Patient information: Bipolar disorder (manic depression) (Beyond the Basics)

OVERVIEW

Bipolar disorder, also known as manic depression, is a mental health problem that causes changes in mood. Sometimes you may feel excessively elated, impulsive, irritable, or irrational (called mania) or hypomanic (a milder form of mania). Other times you may feel excessively sad (called major depression).

Bipolar disorder can make it hard to do a good job at work or school, have relationships with friends and family, and it even increases the risk of suicide if it is not treated or treated incorrectly. However, a number of effective treatment options are available.

More detailed information about bipolar disorder is available by subscription. (See "Bipolar disorder in adults: Epidemiology and diagnosis" and "Bipolar disorder in adults: Pharmacotherapy for acute mania, mixed episodes, and hypomania" and "Bipolar disorder in adults: Maintenance treatment" and "Bipolar disorder in adults and lithium: Pharmacology, administration, and side effects".)

BIPOLAR DISORDER CAUSES

The exact cause of bipolar disorder is not clear. The problem may be related to an imbalance of chemicals in the brain. These chemicals allow cells to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions.

Approximately one percent of people have bipolar disorder. People with a family history of bipolar disorder are at increased risk of developing the condition. Most people develop the first symptoms of bipolar disorder between age 15 to 30 years; it is uncommon to develop the first symptoms of bipolar as a child or as an adult over the age of 65.

BIPOLAR DISORDER SYMPTOMS

Mania — Mania causes you to feel abnormally and persistently happy, angry, hyperactive, impulsive, and irrational at different times. These feelings last at least one week, and may be severe enough that you need to be treated in a hospital. Other symptoms may include:

• Feelings of special powers and superiority
• Decreased need for sleep, restlessness
• Talking excessively
• Increased activity
• Racing thoughts
• Short attention span
• Inappropriate laughing or joking, or getting into lots of arguments
• Inappropriate spending sprees or sexual activity

Mania often causes difficulty maintaining relationships with friends and family, and can interfere with work or other responsibilities. During a manic episode, your moods can change rapidly from euphoria to depression or irritability.

Hypomania — Hypomania is less severe than mania, but it causes a change in mood that is abnormal. Hypomania is usually briefer than manic episodes, although it lasts for at least four days. Hypomania may not seriously affect your ability to work or go to school, and some people actually function better during a hypomanic episode. Hypomania may not need to be treated in a hospital, but it should be treated with medicines because it may lead to a manic or depressive episode.

Depression — People with depression feel very sad and have trouble doing ordinary things like bathing, getting dressed, and cooking. You may feel sad most of the day or you may have little or no interest in any activity. Other symptoms may include:

• Weight loss or gain (due to changes in how much you eat)
• Difficulty falling or staying asleep, or sleeping too much
• Feeling irritated easily
• Fatigue, loss of energy, sluggishness
• Feelings of worthlessness or guilt
• Difficulty concentrating and making decisions
• Recurring thoughts of death or suicide

(See "Patient information: Depression in adults (Beyond the Basics)".)

Alcohol and drugs — More than 60 percent of people with bipolar disorder abuse alcohol or drugs.

Suicide — The risk of suicide also is higher in people with bipolar disorder compared to people with other psychiatric illnesses (including depression). Suicide is often the result of feeling hopeless, and is more likely in people with severe symptoms who must be hospitalized for treatment. If a family member or friend mentions suicide, you should consider this a serious threat and immediately contact the person's doctor or nurse. If you are having thoughts of suicide, call your doctor or nurse or go to the nearest emergency department.

BIPOLAR DISORDER DIAGNOSIS

There is no test that can diagnose bipolar disorder. Instead, the diagnosis is based upon a medical and psychiatric history and a physical and mental status examination. Laboratory testing may be performed to rule out other diagnoses.

TREATMENT OF MANIA IN BIPOLAR DISORDER

Treatment of mania focuses on managing symptoms and keeping you safe. In the early phase of mania (called the acute phase), you may be psychotic (having false, fixed beliefs or hearing voices or seeing things others cannot see or hear). You may not be able to make good decisions and you may be at risk of hurting yourself or others. You may need to be treated in a hospital temporarily, until your medicine begins to work.

Medicines are the main treatment for mania, and a number of medicines are available. It is not usually possible to know ahead of time which medicine will be the most effective and cause the fewest side effects. It may be necessary to try several medicines before finding the best one.

Treatment of mania continues until your symptoms completely resolve and you are able to function. Many people continue to take medicine for a long time to prevent a recurrence of mania.

Mood stabilizers — Medicines such as lithium, lamotrigine, valproate, and carbamazepine, are often used first in the treatment of mania or hypomania. All of these medicines may be effective, and the choice is often made based upon what medicines you have taken before, side effects, and any underlying medical illnesses.

Lithium — Lithium has been used for many years to treat mania. Common side effects of lithium can include frequent urination, tremor, loose stools, difficulty thinking clearly, or weight gain. Problems with kidney function, heart rhythm, or thyroid functioning can occur in people who take lithium for long periods of time.

A test to measure the lithium level in the blood is recommended regularly when taking lithium. Blood testing is usually done every 6 to 12 months once the lithium dose is stabilized.

Lithium can cause serious problems if you take an overdose or if your kidneys do not work normally. This can occur if you becomes severely dehydrated or take certain medicines with lithium. If you take lithium, talk to your healthcare provider before taking any new non-prescription or prescription medicines.

Valproate — Valproate is a medicine that is also effective in treating mania. It may be used instead of or in combination with lithium. Common side effects of valproate include weight gain, nausea, vomiting, hair loss, easy bruising, and tremor. Blood testing is usually done to check blood levels and to check for potential complications.

Carbamazepine — Carbamazepine is also helpful in the treatment of bipolar disorder. The most common side effects of carbamazepine include nausea, vomiting, diarrhea, rash, itching, and fluid retention. Blood testing is recommended to check blood levels and to check for potential complications.

Carbamazepine interferes with certain birth control methods (pill, vaginal ring, patch), making these methods less effective in preventing pregnancy (see 'Birth control' below).

Antipsychotic medicines — Antipsychotic medicines may be used alone or in combination with a mood stabilizer to treat mania or depression.

• Certain antipsychotic medicines, such as olanzapine (Zyprexa®), risperidone (Risperdal®), and quetiapine (Seroquel®) have a risk of weight gain, high blood sugar, diabetes mellitus, and high cholesterol.
• The antipsychotic medicines ziprasidone (Geodon®) and aripiprazole (Abilify®) may work as well as other antipsychotic medicines, but with a lower risk of weight gain and diabetes.
• Clozapine (Clozaril®) is an antipsychotic medicine that may be particularly effective in patients who do not respond to other mood stabilizers or antipsychotics, However, it carries a risk of lowering the white blood cell count to a dangerously low level. Blood testing is required once per week.

TREATMENT OF DEPRESSION IN BIPOLAR DISORDER

Mood stabilizers — Mood stabilizers, such as lamotrigine and lithium, are commonly used to treat depression in people with bipolar disorder. Lithium is discussed above (see 'Lithium' above).

Lamotrigine — Lamotrigine was developed to treat seizures, but it is also effective for people with bipolar depression. Routine blood tests are not needed for monitoring.

Lamotrigine can have serious side effects when taken with other medicines; be sure that your healthcare provider has an updated list of your prescription and nonprescription medicines. An infrequent but serious rash (called Stevens-Johnson syndrome) can occur early in treatment; call your healthcare provider if you notice a new rash while taking lamotrigine.

Antipsychotics — Antipsychotic medicines may help to treat bipolar depression (see 'Antipsychotic medicines' above). In particular, olanzapine or quetiapine can be helpful for patients with bipolar depression.  In some cases, an antipsychotic medicine is combined with an antidepressant medicine.

Antidepressants — Antidepressants are sometimes used to treat people with bipolar depression, sometimes in combination with a mood stabilizer. However, people with bipolar disorder who use antidepressants must be monitored closely because there is a chance that antidepressants can cause a manic episode.

There are several types of antidepressants, each of which works differently.

• Selective serotonin reuptake inhibitors (eg, fluoxetine (Prozac®), fluvoxamine (Luvox®), sertraline (Zoloft®), paroxetine (Paxil®), citalopram (Celexa®), and escitalopram (Lexapro®)) (see "Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects").
• Venlafaxine (Effexor®) and duloxetine (Cymbalta®) (see "Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects").
• Mirtazapine (Remeron®) (see "Monoamine oxidase inhibitors (MAOIs) for treating depressed adults").
• Bupropion (Wellbutrin®) (see "Monoamine oxidase inhibitors (MAOIs) for treating depressed adults").
• Monoamine oxidase inhibitors (tranylcypromine (Parnate®) and phenelzine (Nardil®)) (see "Monoamine oxidase inhibitors (MAOIs) for treating depressed adults").
• Tricyclic antidepressants (see "Unipolar depression in adults and tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects").

Electroconvulsive therapy (ECT) — During electroconvulsive therapy (ECT), an electrical current is passed through the brain, triggering a seizure. Patients typically receive 6 to 12 such treatments, with at least one day in between each treatment. For unknown reasons, these seizures help to restore the normal balance of chemicals in the brain. ECT is especially effective for people with severe, life-threatening depression that has not responded to medicines. (See "Patient information: Electroconvulsive therapy (ECT) (Beyond the Basics)".)

ECT can be used in pregnant women and in those who cannot tolerate antidepressant or mood stabilizing medicines, and is especially useful for those who need a treatment that begins working rapidly. Although ECT has been negatively portrayed as "shock therapy" in the media, this therapy often provides rapid and dramatic relief of symptoms and has few side effects.

Patients who undergo ECT are given anesthesia to induce sleep and prevent pain. The person's heart and breathing rate, oxygen levels, and blood pressure are carefully monitored before, during, and after treatment is given. Side effects of this therapy include confusion and memory loss.

BIPOLAR DISORDER MAINTENANCE THERAPY

Medicines — Once the worst symptoms of mania or depression are under control, treatment focuses on preventing a recurrence. People who have suffered a manic episode are often advised to continue taking medicine(s) to control bipolar disorder. This usually includes a single mood stabilizing medicine, such as lithium or valproate. Other medicines may also be recommended if, for example, a single mood stabilizer is not helpful or you cannot tolerate the side effects.

Psychotherapy (counseling) — Although medicines are the treatment of choice for bipolar disorder, counseling and talk therapy also have an important role in treatment. This is especially true after an acute episode has passed.

Psychotherapy may include individual counseling as well as education, marital and family therapy, or treatment of alcohol and/or drug abuse. Therapy can help you to stick with your medicine, which can decrease the risk of relapse and the need for hospitalization.

WOMEN AND BIPOLAR DISORDER

Pregnancy — Women who are taking medicines for bipolar disorder and considering pregnancy should talk with their doctor or nurse. If you take medicine for bipolar and discover you are pregnant, do not stop your medicine suddenly. Instead, speak with your healthcare provider to determine if you should continue your medicine, change to another medicine, or slowly taper the medicine.

The decision to continue taking medicine during pregnancy is a hard one because of the potential risks to you (if you are not treated or undertreated), your developing baby, and your family. You should discuss all of the risks and benefits of treatment with a knowledgeable and experienced healthcare provider who can help to decide which treatment, if any, is best.

During your discussion, consider the following issues:

• Infants of women who take lithium during the first trimester of pregnancy have an increased risk of heart malformations. However, the risk is very low. Women who require lithium are generally advised to remain on lithium. An ultrasound of the baby's heart is usually recommended at 18 to 20 weeks of pregnancy to screen for heart defects. There are no known long-term behavioral effects of lithium in children.
• Anticonvulsant medicines, including carbamazepine, lamotrigine, and valproate increase the risk of birth defects and are not usually recommended during pregnancy.
• If you continue to take valproate or carbamazepine, you should take a supplement containing 4 milligrams of folic acid starting 3 months before trying to become pregnant and continuing for 3 months after becoming pregnant. This may reduce the risk of a type of birth defect, known as neural tube defects, which may be more common in infants of mothers who take valproate or carbamazepine.
• Newer antipsychotic medicines, including olanzapine and quetiapine are not known to cause birth defects, but there is not as much information about the safety of these medicines during pregnancy. In addition, there are no long-term data about how these medicines could potentially affect the child.
• The potential risks of antidepressant medicines are discussed in a separate article. (See "Patient information: Depression treatment options for adults (Beyond the Basics)", section on 'Antidepressants and pregnancy'.)

Birth control — Some of the medicines used to treat bipolar disorder, including carbamazepine, interact with birth control pills, skin patch, and vaginal ring. As a result, women who take these medicines should consider another method of birth control (eg, an injection of depo-medroxyprogesterone acetate, condoms, or an intrauterine device). (See "Patient information: Birth control; which method is right for me? (Beyond the Basics)".)

The blood level of one medicine, lamotrigine, is decreased in women who take birth control pills. Some women who take lamotrigine and a birth control pill will need a higher dose of lamotrigine.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Bipolar disorder (The Basics)
Patient information: Electroconvulsive therapy (ECT) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Depression in adults (Beyond the Basics)
Patient information: Depression treatment options for adults (Beyond the Basics)
Patient information: Birth control; which method is right for me? (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Adult attention deficit hyperactivity disorder
Bipolar disorder in adults: Epidemiology and diagnosis
Bipolar disorder in adults: Maintenance treatment
Bipolar disorder in adults: Pharmacotherapy for acute mania, mixed episodes, and hypomania
Diagnosis of delirium and confusional states
First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects
First generation (Typical) antipsychotic medication poisoning
Overview of psychosis
Postpartum psychosis: Epidemiology, clinical manifestations, and assessment
Treatment of postpartum psychosis
Seasonal affective disorder
Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects
Second generation (atypical) antipsychotic medication poisoning
Unipolar depression in adults and tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Mental Health

     (www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml)

• Depression and Bipolar Support Alliance (DBSA)

     (www.DBSAlliance.org)

• National Mental Health Association

     (www.nmha.org)

• National Alliance for the Mentally Ill

     (www.nami.org/)

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