoamine oxidase inhibitors (MAOIs) may have to be careful about eating certain smoked, fermented, or pickled foods, drinking certain beverages, or taking some medications because they can cause severe high blood pressure in combination with the medication. MAOIs have other, less severe side effects as well.

· The SSRIs and newer antidepressants tend to have fewer and different side effects, such as nausea, nervousness, insomnia, diarrhea, rash, agitation, or sexual problems, or weight gain or loss.

Reviewed by Husseini Manji, MD June 2003

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