Once considered a relatively uncommon form of depression, bipolar disorder is now believed to affect about three percent of American adults. Nearly one third of these never get treatment. Those who get treatment may go eight years or longer before diagnosis. With or without diagnosis, the disorder can take a huge toll on the individual and on society.
Bipolar disorder is the sixth leading cause of medical disability. Bipolar patients work on average 14 years less than their peers. Most have difficulty maintaining a long-term relationship and getting along with family members and friends. Some end up in jail.
On the other hand, many historical figures believed to suffer from bipolar disorder were creative, talented and highly productive individuals. Some examples include Van Gogh, Napoleon, Winston Churchill and Ernest Hemingway. Handel wrote the Messiah during a frantic three-week period, which was probably a manic episode. Thus the person with this disorder is still capable of doing great things.
Alternating Highs and Lows
In addition to bounding energy, enthusiasm and self-confidence, manic episodes may be characterized by other characteristic symptoms. Mania leads to racing thoughts, lack of concentration, poor judgment, spending sprees, increased sexual drive, alcohol or drug abuse and provocative or even criminal behavior. These episodes may last from several days to several months. They are typically followed by a period when the individual withdraws and seems to lose interest in everything and everybody.
The deep depression that usually follows mania is often made worse by the crashing realization of the damages and debts that occurred during the manic phase. Other symptoms include decreased energy, fatigue, insomnia or excessive sleep, loss of appetite and feelings of worthlessness or guilt. During the depressive cycle of bipolar disorder, the risk of suicide is high.
An alternate form of bipolar disorder may also occur. This involves milder episodes of mania, known as hypomania. A hypomanic episode may feel positive, and the person is often productive and functional during such periods. The less extreme mania causes a lower risk of drastic behavior. The inevitable depression, however, follows.
To family and friends, the person with bipolar disorder may seem to have “problems”. People who are bipolar are often considered irresponsible, tactless, abrasive or to have a drug or alcohol addiction. In addition, the delusional thinking often associated with mania phases is frequently mistaken for schizophrenia or a brain tumor.
Symptoms usually start to appear in young adulthood, and, unlike other types of depression, bipolar disorder affects males and females in approximately equal numbers. There is a strong family connection. A patient’s first-degree relatives have a four- to six-fold increased risk of developing bipolar disorder. These individuals should be alerted and screened. Early diagnosis and treatment may prevent loss of control.
Without treatment, mood swings tend to become progressively more extreme and frequent. Milder forms of hypomania may progress to full-blown mania. Rapid cycling may occur, with multiple episodes of mania followed by depression within a short period. Impulsive behavior and feelings of despair are a deadly combination, so early detection and diagnosis is crucial.
Treatment
While many types of depression can be successfully treated and may never recur, bipolar disorder is nearly always a lifetime illness requiring maintenance therapy–usually involving both medication and psychotherapy. Once a diagnosis is established, the first step is to stabilize mood. If the disorder is mistaken for unipolar depression, as it often is, antidepressant medications carry the risk of inducing a manic episode.
One of the earliest treatments was lithium, used as a mood stabilizer since 1949 and approved for the treatment of bipolar disorder in 1971. Studies have found it effective in lowering the risk of relapse into either manic or depressive phases and reducing the length of episodes when they do occur. Patients taking lithium have significantly lower rates of suicide than those taking placebo.
Some traditional anti-seizure medications have been identified as effective treatment for bipolar disorder. Valproate and carbamazepine are used to stabilize moods. They both work well with few side effects. Another newer anti-seizure medication, lamotrigine, was approved in 2003 for bipolar maintenance therapy.
Recently, second generation antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole) have been found effective in shortening manic episodes with fewer side effects. These drugs affect dopamine, a neurotransmitter believed to be associated with mania.
In some cases, best results can be obtained with a combination of one or more mood stabilizers plus a second generation antipsychotic. All have potential side effects, including weight gain, insulin resistance, nausea, tremor, reduced sexual drive, anxiety and dry mouth.
Once the mood has been stabilized, talk therapy of some kind can be used to work through conflicts and help motivate the patient to comply with treatment. A supportive therapist can help a patient understand the illness, make sense of symptoms and learn to deal with every-day situations and relationship problems. It’s important for the patient and others to understand that the illness is biological and not caused by family or psychological conflicts–although the behavior encountered during manic phases can certainly create psychological problems or exaggerate those that already exist.
For everyone involved, bipolar disorder may seem like an action film with an unhappy ending. It need not be that way. With patience, understanding and compliance with treatment, some of the troubling symptoms and behavior can be controlled or, better yet, channeled into productive energy.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director, Richmond Apothecaries, Inc.
Rev. 1/2010 MHT
