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Bipolar disorder

Introduction

Bipolar disorder – known in the past as manic depression – is a condition that affects your moods, which can swing from one extreme to another.

If you have bipolar disorder, you will have periods or "episodes" of:

  • depression – where you feel very low and lethargic
  • mania – where you feel very high and overactive (less severe mania is known as hypomania)

The symptoms of bipolar disorder depend on which mood you are experiencing. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks or longer, and some people may not experience a "normal" mood very often.

Depression

The depression phase of bipolar disorder is often diagnosed first. You may initially be diagnosed with clinical depression before having a manic episode later (sometimes years later), after which you may be diagnosed with bipolar disorder.

During an episode of depression, you may have overwhelming feelings of worthlessness, which can potentially lead to thoughts of suicide.

If you're feeling suicidal or having severe depressive symptoms, contact your GP, care co-ordinator or the local mental health emergency services as soon as possible.

If you can't or don’t want to contact these people, call the Samaritans on 08457 90 90 90. You can call them 24 hours a day, seven days a week. Alternatively, visit the Samaritans website or email jo@samaritans.org. The Community Advice & Listening Line (CALL) is a mental health helpline for Wales offering a confidential listening and support service - 0800 132 737 or text 'help' to 81066. CALL are available 24 hours a day, 7 days a week.

Mania

During a manic phase of bipolar disorder, you may feel very happy and have lots of ambitious plans and ideas. You may spend large amounts of money on things that you cannot afford and would not normally want. Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common characteristics of the manic phase of bipolar disorder.

During the manic phase, you may feel very creative and view mania as a positive experience. However, during the manic phase of bipolar disorder, you may also have symptoms of psychosis (where you see or hear things that are not there or become convinced of things that are not true).

Living with bipolar disorder

The high and low phases of bipolar disorder are often so extreme that they interfere with everyday life. However, there are several options for treating bipolar disorder that can make a difference. They aim to control the effects of an episode and help someone with bipolar disorder to live life as normally as possible.

It is thought that using a combination of treatments is the best way to control bipolar disorder. Treatment can include:

  • medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilisers and are taken every day, on a long-term basis
  • medication to treat the main symptoms of depression and mania when they occur
  • learning to recognise the triggers and signs of an episode of depression or mania
  • psychological treatment such as talking therapy to help deal with depression and to give you advice about how to improve your relationships
  • lifestyle advice such as doing regular exercise, planning activities that you enjoy and that give you a sense of achievement, and advice on improving your diet and getting more sleep

Help and advice for people with a long-term condition or their carers is also available from charities, support groups and associations. This includes self-help and self-management advice and dealing with the practical aspects of a long-term condition. Find out more about living with bipolar disorder.

What causes bipolar disorder?

The exact causes of bipolar disorder are not known. However, it is thought that several things can trigger an episode. Extreme stress, overwhelming problems and life-changing events are often thought to contribute, as well as genetic and chemical factors.

Who is affected?

Bipolar disorder is relatively common. Around one person in 100 is diagnosed with the condition.

Bipolar disorder can occur at any age, although it often develops between the ages of 18 and 24 years. Men and women from all backgrounds are equally likely to develop bipolar disorder.

The pattern of mood swings in bipolar disorder varies widely between people. For example, some people will only have a couple of bipolar episodes in their lifetime and will be stable in between, while others may experience many episodes.

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Symptoms

Bipolar disorder is characterised by extreme mood swings. The mood swings can range from extreme highs (mania) to extreme lows (depression). Episodes of mania and depression can often last for several weeks or more.

Depression

During a period of depression, your symptoms may include:

  • feeling sad and hopeless
  • lacking energy
  • difficulty concentrating and remembering things
  • loss of interest in everyday activities
  • feelings of emptiness or worthlessness
  • feelings of guilt and despair
  • feeling pessimistic about everything
  • self-doubt
  • being delusional, having hallucinations and disturbed or illogical thinking
  • lack of appetite
  • difficulty sleeping
  • waking up early
  • suicidal thoughts

Mania

The manic phase of bipolar disorder may include:

  • feeling very happy, elated or overjoyed
  • talking very quickly
  • feeling full of energy
  • feeling self-important
  • feeling full of great new ideas and having important plans
  • being easily distracted
  • being easily irritated or agitated
  • being delusional, having hallucinations and disturbed or illogical thinking
  • not feeling like sleeping
  • not eating
  • doing things that often have disastrous consequences, such as spending large sums of money on expensive and sometimes unaffordable items
  • making decisions or saying things that are out of character and that others see as being risky or harmful 

Rapid cycling

If you have bipolar disorder, you may have episodes of depression more regularly than you have episodes of mania. Or you may have mania more often than depression.

Between episodes of depression and mania, you may sometimes have periods of "normal" mood. However, some people with bipolar disorder can repeatedly swing from a high to low phase quickly without having a "normal" period in between. This is known as rapid cycling.

Living with bipolar disorder

Bipolar disorder is a condition of extremes. A person with bipolar disorder may be unaware of being in the manic phase of the condition. After the episode is over, they may be shocked at their behaviour. However, at the time, they may think that other people are being negative or unhelpful.

Some people with bipolar disorder have more frequent and severe episodes than others. The extreme nature of the condition means that staying in a job may be difficult and relationships may become strained. There is also an increased risk of suicide.

During episodes of mania and depression, someone with bipolar disorder may experience strange sensations, such as seeing, hearing or smelling things that are not there (hallucinations). They may also believe things that seem irrational to other people (delusions). These types of symptoms are known as psychosis or a psychotic episode.

Read more information about living with bipolar disorder.

Bipolar disorder and driving

If you have bipolar disorder, it may have implications for driving. You must inform the Driver and Vehicle Licensing Agency (DVLA) about any medical condition that could affect your ability to drive.

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Causes

The exact cause of bipolar disorder is not fully understood. However, experts believe that a number of different factors act together and make a person more likely to develop the condition. These are thought to be a complex mix of physical, environmental and social factors.

Chemical imbalance in the brain

Bipolar disorder is widely believed to be the result of chemical imbalances in the brain. The chemicals responsible for controlling the functions of the brain are called neurotransmitters, examples of which include norepinephrine, serotonin and dopamine.

If there is an imbalance in the levels of one or more neurotransmitters, it may cause the symptoms of bipolar disorder. For example, episodes of mania may occur when levels of norepinephrine are too high, and episodes of depression may be the result of norepinephrine levels becoming too low.

Genetics

Bipolar disorder is also thought to be linked to genetics. Bipolar disorder seems to run in families, and the family members of a person with the condition have an increased risk of developing it themselves.

However, no single gene is responsible for bipolar disorder. Instead, it is thought that a number of genetic and environmental factors act as triggers for the condition.

Triggers

A stressful circumstance or situation often triggers the symptoms of bipolar disorder. Examples of stressful triggers include: 

  • physical, sexual or emotional abuse
  • the breakdown of a relationship
  • the death of a close family member or loved one

These types of life-altering events can cause episodes of depression throughout a person’s life.

Bipolar disorder may also be triggered by physical illness, sleep disturbances and overwhelming problems in everyday life, such as problems with money, work or relationships.

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Diagnosis

If your GP suspects that you have bipolar disorder, they will usually refer you to a psychiatrist (a medically qualified mental health specialist).

If there is a risk that you could harm yourself as a result of your illness, your GP will arrange for you to have an appointment immediately.

Specialist assessment

You will be assessed at your appointment. The psychiatrist will ask you a number of questions to determine whether you have bipolar disorder and, if so, what treatments will be most suitable for you.

During the assessment, you will be asked about your symptoms and when you first experienced them. The psychiatrist will also ask you about how you usually feel leading up to and during an episode of mania or depression, and whether you have had thoughts about harming yourself.

The psychiatrist will also want to find out about your medical background and family history, to determine whether any of your relatives have had bipolar disorder. If someone else in your family has the condition, the psychiatrist may want to talk to them. However, they will ask for your agreement before doing so.

Other tests

Depending on your symptoms, you may also need tests to see whether you have a physical problem, such as an underactive thyroid or overactive thyroid.

If you have bipolar disorder, you will need to visit your GP regularly for a physical health check.

Advanced directives

If you are diagnosed with bipolar disorder, it is important to discuss your condition with the psychiatrist so you are fully involved in the decisions about your treatment and care.

However, in some cases, a person may not be able to make an informed decision about their care, or to communicate their needs. This might be the case if their symptoms become severe. In such situations, it may be possible to draw up an advanced directive.

An advanced directive is a set of written instructions that state what treatments and help you want (or do not want) in advance in case you cannot communicate your decisions at a later stage. Your GP or psychiatrist will be able to give you further help and advice about this.

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Treatment

Treatments for bipolar disorder aim to reduce the severity and frequency of the episodes of depression and mania so that a person can live life as normally as possible.

NICE guidance

According to the National Institute for Health and Clinical Excellence (NICE), good care for people with bipolar disorder should include:

  • working with patients and their families to develop a collaborative relationship
  • providing written information at every stage of the process, including information about medications
  • encouraging patients and their families and carers to join self-help and support groups
  • advising patients about monitoring their own symptoms, looking out for triggers and early warning signs
  • offering lifestyle advice, including good sleeping habits and coping strategies
  • writing, with patients and their families and carers if they agree, advance statements about their mental and physical healthcare, especially if they have severe episodes or have been treated under the Mental Health Act (these should be included in the care plans and circulated to the healthcare team)
  • taking into account the needs of the patient’s family or carers, including physical, social and mental needs, and being accessible in times of crisis

Read the full NICE guidelines for the management of bipolar disorder (PDF, 320Kb).

Treatment options for bipolar disorder

If they are not treated, episodes of bipolar-related depression or mania can last for 6 to 12 months. On average, someone with bipolar disorder will have five or six episodes over a period of 20 years. However, with effective treatment, episodes usually improve within about three months.

Most people with bipolar disorder can be treated using a combination of different treatments. The treatment may include one or more of the following:

  • medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilisers and are taken every day, on a long-term basis
  • medication to treat the main symptoms of depression and mania when they occur
  • learning to recognise the triggers and signs of an episode of depression or mania
  • psychological treatment such as talking therapy to help deal with depression and to give you advice about how to improve your relationships
  • lifestyle advice such as doing regular exercise, planning activities that you enjoy and that give you a sense of achievement, and advice on improving your diet and getting more sleep.

Read more information about living with bipolar disorder.

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.

However, treatment in hospital may be required if your symptoms are severe, or if you are being treated under the Mental Health Act because there is a danger that you will harm yourself or others. In some circumstances, you may be able to have treatment in a day hospital and return home at night.

Medication

Several medications are available to help stabilise mood swings. These include:

  • lithium carbonate
  • anticonvulsant medicines
  • antipsychotic medicines

If you are already taking medication for bipolar disorder and you develop depression, your GP will check that you are taking the correct dose and, if necessary, will adjust it.

Episodes of depression in bipolar disorder can be treated in a similar way to clinical depression. This includes using antidepressant medication. Read information about how depression is treated and antidepressants.

If your GP or psychiatrist recommends that you stop taking medication for bipolar disorder, the dose should be gradually reduced over a minimum of four weeks, and up to three months if you are taking an antipsychotic or lithium. If you have to stop taking lithium for any reason, see your GP about taking an antipsychotic or valproate (see below) instead.

Lithium carbonate

In the UK, lithium carbonate (often referred to as just lithium) is the medication that is most commonly used to treat bipolar disorder. Lithium is a long-term method of treatment for episodes of mania, hypomania and depression. It is usually prescribed for a minimum of six months.

If you are prescribed lithium, stick to the prescribed dose and do not stop taking it suddenly (unless told to by your doctor).

For lithium to be effective, the dosage must be correct. If the dose is incorrect, it may cause side effects, such as diarrhoea and vomiting. If you are taking lithium and you have side effects, tell your doctor immediately.

While taking lithium, you will need to have regular blood tests (at least once every three months) to ensure that your levels of lithium are not too high or too low. Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you are taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they are prescribed by your GP. Your GP can advise you further about this.

In the UK, lithium is currently the only medication that is licensed for use in children who have bipolar disorder (who are aged 12 or over). However, in 2000, the Royal College of Paediatrics and Child Health stated that unlicensed medicines may be prescribed for children if there are no suitable alternatives, and where their use can be justified by expert agreement.

Anticonvulsant medicines

Anticonvulsant medicines include:

  • valproate 
  • carbamazepine
  • lamotrigine

These medicines are sometimes used to treat episodes of mania. Like lithium, they are long-term mood stabilisers. Anticonvulsant medicines are often used to treat epilepsy, but they are also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used or, where the condition does not respond to lithium on its own, they may be used in combination with lithium.

Valproate

Valproate is not usually prescribed for women of child-bearing age because there is a risk that it could damage an unborn child. However, if there is no alternative, your GP will need to ensure that you are using a reliable form of contraception.

If you are prescribed valproate, you will need to visit your GP to have a blood count when you begin the medication and then again six months later.

Carbamazepine

Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low before it's gradually increased. If you're taking other medication (including the contraceptive pill), your progress will be carefully monitored.

Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine and again after six months. You will also need to have a blood count (at the start and after six months) and you may also have your weight and height monitored.  

Lamotrigine

If you are prescribed lamotrigine, you will usually be started on a low dose that will be increased gradually.

If you are taking lamotrigine and you develop a rash, see your GP immediately. You will need to have an annual health check, but other tests will not usually be required.

Women who are taking the contraceptive pill should talk to their GP about changing to a different method of contraception.

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania or hypomania. Antipsychotic medicines include: 

  • aripiprazole olanzapine 
  • quetiapine 
  • risperidone

They may also be used as a long-term mood stabiliser. Quetiapine may be used for long-term bipolar depression.

Antipsychotic medicines can be particularly useful if symptoms are severe or behaviour is disturbed. As antipsychotics can cause side effects, such as blurred vision, dry mouth, constipation and weight gain, the initial dose will usually be kept low.

If you are prescribed an antipsychotic medicine, you will need to have regular health checks (at least every three months but possibly more often), particularly if you have diabetes. If your symptoms do not improve, you may be offered lithium and valproate as well.

Rapid cycling

If you have rapid cycling (you quickly change from highs to lows without a "normal" period in between), you may be prescribed a combination of lithium and valproate.

If this does not help, you may be offered lithium on its own or a combination of lithium, valproate and lamotrigine. However, you will not usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.

Learning to recognise triggers

If you have bipolar disorder, you can learn to recognise the warning signs of an approaching episode of mania or depression.

This will not prevent the episode from occurring, but it will allow you to get help in time.

This may mean making some changes to your treatment, perhaps adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you are already taking. Your GP or specialist can advise you about this.

Psychological treatment

Some people find psychological treatment helpful when used alongside medication in between episodes of mania or depression. This may include:

  • psychoeducation to help you find out more about bipolar disorder
  • cognitive behavioural therapy (CBT), which is most useful when treating depression
  • family therapy, a type of psychotherapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Pregnancy

The management of bipolar disorder in women who are pregnant, or those who are trying to conceive, is complex and challenging. One of the main problems is that the risks of taking medication during pregnancy are not always that well understood.

The National Institute for Health and Clinical Excellence (NICE) recommends that the risks of treating or not treating women with bipolar disorder during pregnancy should be fully discussed.

NICE also recommends that specialist mental health services should work closely with maternity services. A written plan for managing the treatment of a pregnant woman with bipolar disorder should be developed as soon as possible. The plan should be drawn up with the patient, her partner, her obstetrician (pregnancy specialist), midwife, GP and health visitor.

The following medication is not routinely prescribed for pregnant women with bipolar disorder:

  • valproate – there is a risk to the foetus and the subsequent development of the child
  • carbamazepine – it has limited effectiveness and there is risk of harm to the foetus
  • lithium – there is a risk of harm to the foetus, such as cardiac problems
  • lamotrigine – there is a risk of harm to the foetus
  • paroxetine – there is a risk of harm to the foetus, such as cardiovascular malformations
  • long-term treatment with benzodiazepines – there are risks during the pregnancy and immediately after the birth, such as cleft palate and floppy baby syndrome
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Living with

Although it is usually a long-term condition, effective treatments for bipolar disorder combined with self-help techniques can limit its impact on your everyday life.

Staying active and eating well

Eating well and keeping fit are important for everyone. Exercise can also help reduce the symptoms (particularly depressive symptoms) of bipolar disorder. It may also give you something to focus on and provide a routine, which is important for many people.

A healthy diet combined with exercise may also help limit weight gain, which is a common side effect of medical treatments for bipolar disorder.

Some treatments also increase the risk of developing diabetes or that diabetes gets worse. Maintaining a healthy weight and exercising is an important way of limiting that risk.

You should have a check-up at least once a year to monitor your risk of developing cardiovascular disease or diabetes. This will include recording your weight, checking your blood pressure and having any appropriate blood tests

Self care and self management

Self care

Self care is an essential part of daily life. It involves taking responsibility for your own health and wellbeing with support from the people involved in your care. Self care includes staying fit and maintaining good physical and mental health, preventing illness or accidents and caring more effectively for minor ailments and long-term conditions.

People with long-term conditions can benefit enormously from being helped with self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and be more active and independent.

Self-management programmes

Self-management programmes aim to help people with bipolar disorder take an active part in their own recovery, so that they're not controlled by their condition.

One course run by Bipolar UK aims to teach people with bipolar disorder how to manage their illness. The programme includes information about:

  • triggers and warning signs
  • coping strategies and self-medication
  • support networks and action plans
  • maintaining a healthy lifestyle
  • drawing up an advance directive
  • complementary therapies
  • action plans

There are other courses, such as those run by the Expert Patients Programme, for mild to moderate mental health conditions.

Courses like these help people who may feel distressed and uncertain about their bipolar disorder to improve their own lives.

Talking about it

Some people with bipolar disorder find it easy to talk to family and friends about their condition and its effects. Other people find it easier to turn to charities and support groups. Many organisations run self-help groups that can put you in touch with other people with the condition. This enables people to share helpful ideas and realise that they're not alone in feeling the way they do. These organisations also provide online support in forums and blogs.

Some useful charities, support groups and associations include:

Talking therapies are useful for managing bipolar disorder, particularly during periods of stability.

Services that can help

During treatment for bipolar disorder, you may be involved with many different services. Some are accessed through referral from your GP, others through your local authority. These services may include:

  • Community mental health teams (CMHT) – these provide the main part of local specialist mental health services. They offer assessment, treatment and social care to people with bipolar disorder and other mental illnesses.
  • Early intervention teams – these provide early identification and treatment for people who have the first symptoms of psychosis. Your GP may be able to refer you directly to be seen by an early intervention team.
  • Crisis services – these allow people to be treated at home, instead of in hospital, for an acute episode of illness. They're specialist mental health teams that help with crises that occur outside normal office hours.
  • Acute day hospital – these exist in some places as an alternative to inpatient care in a hospital. You can visit every day or as often as necessary.
  • Assertive outreach teams – these deliver intensive treatment and rehabilitation in the community for people with severe mental health problems. They provide rapid help in a crisis. Staff often visit people at home and liaise with other services, such as your GP or social services. They can also help with practical problems, such as helping to find housing and work, or doing the shopping and cooking.

Avoiding drugs and alcohol

Some people with bipolar disorder use alcohol or illegal drugs to try to take away their pain and distress. Both have well-known harmful physical and social effects, and they're not a substitute for effective treatment and good healthcare.

Some people with bipolar disorder find that once they're on effective treatments, they can stop misusing alcohol and drugs. Others may have separate but related problems of alcohol and drug abuse, which may need to be treated separately.

Avoiding alcohol and drugs is an important part of recovery from episodes of manic, hypomanic or depressive symptoms, and can contribute to periods of stability.

Read more information about alcohol misuse and drug misuse.

Money and benefits

It's important to avoid too much stress, including work-related stress. If you're employed, you may be able to work shorter hours or in a more flexible way, particularly if job pressures play a role in episodes of symptoms. Under the Disability Discrimination Act (1995), all employers must make reasonable adjustments to make the employment of people with disabilities possible. This can include people with a diagnosis of bipolar disorder or other mental illnesses.

A range of benefits may be available to people with bipolar disorder who cannot work as a result of their mental illness. These may include:

Living with or caring for someone with bipolar disorder

People living with or caring for someone with bipolar disorder can have a tough time. During episodes of illness, the personalities of people with bipolar disorder may change, and they may become abusive or even violent. Sometimes, social workers and the police may become involved. Relationships and family life are likely to feel the strain.

If you're the nearest relative (as defined by the Mental Health Act 1983) of a person with bipolar disorder, you have certain rights, which can be used to protect the person's interests. These include requesting that the local social services authority ask an approved mental health professional to consider whether the person with bipolar disorder should be detained in hospital (also known as "sectioning").

If you’re caring for someone with bipolar disorder, you may feel at a loss. Finding a support group and talking to other people in a similar situation might help.

If you’re having relationship or marriage difficulties, you can contact specialist relationship counsellors who can talk things through with you and your partner.

Want to know more?

Dealing with suicidal feelings

Having suicidal thoughts is a common depressive symptom of bipolar disorder. Without treatment, these thoughts may get stronger. Some research has shown that the risk of suicide for people with bipolar disorder is 15 to 20 times greater than the general population. Studies have also shown that as many as 25–50% of people with bipolar disorder attempt suicide at least once.

The risk of suicide seems to be higher earlier in the course of the illness, so early recognition and intervention may help prevent it.

If you're feeling suicidal or you're having severe depressive symptoms, contact your GP, care co-ordinator or the local mental health emergency services as soon as possible. 

If you can't or don’t want to contact these people, contact the Samaritans on 08457 90 90 90. You can call them 24 hours a day, seven days a week. Alternatively, visit the Samaritans website or email jo@samaritans.org. The Community Advice & Listening Line (CALL) is a mental health helpline for Wales offering a confidential listening and support service - 0800 132 737 or text 'help' to 81066. CALL are available 24 hours a day, 7 days a week.

Mania

Self-harm

Self-harm (sometimes called self-injury) is often a symptom of mental health problems such as bipolar disorder. For some people, self-harm is a way of gaining control over their lives or temporarily distracting themselves from mental distress. It may not be related to suicide or attempted suicide.

Want to know more? 

Recommended communities

Online communities help you talk to people, share your experiences and learn from others.

You can visit the website of Bipolar UK:  www.bipolaruk.org.uk

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