This entry provides some background on bipolar disorder, information on how to get help, and testimonies on what life is like living with it. If you are currently suffering, or you know someone who is, you may wish to skip to the 'How To Get Help' section. At the end of the Entry, there are also some links to organisations that might be able to help you.

Bipolar disorder, sometimes known as 'manic depression', is a brain disorder that affects between 1% and 1.5% of the adult population in any given year. It is equally prevalent in men and women. It is characterised by alternating periods of extreme moods, ranging from overly elated or irritable states (mania) to extreme sadness and hopelessness (depression), with normal moods in between. The disorder can be disruptive and distressing, both to sufferers and their loved ones.

What Causes Bipolar Disorder?

The short answer is, 'nobody knows'. Researchers generally agree that there is no single cause for bipolar disorder, only that many factors act together to cause the illness.

Certainly there is a strong genetic component. A predisposition to bipolar disorder runs in families. What is not certain is whether this relates to any physical phenomena - although some limited evidence is emerging from imaging techniques that the brains of people with bipolar disorder may differ from those of healthy people. There are also complex changes in brain chemistry.

Bipolar disorder typically has its onset in adolescence or early adulthood and continues throughout life. Others, however, do not develop it until later adulthood (the 40s is a common time) - and it can also afflict children. Sometimes, but by no means always, there can be an identifiable trigger such as an illness, trauma, prolonged loss of sleep or stress (for which some sufferers have inadequate coping mechanisms). However, once the illness has taken hold, the sufferer will typically cycle between mood states with no discernible trigger.

The Symptoms of Bipolar Disorder

A person with bipolar disorder cycles between depression, mania and sometimes 'mixed' states with features of both mania and depression, usually with periods of normal mood in between. These typically recur, and at their extremes can cause severe disruption to the sufferer's life if they are not treated.

It is important to recognise that the highs and lows of bipolar disorder are extremes of what might ordinarily be regarded as normal moods: everyone has their 'ups and downs'. The recognition of a depressive or manic episode rests on identifying a combination of symptoms and their severity.

In the depressive state, mood is characterised by symptoms such as:

• Feeling very sad and hopeless
• Mental and physical slowing
• Fatigue and lack of energy
• Finding it difficult to concentrate
• Losing interest in everyday activities
• Inability to enjoy activities that previously gave pleasure
• Feelings of emptiness or worthlessness
• Feeling pessimistic about everything
• Feelings of serious self-doubt
• Feelings of guilt
• Avoiding contact with others and wanting to hide
• Difficulty sleeping, waking up early
• Loss of appetite, sometimes accompanied by stomach upsets or nausea
• Loss of interest in sex
• Thoughts of suicide or self-harm

These are general symptoms of depressive illness. The difference for bipolar disorder is that, usually after two to four major episodes of depression, the sufferer experiences a shift into a manic state, symptoms of which include:

• Feeling extremely happy, elated or euphoric
• Decreased need for sleep
• Feeling full of energy
• Feeling full of great new ideas, or the subjective experience that thoughts are racing
• Feeling important, having inflated self-esteem or grandiosity
• Being more talkative than usual or pressure to keep talking
• Attention is easily drawn to unimportant or irrelevant items
• Increased sociability and social engagement, even with strangers - feeling the life and soul of the party
• Increase in goal-directed activity (either socially, at work/school, or sexually)
• Psychomotor agitation (restlessness, fidgeting, being always on the move)
• Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
• Irritability, especially at not being 'understood' by others.

A major problem during manic episodes is that sufferers may not be aware, or may be only partially aware, that their thoughts and behaviour are abnormal. From their point of view, they may be having a whale of a time and may well be irritated when others point out that they are acting unusually.

The extreme manic and depressive states may also be accompanied by psychosis - strange sensations or ideas which are not based on reality. This can include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not actually there) and delusions (false fixed beliefs that are not subject to reason or contradictory evidence and are not explained by a person's usual cultural concepts).

The combination and severity of symptoms differ widely from person to person. Mania, for example, can be experienced in the milder form of hypomania, characterised by lower-level, non-psychotic symptoms such as increased energy, euphoria, irritability, and intrusiveness. Hypomania may not impair the individual's functioning, but is noticeable to others. In some cases, sufferers experience 'mixed' episodes with characteristics of both depression and mania.

Types of Bipolar Disorder

The key characteristic of bipolar disorder is that it involves cycles between mood states. The frequency and duration of swings and their severity varies between individuals.

For diagnostic purposes, psychiatrists have identified some broad patterns:

• Bipolar I disorder is diagnosed when a person has experienced at least one episode of severe mania, with or without previous experience of a major depressive episode.

• Bipolar II disorder is when a person has experienced at least one hypomanic episode but has not met the criteria for a full manic episode, but with previous experience of major depression.

• There is also Cyclothymic disorder, a milder illness in which the person cycles between numerous hypomanic and depressive episodes, without meeting the full criteria for mania or major depression, over a period of two years or more (one year for children and adolescents).

The majority of people with bipolar disorder experience extreme cycles only every few years (a two-yearly cycle seems fairly common) - indeed, with successful treatment the cycles may be ironed out. Usually the first episode of mania or hypomania follows a number of periods of depression over several years. Many find that a manic episode is followed shortly by a plunge into particularly severe depression.

Others cycle more rapidly, experiencing four or more episodes of depression and mania in a year. In a few cases, the cycles are ultra-rapid, with episodes shorter than a week, and distinct and dramatic mood shifts within a single day. People who cycle most rapidly are the most difficult to treat.

Managing and Treating Bipolar Disorder

Hospitals

Many people with bipolar disorder will experience hospitalisation at some point in their life. Those who are depressed and at risk of self-harm often realise or are persuaded of the need for hospital treatment for their own safety. Those who are manic often find themselves in hospital involuntarily, sometimes following contact with the police. This is not to imply that they are violent or commit unlawful acts: their unusual behaviour may land them in trouble with others or otherwise draw the police's attention. The purpose of hospitalisation is to ensure that the person is in a safe place where their condition can be diagnosed and monitored and the effects of medication assessed¹. Hospitalisation is not always necessary and, with suitable support, these aspects can often be managed in the person's own family or community.

Medication

Drug therapy is important for the treatment of bipolar disorder, the main focus being on mood stabilisers. The most common medication for mood stabilisation is lithium, taken orally as lithium carbonate. Because lithium has a narrow therapeutic range for blood concentration, which means that blood samples have to be taken regularly, and because some have difficulties with its side effects, other drugs are increasingly used. These include anticonvulsants, principally valproate (Depakote) and carbamazepine. For patients who are psychotic, an anti-psychotic tranquillizer such as olanzapine (Zyprexa) or haloperidol (Haldol) may be administered, and for depressed patients a mood stabiliser is often combined with an anti-depressant such as venlafaxine (Effexor), bupropion (Wellbutrin), paroxetine (Paxil) or sertraline (Zoloft). Use of antidepressants requires careful monitoring, because they can sometimes precipitate a manic state.

Although there is sometimes a certain fear and stigma surrounding psychiatric medication, the importance of drug therapies cannot be over-stressed. Some initial adjustment may be needed, but most patients will find a long-term regime that both controls their condition and has tolerable or zero side effects. Psychopharmacology has made great advances since the days when tranquillisers were the only weapon in the armoury!

ECT

In a very small number of cases, patients do not respond to drug treatments. In cases of very severe depression or mania, ECT (electro-convulsive therapy) is occasionally used. This may also be necessary in order to avoid giving drugs to pregnant women.

Complementary Therapy

It is also worth mentioning some complementary therapies which may be applied in combination with drug treatment. St John's Wort, which is sometimes used to treat mild depression, appears to have little or no effect for bipolar disorder. However, there is emerging clinical evidence for the benefit of Omega-3 oils, found in oily fish such as mackerel, sardines and tuna. The effective component is believed to be eicosapentaenoic acid (EPA)². Large doses are needed (1g per day of EPA). The corresponding dosage of oil varies, since different brands contain different proportions of EPA. Because of the amounts involved, it is difficult to get a sufficient dosage simply by eating more oily fish. Omega-3 oil should be used as only an adjunct to mainstream drug therapy (it should not be the sole therapy).

Support

Besides first-line medical therapies, 'talking cures' have a role to play in the management of bipolar disorder. Cognitive Behaviour Therapy, in which patients are encouraged to identify and modify negative thoughts, has been found to be effective in managing depression.

However, there are no 'magic wands' that can talk a person out of bipolar disorder. The emphasis in therapy is to help people come to terms with their condition and to teach them to identify the feelings and actions that might suggest another episode is on the way. Regular contact with professionals (psychiatrists, community psychiatric nurses) is essential and the involvement of family and friends is strongly encouraged. Self-help groups are also available to give support and understanding to sufferers and carers.

How To Get Help

On average, people with bipolar disorder wait ten years before they are properly diagnosed. In many cases the disorder is treated as unipolar depression. Since the treatment for this is only partially successful for bipolar depression, the individual may undergo several long and severe depressive episodes before receiving proper treatment.

For most, the first port of call for depression (or hypomania) will be a General Practitioner (US: physician). This can be hit and miss because GPs will encounter depressed patients daily and, unless symptoms are severe enough, or unless the person is exhibiting manic symptoms that are clearly different to depression, immediate access to a psychiatrist may not be immediately forthcoming - especially in the UK where specialist medicine is rationed. When someone is suffering from mania, it can be useful to get friends or relatives involved in persuading the GP. Psychiatric hospitals will take emergency referrals from GPs.

Another useful channel is community psychiatric services. In the UK, most local health authorities have established services that allow people with mental health problems to contact psychiatric nurses, 24 hours a day. While these are primarily intended for those who have already had contact with psychiatric services, they are very unlikely to brush off a caller who is experiencing problems and who needs quick access to specialists.

As a fallback, there are various voluntary organizations dealing with bipolar disorder and other mental health issues who are able to offer advice and support. For those in distress, the Samaritans will lend an ear and, if necessary, put you in contact with others. They are available 24 hours a day, 365 days per year, by phone or email. If you need them, do not hesitate to call.

If you are already thinking of harming yourself, please, please contact the Samaritans right away. They are there for you.

• Telephone 08457 90 90 90 (UK), 1850 60 90 90 (ROI), or email: [email protected]

• In the US and elsewhere, you can find numbers for local crisis lines in your phone book, or from the various sites listed at the end of this entry.

Living with Bipolar Disorder

Anyone, at any time, can find that they have bipolar disorder. It affects men, woman and children of all ethnic groups, social classes and levels of education. It is a highly disorienting and disrupting illness, both during manic and depressed episodes, as testaments from people with bipolar disorder reveal.³

The Illness

One of the problems in the early stages of episodes is recognising the symptoms in time to intervene. This is certainly true for hypomania:

I had no real idea I was getting ill. I was feeling dynamic at work, sociable and full of energy. I had sort of half an inkling that I was not my usual self, but attributed this to the fact that life was stimulating. Anyway - it was spring! I always feel good when the sun shines!

It can be equally true for depression:

I was generally feeling down and it was beginning to affect my work and social life. I was afraid to admit that I needed help. That would mean taking time out and letting everyone down. I had to be strong and tough my way through it.

But it is important to seek help when it is needed. The onset of extreme episodes can be rapid and drastic:

With hindsight, my thoughts started to spin out of control. I was young again, fearless and capable of great things. I was making unrealistic plans for alternative careers which would make me super-rich. Before long, I had abandoned my family, citing temporary marital differences, and was charging around the city meeting all sorts of people and having all sorts of adventures. A few times I was in danger of being attacked by people who found my behaviour and conversation odd. My mind was constantly skipping from one scheme to another, until everything seemed connected. One of my many notions was to capture all my thoughts and experiences in a great, earth-shattering novel that would revolutionise the world! There were also times where I would simply wander around, smiling or muttering to myself, and spending money on whatever seemed fascinating at the time.

It's hard to convey depression to someone who hasn't experienced it. 'Sadness' doesn't even come close. I couldn't even do the simplest things like drag myself out of bed. I was constantly afraid of how my absence would be going down at work. Everything was bleak, bleak, bleak and I just wanted to run away. My thoughts turned to suicide and I started to make plans.

Reaching Out

Depressed people are often desperate to seek help...

My suicidal thoughts scared me. I just wanted to get better and would do anything it took.

I hated to admit how bad things had got and was scared of submitting myself to a psychiatrist. Besides, my business was going to ruin and I had to get back out there. Anyway, it was all my fault and there was nothing that anyone could do or say.

For those in a manic or hypomanic episode, their euphoria and pre-occupation can make it difficult to get them help:

I only agreed to see a doctor to humour my husband. Even then I was annoyed at having to take medicine and had to be visited daily by a community nurse. Looking back, I can see that my flighty behaviour was stopping me from looking after my family properly.

My head was full of racing ideas and sometimes I would trip out. At times it was desperately scary, and part of me realised it wasn't right - but even then I didn't want it to stop. I was a super-god on an amazing high!

Eventually my wife tracked me down with the help of the police. She persuaded me to go to a hospital, which I did to humour her. To my utter surprise, I was detained. For the first week or so I planned to take my case to the European Court of Human Rights!

The Treatment

Should admission to a psychiatric hospital be necessary, whether voluntary or compulsory, this can be disorienting and frightening - especially for the first-timer:

I really didn't know what to expect. Would the place be full of loonies? Would I be safe?

I couldn't work out how I'd ended up here against my will. I became uncooperative and disruptive as I repeatedly failed to convince my psychiatrist that there was nothing wrong with me.

I never felt that I would come to harm. The staff were there to look after me and I could talk to them if I was feeling low.

Yes, there were some sad and desperate people in my ward - but there was a wide mix and I established friendships. I realised that there were all sorts - from professionals to the homeless - and my situation was nothing unusual.

My main memory is of boredom, punctuated by relaxation sessions and games of Trivial Pursuit.

Most hospital stays are brief and last only until medication has been established.

The importance of proper medication can't be over-emphasised:

My psychiatrist and pharmacist discussed the options with me and gave me a pretty free choice. I settled on Depakote because it avoids the need for regular blood tests.

I was worried about side-effects. Some pills did cause problems, and I've had to chop and change. Now the only thing is that lithium can give me a dry mouth - plus I have to go to the gym more often or it makes me put on weight! Sometimes I'm tempted to try and live without medication. I'm feeling fine, so why should I need it? I have to remember that they're what's keeping me even. The risks of stopping are just too great.

When I was depressed, it took a few weeks for my anti-depressants to kick in. But then, quite unexpectedly, I realised I wasn't feeling nearly so bad any more. Over the years I'd tried various types, with mixed results. Some would work for a while and then stop. But now I've found one which seems to work and I take it long-term.

I only need anti-depressants occasionally. I have to be careful to stop taking them when I'm over the depression, because in the past they've made me start to get high again.

The Aftermath

Bipolar episodes can be a major shock to the system, and it can be difficult for people to come to terms with the facts of their condition.

A particular problem following a manic episode is that it is often shortly followed by severe depression. Even those who have been depressed before can find its severity surprising:

It was like a light being switched off. Without warning I flipped over into the darkest place I have ever been.

What planet had I been on? What on earth had I been thinking? What must all those friends who I'd phoned in the middle of the night be thinking of me?

I'd emptied my bank account and said some mean things to my wife. I couldn't see how I was going to put my life back together.

I knew he'd been ill and was better now... but I was still scared of it happening again and wanted to protect our children.

I've relied on my husband to get me through this horrible time. It may be a soppy cliché - but I love him a thousand times more for sticking by me.

One or two 'friends' have steered clear of me. But the important ones have stayed with me all the way - and I'm not sure that I want the others as friends anyway.

Getting On With Life

Life goes on. There is nothing particularly unusual about people with bipolar disorder. Most lead perfectly normal lives. But at the outset, the illness can be devastating:

If you had told me at age 25 that I would have a nervous breakdown and be diagnosed bipolar within two years, I would have laughed in your face. Actually, I would have asked what bipolar meant, and then laughed. When I did have a manic episode, I was devastated, and pictured a horrific future. But luckily I live in an age where bipolar illness is treatable. My mood swings, while not perfectly under control, are manageable. And I know research continues to find even more effective treatments.

The potential disruption of bipolar disorder should not be underestimated. For some, it can lead to job loss, the break-up of relationships or financial hardship. However, the illness is usually treatable, and most people with bipolar disorder lead normal lives:

My medication is working fine, and I'm holding down a well-paid professional job. I still have my 'blue' periods - but they're far less intense. I use what I learnt from Cognitive Behaviour Therapy to manage my self-doubts.

Unfortunately, those with bipolar disorder are also affected by society's stigma about mental illness. But even this can be overcome:

I'm quite open about my illness. In fact, though, nobody mentions it. Perhaps they're scared or embarrassed - but then... I wouldn't stigmatise anyone, so why would they?

On the positive side, evidence suggests that people with bipolar disorder tend to be more creative and intelligent than average. Many noted celebrities have bipolar disorder.⁴ Part of the 'trick' of managing the illness is in recognising when this normal, positive creativity gives way to something less benign:

At first I'd feel scared if I had a creative idea or started to feel too happy or enthusiastic. But I know I've got all the support in place. If I don't realise it myself, I know they know about my illness, people will let me know if they think I'm getting too hyper.

So, yes, bipolar disorder is a serious, disorienting illness which impacts both sufferers and those around them. But it is just an illness - like diabetes, hypertension or the common cold. With proper treatment and support, life can and does go on.

Related weblinks

• Understanding Manic Depression: a guide from the mental health charity, MIND.

• The Manic Depressive Fellowship: a UK-based self-help group.

• Pendulum: a US-based resource on bipolar disorder.

• Omega-3 for Depression and Bipolar: an article summarising research into the benefits of fish oil.

• Medications on mentalhealth.com: a comprehensive list of psychiatric medications with links to further information.

Suggested Reading

• A Brilliant Madness by Patty Duke and Gloria Hochman. A good resource for understanding and coping with bipolar disorder.

• An Unquiet Mind by Kay Jamison. A moving autobiography of a doctor who has the illness and who treats bipolar patients.

For Help in a Crisis

If you are already thinking about harming yourself, please, please contact someone right away.

• The Samaritans: contact them if you need help at any time.

• US Crisis Lines: lists phone numbers by state.

• National Crisis Helpline: for use in locating the nearest crisis service in the United States. Phone toll-free 1-800-999-9999.

• Canadian Crisis Centres: lists phone numbers by province/territory.

• International Crisis Lines: lists worldwide phone numbers.