3 types of bipolar

Treatment for Persistent Depressive Disorder

Staying in a constant state of moodiness is no way to live. That’s one reason to seek treatment. Another is that PDD can also increase your risk for physical diseases. Yet another reason to pursue treatment? If left untreated, this mood disorder can develop into more severe depression. It can also increase your risk for attempting suicide.

Antidepressants , such as selective-serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), or tricyclic antidepressants, are often used to treat PDD. Because you may need to continue treatment for a lengthy period, it’s important to consider which medications not only work well but also ideally have few side effects. You may need to try more than one medication to find the one that works best. But know that it may take several weeks or longer to take effect. Successful treatment for chronic depression often takes longer than for acute (non-chronic) depression.

Take your medications as your doctor instructs. If they’re causing side effects or still not working after several weeks, discuss this with your doctor. Don’t suddenly stop taking your medications.

Doctors believe treatment for PDD is effective with a combination of antidepressants and psychotherapy.

Specific kinds of talk therapy, such as cognitive behavioral therapy (CBT), psychodynamic psychotherapy, or interpersonal therapy (IPT), are known to be effective forms of psychotherapy that treat PDD. A structured treatment lasting for a certain period of time, CBT involves recognizing and restructuring thoughts. It can help you change your distorted thinking. IPT is also a time-limited, structured treatment. Its focus is on addressing current problems and solving interpersonal conflicts. Psychodynamic psychotherapy involves exploring unhealthy or unsatisfying patterns of behavior and motivations that you may not be consciously aware of which could lead to feelings of depression and negative expectations and life experiences.

Some studies also suggest that aerobic exercise can help with mood disorders. This is most effective when done four to six times a week. But some exercise is better than none at all. Other changes may also help, including seeking social support and finding an interesting occupation. Used for patients with major depressive disorder with seasonal pattern (formerly known as seasonal affective disorder), bright-light therapy may also help some people with PDD.

Bipolar Disorder

What is bipolar disorder?

Bipolar disorder is a chronic or episodic (which means occurring occasionally and at irregular intervals) mental disorder. It can cause unusual, often extreme and fluctuating changes in mood, energy, activity, and concentration or focus. Bipolar disorder sometimes is called manic-depressive disorder or manic depression, which are older terms.

Everyone goes through normal ups and downs, but bipolar disorder is different. The range of mood changes can be extreme. In manic episodes, someone might feel very happy, irritable, or “up,” and there is a marked increase in activity level. In depressive episodes, someone might feel sad, indifferent, or hopeless, in combination with a very low activity level. Some people have hypomanic episodes, which are like manic episodes, but less severe and troublesome.

Most of the time, bipolar disorder develops or starts during late adolescence (teen years) or early adulthood. Occasionally, bipolar symptoms can appear in children. Although the symptoms come and go, bipolar disorder usually requires lifetime treatment and does not go away on its own. Bipolar disorder can be an important factor in suicide, job loss, and family discord, but proper treatment leads to better outcomes.

What are the symptoms of bipolar disorder?

The symptoms of bipolar disorder can vary. An individual with bipolar disorder may have manic episodes, depressive episodes, or “mixed” episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that last a week or two or sometimes longer. During an episode, the symptoms last every day for most of the day. Mood episodes are intense. The feelings are intense and happen along with changes in behavior, energy levels, or activity levels that are noticeable to others.

Symptoms of a Manic Episode Symptoms of a Depressive Episode
Feeling very up, high, elated, or extremely irritable or touchy Feeling very down or sad, or anxious
Feeling jumpy or wired, more active than usual Feeling slowed down or restless
Racing thoughts Trouble concentrating or making decisions
Decreased need for sleep Trouble falling asleep, waking up too early, or sleeping too much
Talking fast about a lot of different things (“flight of ideas”) Talking very slowly, feeling like you have nothing to say, or forgetting a lot
Excessive appetite for food, drinking, sex, or other pleasurable activities Lack of interest in almost all activities
Thinking you can do a lot of things at once without getting tired Unable to do even simple things
Feeling like you are unusually important, talented, or powerful Feeling hopeless or worthless, or thinking about death or suicide

Some people with bipolar disorder may have milder symptoms than others with the disorder. For example, hypomanic episodes may make the individual feel very good and be very productive; they may not feel like anything is wrong. However, family and friends may notice the mood swings and changes in activity levels as behavior that is different from usual, and severe depression may follow mild hypomanic episodes.

There are three basic types of bipolar disorder; all of them involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely “up,” elated, and energized behavior or increased activity levels (manic episodes) to very sad, “down,” hopeless, or low activity-level periods (depressive episodes). People with bipolar disorder also may have a normal (euthymic) mood alternating with depression. Four or more episodes of mania or depression in a year are termed “rapid cycling.”

  • Bipolar I Disorder is defined by manic episodes that last at least seven days (most of the day, nearly every day) or when manic symptoms are so severe that hospital care is needed. Usually, separate depressive episodes occur as well, typically lasting at least two weeks. Episodes of mood disturbance with mixed features (having depression and manic symptoms at the same time) are also possible.
  • Bipolar II Disorder is defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes described above.
  • Cyclothymic Disorder (also called cyclothymia) is defined by persistent hypomanic and depressive symptoms that are not intense enough or do not last long enough to qualify as hypomanic or depressive episodes. The symptoms usually occur for at least two years in adults and for one year in children and teenagers.
  • Other Specified and Unspecified Bipolar and Related Disorders is a category that refers to bipolar disorder symptoms that do not match any of the recognized categories.

Conditions That Can Co-Occur With Bipolar Disorder

Many people with bipolar disorder also may have other mental health disorders or conditions such as:

  • Psychosis. Sometimes people who have severe episodes of mania or depression also have psychotic symptoms, such as hallucinations or delusions. The psychotic symptoms tend to match the person’s extreme mood. For example:
    • Someone having psychotic symptoms during a manic episode may falsely believe that he or she is famous, has a lot of money, or has special powers.
    • Someone having psychotic symptoms during a depressive episode may believe he or she is financially ruined and penniless or has committed a crime.
  • Anxiety Disorders Deficit/Hyperactivity Disorder (ADHD). Anxiety disorders and ADHD often are diagnosed in people with bipolar disorder.
  • Misuse of Drugs or Alcohol. People with bipolar disorder are more prone to misusing drugs or alcohol.
  • Eating Disorders. People with bipolar disorder occasionally may have an eating disorder, such as binge eating or bulimia.

Some bipolar disorder symptoms are like those of other illnesses, which can lead to misdiagnosis. For example, some people with bipolar disorder who also have psychotic symptoms can be misdiagnosed with schizophrenia. Some physical health conditions, such as thyroid disease, can mimic the moods and other symptoms of bipolar disorder. Street drugs sometimes can mimic, provoke, or worsen mood symptoms.

Looking at symptoms over the course of the illness (longitudinal follow-up) and the person’s family history can play a key role in determining whether the person has bipolar disorder with psychosis or schizophrenia.

What causes bipolar disorder?

The exact cause of bipolar disorder is unknown. However, research suggests that there is no single cause. Instead, a combination of factors may contribute to bipolar disorder.

Genes

Bipolar disorder often runs in families, and research suggests that this is mostly explained by heredity—people with certain genes are more likely to develop bipolar disorder than others. Many genes are involved, and no one gene can cause the disorder.

But genes are not the only factor. Some studies of identical twins have found that even when one twin develops bipolar disorder, the other twin may not. Although people with a parent or sibling with bipolar disorder are more likely to develop the disorder themselves, most people with a family history of bipolar disorder will not develop the illness.

Brain Structure and Function

Researchers are learning that the brain structure and function of people with bipolar disorder may be different from the brain structure and function of people who do not have bipolar disorder or other psychiatric disorders. Learning about the nature of these brain changes helps doctors better understand bipolar disorder and may in the future help predict which types of treatment will work best for a person with bipolar disorder. At this time, diagnosis is based on symptoms rather than brain imaging or other diagnostic tests.

How is bipolar disorder diagnosed?

To diagnose bipolar disorder, a doctor or other health care provider may:

  • Complete a full physical exam.
  • Order medical testing to rule out other illnesses.
  • Refer the person for an evaluation by a psychiatrist.

A psychiatrist or other mental health professional diagnoses bipolar disorder based on the symptoms, lifetime course, and experiences of the individual. Some people have bipolar disorder for years before it is diagnosed. This may be because:

  • Bipolar disorder has symptoms in common with several other mental health disorders. A doctor may think the person has a different disorder, such as schizophrenia or (unipolar) depression.
  • Family and friends may notice the symptoms, but not realize that the symptoms are part of a more significant problem.
  • People with bipolar disorder often have other health conditions, which can make it hard for doctors to diagnose bipolar disorder.

How is bipolar disorder treated?

Treatment helps many people, even those with the most severe forms of bipolar disorder. Doctors treat bipolar disorder with medications, psychotherapy, or a combination of treatments.

Medications

Certain medications can help control the symptoms of bipolar disorder. Some people may need to try several different medications and work with their doctor before finding the ones that work best. The most common types of medications that doctors prescribe include mood stabilizers and atypical antipsychotics. Mood stabilizers such as lithium can help prevent mood episodes or reduce their severity when they occur. Lithium also decreases the risk for suicide. Additional medications that target sleep or anxiety are sometimes added to mood stabilizers as part of a treatment plan.

Talk with your doctor or a pharmacist to understand the risks and benefits of each medication. Report any concerns about side effects to your doctor right away. Avoid stopping medication without talking to your doctor first.

Psychotherapy

Psychotherapy (sometimes called “talk therapy”) is a term for a variety of treatment techniques that aim to help a person identify and change troubling emotions, thoughts, and behaviors. Psychotherapy can offer support, education, skills, and strategies to people with bipolar disorder and their families. Psychotherapy often is used in combination with medications; some types of psychotherapy (e.g., interpersonal, social rhythm therapy) can be an effective treatment for bipolar disorder when used with medications.

Other Treatments

Some people may find other treatments helpful in managing their bipolar symptoms, including:

  • Electroconvulsive therapy is a brain stimulation procedure that can help people get relief from severe symptoms of bipolar disorder. This type of therapy is usually considered only if a patient’s illness has not improved after other treatments (such as medication or psychotherapy) are tried, or in cases where rapid response is needed, as in the case of suicide risk and catatonia (a state of unresponsiveness), for example.
  • Regular vigorous exercise, such as jogging, swimming, or bicycling, helps with depression and anxiety, promotes better sleep, and is healthy for your heart and brain. Check with your doctor before you start a new exercise regimen.
  • Keeping a life chart, which records daily mood symptoms, treatments, sleep patterns, and life events, can help people and their doctors track and treat bipolar disorder.

Not much research has been conducted on herbal or natural supplements and how they may affect bipolar disorder. Talk to your doctor before taking any supplement. Certain medications and supplements taken together can cause serious side effects or life-threatening drug reactions. Visit the National Center for Complementary and Integrative Health for more information.

Finding Treatment

The National Institute of Mental Health (NIMH) is a federal research agency and cannot provide medical advice or referrals to practitioners. However, there are tools and resources available that may help you find a provider or treatment. You can also:

  • Call your doctor. Your doctor can be the first step in getting help.
  • Call the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Referral Helpline at 800-662-HELP (4357) for general information on mental health and to find local treatment services.
  • Visit the SAMHSA website, which has a Behavioral Health Treatment Services Locator that can search for treatment information by address, city, or ZIP code.
  • Seek immediate help from a doctor or the nearest hospital emergency room, or call 911, if you or someone you know is in crisis or considering suicide.

Call the toll-free National Suicide Prevention Lifeline at 800-273-TALK (8255), available 24 hours a day, seven days a week. This service is available to everyone. The deaf and hard of hearing can contact the Lifeline via TTY at 800-799-4889. All calls are free and confidential. Contact social media outlets directly if you are concerned about a friend’s social media updates, or dial 911 in an emergency.

Coping With Bipolar Disorder

Living with bipolar disorder can be challenging, but there are ways to help make it easier for yourself, a friend, or a loved one.

  • Get treatment and stick with it—recovery takes time and it’s not easy. But treatment is the best way to start feeling better.
  • Keep medical and therapy appointments, and talk with the provider about treatment options.
  • Take all medicines as directed.
  • Structure activities: keep a routine for eating and sleeping, and make sure to get enough sleep and exercise.
  • Learn to recognize your mood swings.
  • Ask for help when trying to stick with your treatment.
  • Be patient; improvement takes time. Social support helps.

Remember, bipolar disorder is a lifelong illness, but long-term, ongoing treatment can help control symptoms and enable you to live a healthy life.

How is NIMH addressing bipolar disorder?

The National Institute of Mental Health (NIMH) conducts and supports research on bipolar disorder that increases our understanding of its causes and helps develop new treatments. Researchers continue to study genetics and bipolar disorder, brain function, and symptoms in children and teens who have bipolar disorder, as well as family history in health and behavior.

Learn more about NIMH’s research priorities and current studies.

Participating in Clinical Research

Clinical research is medical research that involves people like you. People volunteer to participate in carefully conducted investigations that ultimately uncover better ways to treat, prevent, diagnose, and understand human disease. Clinical research includes trials that test new treatments and therapies as well as long-term natural history studies, which provide valuable information about how disease and health progress.

Please Note: Decisions about participating in a clinical trial and determining which ones are best suited for you are best made in collaboration with your licensed health professional.

Join a Study

NIMH researchers conduct studies in a wide range of areas related to the brain and mental disorders. The studies usually take place at the NIH Clinical Center in Bethesda, MD, and may require regular visits. After the initial phone interview, you will come to an appointment at the clinic and meet with a clinician. Visit www.nimh.nih.gov/health/trials/index.shtml or www.nimh.nih.gov/joinastudy for more information.

To find a clinical trial near you, you can visit www.clinicaltrials.gov. This website is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov gives you information about a trial’s purpose, who may participate, locations, and phone numbers for more details. This information should be used in conjunction with advice from health professionals.

Talk to your doctor about clinical trials, their benefits and risks, and whether one is right for you. Learn more about clinical trials by visiting the following websites:

  • NIMH’s Clinical Research Trials and You: Questions and Answers (also available in print)
  • NIMH’s Join a Study webpage
  • National Institutes of Health (NIH) Clinical Research Trials and You

Through clinical trials, researchers are making discoveries that can be used in everyday practice to help people.

Finding Help

Mental Health Treatment Locator

The Substance Abuse and Mental Health Services Administration provides this online resource for locating mental health treatment facilities and programs. The Mental Health Treatment Locator section of the Behavioral Health Treatment Services Locator lists facilities providing mental health services to persons with mental illness. Find a facility in your state at https://findtreatment.samhsa.gov. For additional resources, visit www.nimh.nih.gov/findhelp.

Questions to Ask Your Doctor

Asking questions and providing information to your doctorealth care provider can improve your care. Talking with your doctor builds trust and leads to better results, quality, safety, and satisfaction. Visit the Agency for Healthcare Research and Quality website for tips.

Reprints

This publication is in the public domain and may be reproduced or copied without permission from NIMH. Citation of NIMH as a source is appreciated. We encourage you to reproduce this publication and use it in your efforts to improve public health. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to follow these guidelines:

  • NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
  • NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of providing such information.
  • NIMH requests that non-federal organizations do not alter our publications in ways that will jeopardize the integrity and “brand” when using the publication.
  • The addition of non-federal government logos and website links may not have the appearance of NIMH endorsement of any specific commercial products or services, or medical treatments or services.
  • Images pictured in NIMH publications are of models and are used for illustrative purposes only. Use of some images is restricted.

If you have questions regarding these guidelines and the use of NIMH publications, please contact the NIMH Information Resource Center at 866‑615‑6464 or email [email protected]

For More Information

NIMH website

MedlinePlus (National Library of Medicine)
https://medlineplus.gov
(En español: https://medlineplus.gov/spanish)

ClinicalTrials.gov
www.clinicaltrials.gov
(En español: https://salud.nih.gov/investigacion-clinica)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 19-MH-8088
Revised October 2018

Q: What’s the difference between bipolar disorder and cyclothymia?
A: The difference between the two is a matter of degree. Cyclothymia is a milder version of bipolar disorder.
There are no sharp lines dividing the different categories of mood disorders. These labels are a starting point for understanding a person’s problem.
When trying to diagnose a person, mental health professionals consider a short list of probable or possible problems. This creates a framework for treatment. Refining the diagnosis is a gradual process. As the patient and doctor learn more about the problem, they modify the treatment based on what helps and what doesn’t.
Here are short definitions for bipolar disorder and cyclothymia:
BIPOLAR DISORDER. Doctors make this diagnosis if a person has had at least one manic or mixed episode. This is a period (of at least one week) when the person is in a high, expansive, or elated mood. People with bipolar disorder often also have episodes of depression. Sometimes these are severe enough to be called “major depression.”
Think of a manic episode as the polar opposite of a major depressive episode. A person in a manic state feels energetic and active, has little need for sleep, and may behave recklessly and be overly optimistic. In a mixed episode, symptoms of both depression and mania alternate. Sometimes the symptoms overlap in confusing ways.
CYCLOTHYMIA. This is a less intense but often longer lasting version of bipolar disorder. A person with cyclothymia has both high and low mood, but never as severe as either mania or major depression. To make this diagnosis, the person usually has symptoms that last for at least two years.
I would not be too concerned with these labels. The treatment for both can be very similar. A person with cyclothymia, for example, may be helped by the same mood stabilizing medications that help a person with bipolar disorder.
By the way, the reverse can also be true: Two people with the same diagnosis (whether it be bipolar disorder or cyclothymia) may receive very different treatments!
It’s confusing, I know. Fortunately, these disorders are often treated successfully with a combination of psychotherapy and medication. The key is to find a doctor who can help you with your situation without getting too hung up on the label.
(Michael Craig Miller, M.D., is an Assistant Professor of Psychiatry at Harvard Medical School and an associate physician at Beth Israel Deaconess Medical Center in Boston. Dr. Miller is the editor-in-chief of the Harvard Mental Health Letter.)
(For additional consumer health information, please visit www.health.harvard.edu.)
(c) 2008 PRESIDENT AND FELLOWS OF HARVARD COLLEGE. ALL RIGHTS RESERVED. DISTRIBUTED BY TRIBUNE MEDIA SERVICES, INC.

Cyclothymic Disorder

Treatment

Treatment for cyclothymia is similar to treatment for bipolar I disorder and bipolar II disorder. The level of treatment is dependent on the severity of symptoms.

Most people with bipolar disorder—even the most severe forms—can achieve substantial stabilization of their symptoms with proper treatment. Even in the most severe cases, bipolar disorders are highly treatable conditions. The sooner treatment begins, the greater the likelihood of reducing the severity and frequency of manic and depressive episodes. Because bipolar disorders are lifelong conditions, treatment is also lifelong and aimed not just at treating symptoms when they occur but also at preventing recurrence of symptoms. Most people with bipolar disorders can achieve substantial stabilization of their mood swings and related symptoms

The most effective treatment strategy combines medication and psychotherapy. In addition, patients are often instructed to keep a chart of daily mood symptoms, treatments, sleep patterns, and life events. Such tracking has been shown to help patients and their families to better understand and manage the illness; mood changes can often be spotted in time to prevent a full-blown episode. Even when there are no breaks in treatment, mood changes can occur and should be reported immediately to the doctor, who may make adjustments to the treatment plan.

Medications

While primary-care physicians who do not specialize in psychiatry may prescribe psychotropic medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment. Several types of medication are commonly used the treat bipolar disorders.

Mood stabilizers are generally prescribed to control manic episodes. Lithium is perhaps the best-known mood stabilizer. The first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, it is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes. Other types of mood stabilizers include the anticonvulsants lamotrigine (Lamictal), valproic acid (Depakene), divalproex sodium (Depakote), and carbemazepine (Tegretol and others). Valproate was FDA-approved in 1995 for the treatment of mania.

Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression.

Sometimes treatment with antidepressants results in mood-switching, prompting a manic or hypomanic episode or rapid cycling. Mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect against such a switch.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine are also used.

Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to possible effects of mood stabilizing medications on the developing fetus and the nursing infant. A skilled clinician can help such women weigh the benefits and risks of all available treatment options.

Antipsychotic medications are also often used to help control manic and depressive symptoms in bipolar disorder, and some help to stabilize mood as well. Antipsychotic drugs include olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) among others.

If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam or lorazepam may be helpful. However, because these medications may be habit-forming, they are best prescribed short-term. Other types of sedative medications, such as zolpidem, are sometimes used instead.

Omega-3 fatty acids found in fish oil are under study for their usefulness, alone or when added to conventional medications, for long-term treatment of bipolar disorder.

Effective management of cyclothymia may involve changes to the treatment plan at various times over the course of illness. Any changes in type or dose of medication should be made under the guidance of a psychiatrist. To avoid adverse reactions, patients should tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements they may be taking.

People with a bipolar disorder, particularly those with rapid mood cycling, often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, thyroid levels are usually carefully monitored by a physician. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

All medications have side effects. Depending on the medication, side effects may include weight gain, nausea, tremors, reduced sex drive, anxiety, hair loss, movement problems, or dry mouth. Getting the right balance of treatment benefits may require a physician-monitored adjustment in dosage or type of medication. Medication should not be changed or stopped without the psychiatrist’s guidance.

Psychotherapy

Studies have documented that several kinds of psychotherapy provided to patients and their families can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. Psychotherapeutic interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and interpersonal and social rhythm therapy (IPSRT). IPSRT emphasizes the importance of establishing stable daily patterns of sleeping and waking, as prolonged wakefulness is a known trigger for manic episodes.

A licensed psychologist, social worker, or counselor typically provides such therapies and often works in concert with the psychiatrist to monitor patient progress. Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

Psychoeducation involves teaching people with bipolar disorder about the condition and its treatment and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation is also often helpful for family members.

Family therapy helps reduce the level of family distress that may contribute to or result from the ill person’s symptoms.

Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve relationships and to regulate daily routines. Maintaining a daily routine and sleep schedule can help protect against manic episodes.

Acute treatment for mania and hypomania

  • Acute mania is considered a psychiatric emergency and requires immediate management.
  • The goal of acute treatment is resolution of mania and psychosis (if present) as well as preventing any harm to the patient or others.
  • General principles
    • Reduce external stimuli.
    • Assess for possible contributing substances (e.g., cocaine, alcohol, phencyclidine, etc.).
    • Limit access to cars, bank accounts/credit cards, cell phones, etc., because of the potential for reckless behavior.
  • Mild to moderate mania: : lithium monotherapy or atypical antipsychotics (olanzapine, quetiapine)
  • Severe mania: mood stabilizer (lithium or valproate) PLUS antipsychotic
    • If a patient doesn’t respond to medication within 1–3 weeks, continue with the antipsychotic and switch lithium to valproate or vice versa.
    • If a patient is still not responsive, switch the antipsychotic to another antipsychotic drug.
    • If a patient has refractory mania, discontinue pharmacotherapy and switch to ECT.
  • Mania/hypomania in pregnancy: typical antipsychotics (e.g., haloperidol) or ECT (if severe or refractory mania)
  • Management of agitation: rapid-acting intramuscular atypical antipsychotics (olanzapine, aripiprazole) or benzodiazepines (e.g., lorazepam)

Antipsychotics are the preferred initial therapy in agitated patients because of their rapid onset of action!

Suicidal patients require immediate management and monitoring to ensure their safety.

Long-term maintenance treatment

  • The goal of maintenance therapy is to prevent future manic episodes, reduce the risk of suicide, and improve social functioning.
  • Duration of therapy
    • Maintenance therapy is indicated following even a single manic episode.
    • Treat for at least 1 year following an acute manic episode.
    • In patients who experience 2 or more episodes, long-term or lifetime therapy should be considered.
  • Medication
    • A patient with an acute manic episode at presentation can be continued on the medication that resolved it.
    • First-line: mood stabilizers
      • Lithium
      • Valproic acid (useful for patients with renal dysfunction)
      • Lamotrigine
      • Carbamazepine
    • Refractory or severe bipolar episodes: : combination therapy with lithium; or valproic acid PLUS atypical antipsychotic (e.g., quetiapine, aripiprazole, olanzapine, risperidone)
    • Severe depression or predominantly depressive bipolar II disorder: Antidepressants may be started after initiating mood stabilizers.

In a patient with bipolar disorder, antidepressants should not be used before initiating therapy with mood stabilizers because antidepressants can precipitate a manic episode!

Lithium should not be administered to patients with renal dysfunction! An overdose may result in life-threatening lithium toxicity.

Lithium is the only maintenance drug shown to lower suicide risk.

References:

How Many Types of Bipolar Disorder Are There?

Bipolar disorder is a severe psychiatric/psychological disorder that involves specific fluctuations of:

  • Mood, which is the subjective emotional content that an individual personally experiences and can describe to others (e.g., “I feel very sad.”)
  • Affect, which are the behaviors that a person exhibits and that are used to infer internal emotional states in someone (e.g., a person who is continually crying is considered to be very sad)

Mood and affect in bipolar disorder range from depression to mania.

The eminent psychiatrist Emil Krapelin, who is considered the founding father of modern psychiatric diagnoses by many, first described a disorder known as manic-depression, which is the forerunner to the current conceptualization of what is now called bipolar disorder. For practical purposes, there is essentially no difference in the disorders associated with the diagnostic labels of manic depression or bipolar disorder; however, recent reconceptualizations of bipolar disorder and new knowledge have added information to this diagnostic category.

Bipolar Disorder in the DSM

For many years, bipolar disorder or manic-depression was characterized as a specific type of mood disorder that grouped depression and mania within the same diagnostic category. The term bipolar was used as a descriptive reference to an individual’s fluctuation between two different extreme poles of emotions: depression and manic behavior. Researchers investigating the causes and manifestations of bipolar disorder have indicated that this disorder may actually represent a sort of bridge or connection between depression and more severe psychiatric disorders like schizophrenia.

As a result of this research, the American Psychiatric Association (APA) placed bipolar disorder in its own category, separate from depression. Previously, these disorders were both listed in the category of “mood disorders.”

However, the actual diagnostic criteria associated with bipolar disorder and its subtypes essentially remain consistent with previous conceptualizations of the disorder.

In order for an individual to be diagnosed with bipolar disorder, they must meet the diagnostic criteria for mania or hypomania. The DSM–5 (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition) presents extensive formal diagnostic criteria for bipolar disorder.

In general, mania and hypomania are identified by the following features:

  • The person exhibits abnormally expansive, elevated, or irritable displays of mood/affect that are persistent and last for at least one week. If the person’s elevated mood is so severe that it forces them to be hospitalized, they need not display these for an entire week.
  • Additional signs and symptoms must also be displayed. If the individual is primarily displaying increased levels of energy or expansive mood, they must also display three of the following symptoms, whereas if they are primarily displaying irritable mood, they must display at least four of the following symptoms:
    • Inflated self-esteem or grandiosity
    • Being markedly more talkative than normal
    • A significant decrease in sleep or the need for sleep
    • Racing thoughts (this is often assessed by rapid speech patterns)
    • Extreme distractibility
    • A significant increase in goal-directed behavior, such as work-related activities or cleaning the house, or in non-goal-directed behavior, such as pacing
    • A significant increase in behavior that could be potentially dangerous or damaging, such as engaging in multiple sexual relationships, shopping binges, excessive investing, etc.
  • Mania and hypomania are differentiated by:
    • The duration of mania is at least one week where hypomania can last for four days or more.
    • Mania is associated with significant impairment in daily functioning (e.g. issues at work, school, being hospitalized, having legal issues, or issues in one’s personal relationships), whereas hypomania is not.

In addition to displaying manic or hypomanic behaviors, individuals may also display corresponding periods of depression. Depression is diagnosed when an individual displays at least five of 11 potential symptoms consistently over a two-week period. These symptoms include:

  • Feeling sad most of the day nearly every day
  • Displaying an inability to experience pleasure nearly every day
  • Sleeping excessively or not being able to sleep at all
  • Feeling guilty or worthless nearly every day
  • Issues with thinking nearly every day that include issues with concentration, attention, remembering things, making decisions, etc.
  • Significant weight loss or gain in the absence of trying to intentionally lose or gain weight
  • Feeling extremely tired or fatigued nearly every day
  • Feeling restless and irritable nearly every day
  • Moving as if in “slow motion” most of the day nearly every day
  • Excessively thinking about death, dying, or killing or hurting oneself nearly every day

The formal diagnosis of clinical depression can only be made if at least five of the formal diagnostic symptoms are met consistently over two weeks, and one of the five symptoms is either the experience of sadness nearly every day or a loss of the ability to feel pleasure nearly every day. Typically, manic or hypomanic episodes are relatively short-lived (most often extend for a week or two without formal treatment), and depressive episodes last much longer (can extend for months at a time without treatment).

Types of Bipolar Disorder

The potential number of so-called “types” of bipolar disorder depends on how one defines a “type.”

The American Psychiatric Association depicts only two major types of bipolar disorder; however, it also recognizes a number of different presentations of bipolar disorder that many might consider to be different types of bipolar disorder. These different presentations focus on some of the predominant symptoms that occur in the individual expression of bipolar disorder and are referred to in diagnostic processes as specifiers; as special presentations of symptoms that resemble bipolar disorder, but are caused by drugs or medical conditions; or represent other clinical observations that present with bipolar-like symptoms but do not meet the formal diagnostic criteria for any type of bipolar disorder.

The two major types of bipolar disorder are:

  • Bipolar I: This type of bipolar disorder is diagnosed when the person is formally diagnosed with at least one full manic episode. The individual may not have displayed any clinical depression and may have experienced past episodes of hypomania; however, whenever a full manic episode is diagnosed, the individual is automatically diagnosed with this type of bipolar disorder.
  • Bipolar II: This type of bipolar disorder is diagnosed when the individual has only displayed formal hypomanic episodes. They may or may not have displayed episodes of depression, but they have never displayed a full manic episode.

Other “types” of bipolar disorder are commonly designated as specifiers to the formal diagnosis of bipolar disorder. These specifiers are added to the diagnosis of bipolar disorder and allow for a more complete clinical description of the individual case and the symptoms being expressed in that case.

The major specifiers for bipolar disorder follow.

  • Bipolar disorder with psychotic features is diagnosed when the individual who has bipolar disorder also presents with hallucinations (seeing or hearing things that are not really there) or delusions (fixed, irrational, and dysfunctional beliefs, such as the belief that everyone is out to harm them).
  • Bipolar disorder with catatonia may be diagnosed when individuals who have bipolar disorder start remaining frozen in various poses or engage in repetitive, useless, non-goal-directed behavioral acts, such as dancing, scratching, etc. These acts are sequences of behavior that are typically relatively short in nature and repeated continually.
  • Rapid cycling results when a person experiences four or more episodes of mania, hypomania, or depression within 12 months. Again, one of these episodes must have been mania or hypomania for an initial diagnosis of bipolar disorder to be made.
  • Bipolar disorder with mixed features is diagnosed when the individual actually displays combinations of mania or hypomania in conjunction with depressive symptoms; these combinations occur at the same time.
  • Bipolar disorder with anxious distress occurs when the individual displays the symptoms of bipolar disorder and also at least two of a total of five potential symptoms of anxiety.
  • Bipolar disorder with atypical features occurs when the symptoms do not represent the typical presentation associated with the overall presentation of the disorder. For instance, most people with depression lose weight or have decreased appetite. An atypical feature of depression is weight gain or increased appetite. A person with bipolar disorder displaying these features could receive this specifier.
  • Bipolar disorder with melancholic features is diagnosed when the depressive episode is primarily concerned with an inability to experience pleasure.
  • Bipolar disorder with seasonal pattern is diagnosed when some of the symptoms of bipolar disorder can be consistently diagnosed during a specific time of year.

Two other potential categories of bipolar disorder relate to bipolar disorder-like symptoms that occur in response to the use of drugs or medications (substance/medication-induced bipolar and related disorder) or the symptoms result from some other medical condition (bipolar and related disorder due to another medical condition). For example, individuals who take large amounts of stimulant medications may exhibit alterations in mood that appear to represent formal manic episodes and depressive episodes, whereas individuals with certain types of head injuries or strokes may also display these symptoms.

Cyclothymic disorder is a longer and less intense manifestation of the symptoms that occur in bipolar disorder. Even though it is a separate diagnostic category, it is often considered by many to be a formal type of bipolar disorder, and it is listed by APA in the same overall category as other forms of bipolar disorder. This disorder consists of episodes of hypomania and depression that do not formally meet the criteria for bipolar disorder and continue for a period of two years or more.

APA recognizes several other types of bipolar disorder-like presentations that may be observed in clinical practice, but do not actually meet the formal diagnostic criteria for bipolar disorder:

  • Short-duration hypomanic episodes and major depressive episodes involve a shorter duration of hypomania as the name suggests. Hypomania typically must last at least four days, whereas in this specific condition, the hypomania may only last 2-3 days. The depression presents as normal.
  • Hypomania with insufficient symptoms and major depressive episodes occurs when the individual experiences irritability but the symptoms do not meet the full diagnostic specifications for hypomania. Depression occurs as specified.
  • Hypomanic episode without major depression occurs when the individual experiences one or more hypomanic episodes but never has experienced a clinically diagnosable or significant episode of depression.
  • Short-duration cyclothymia occurs when the individual meets the criteria for cyclothymia but has not met them consistently for 24 months.

Finally, in an effort to provide descriptive information to other clinicians and individuals who treat these disorders, the above diagnoses can sometimes be specified as either being mild, moderate, or severe in terms of their presentation. These designations are typically made based on the number of symptoms the individual formally presents with. Mild manifestations have fewer symptoms than moderate manifestations of bipolar disorder; moderate manifestations have fewer symptoms than severe manifestations of bipolar disorder.

Treatment can help many people, including those with the most severe forms of bipolar disorder. An effective treatment plan usually includes a combination of medication and psychotherapy, also called “talk therapy.”

Bipolar disorder is a lifelong illness. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of mood changes, but some people may have lingering symptoms. Long-term, continuous treatment can help people manage these symptoms.

Certain medications can help manage symptoms of bipolar disorder. Some people may need to try several different medications and work with their health care provider before finding medications that work best.

Medications generally used to treat bipolar disorder include mood stabilizers and second-generation (“atypical”) antipsychotics. Treatment plans may also include medications that target sleep or anxiety. Health care providers often prescribe antidepressant medication to treat depressive episodes in bipolar disorder, combining the antidepressant with a mood stabilizer to prevent triggering a manic episode.

People taking medication should:

  • Talk with their health care provider to understand the risks and benefits of the medication.
  • Tell their health care provider about any prescription drugs, over-the-counter medications, or supplements they are already taking.
  • Report any concerns about side effects to a health care provider right away. The health care provider may need to change the dose or try a different medication.
  • Remember that medication for bipolar disorder must be taken consistently, as prescribed, even when one is feeling well.

Avoid stopping a medication without talking to a health care provider first. Suddenly stopping a medication may lead to a “rebound” or worsening of bipolar disorder symptoms. For basic information about medications, visit NIMH’s Mental Health Medications webpage. For the most up-to-date information on medications, side effects, and warnings, visit the U.S. Food and Drug Administration (FDA) Medication Guides website.

Psychotherapy, also called “talk therapy,” can be an effective part of the treatment plan for people with bipolar disorder. Psychotherapy is a term for a variety of treatment techniques that aim to help a person identify and change troubling emotions, thoughts, and behaviors. It can provide support, education, and guidance to people with bipolar disorder and their families. Treatment may include therapies such as cognitive-behavioral therapy (CBT) and psychoeducation, which are used to treat a variety of conditions.

Treatment may also include newer therapies designed specifically for the treatment of bipolar disorder, including interpersonal and social rhythm therapy (IPSRT) and family-focused therapy. Determining whether intensive psychotherapeutic intervention at the earliest stages of bipolar disorder can prevent or limit its full-blown onset is an important area of ongoing research.

Visit NIMH’s Psychotherapies webpage to learn about the various types of psychotherapies.

Other Treatment Options

Some people may find other treatments helpful in managing their bipolar symptoms, including:

Electroconvulsive Therapy (ECT): ECT is a brain stimulation procedure that can help people get relief from severe symptoms of bipolar disorder. With modern ECT, a person usually goes through a series of treatment sessions over several weeks. ECT is delivered under general anesthesia and is safe. It can be effective in treating severe depressive and manic episodes, which occur most often when medication and psychotherapy are not effective or are not safe for a particular patient. ECT can also be effective when a rapid response is needed, as in the case of suicide risk or catatonia (a state of unresponsiveness).

More research is needed to determine the effects of other treatments, including:

Transcranial magnetic stimulation (TMS): TMS is a newer approach to brain stimulation that uses magnetic waves. It is delivered to an awake patient most days for 1 month. Research shows that TMS is helpful for many people with various subtypes of depression, but its role in the treatment of bipolar disorder is still under study.

Supplements: Although there are reports that some supplements and herbs may help, not enough research has been conducted to fully understand how these supplements may affect people with bipolar disorder.

It is important for a health care provider to know about all prescription drugs, over-the-counter medications, and supplements a patient is taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.

Beyond Treatment: Things You Can Do

Regular Exercise: Regular aerobic exercise, such as jogging, brisk walking, swimming, or bicycling, helps with depression and anxiety, promotes better sleep, and is healthy for your heart and brain. There is also some evidence that anaerobic exercise such as weightlifting, yoga, and Pilates can be helpful. Check with your health care provider before you start a new exercise regimen.

Keeping a Life Chart: Even with proper treatment, mood changes can occur. Treatment is more effective when a patient and health care provider work together and talk openly about concerns and choices. Keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and life events can help patients and health care providers track and treat bipolar disorder over time. Patients can easily share data collected via smartphone apps – including self-reports, self- ratings, and activity data – with their health care providers and therapists.

  • A family health care provider or doctor is a good resource and can be the first stop in searching for help. For tips for talking with your health care provider, see NIMH’s Taking Control of Your Mental Health: Tips for Talking with Your Health Care Provider fact sheet.
  • For general information on mental health and to find local treatment services, call the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Referral Helpline at 1-800-662-HELP (4357).
  • The SAMHSA website has a Behavioral Health Treatment Services Locator that can search for treatment information by address, city, or ZIP code.
  • Visit NIMH’s Help for Mental Illnesses webpage for more information and resources.

For Immediate Help

If you are in crisis: Call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is available to everyone. All calls are confidential. Contact social media outlets directly if you are concerned about a friend’s social media updates or dial 911 in an emergency.

If you are thinking about harming yourself or thinking about suicide:

  • Tell someone who can help right away.
  • Call your licensed mental health professional if you are already working with one.
  • Call your doctor or health care provider.
  • Go to the nearest hospital emergency department or call 911.

If a loved one is considering suicide:

  • Do not leave him or her alone.
  • Try to get your loved one to seek immediate help from a doctor, health care provider, or the nearest hospital emergency room or call 911.
  • Remove access to firearms or other potential tools for suicide, including medications.

Coping with Bipolar Disorder

Living with bipolar disorder can be challenging, but there are ways to help make it easier for yourself, a friend, or a loved one.

  • Get treatment and stick with it—recovery takes time and it’s not easy. But treatment is the best way to start feeling better.
  • Keep medical and therapy appointments and talk with the provider about treatment options.
  • Take all medicines as directed.
  • Structure activities: keep a routine for eating and sleeping, and make sure to get enough sleep and exercise.
  • Learn to recognize your mood swings and warning signs, such as decreased sleep.
  • Ask for help when trying to stick with your treatment.
  • Be patient; improvement takes time. Social support helps.
  • Avoid misuse of alcohol and drugs.

Remember: Bipolar disorder is a lifelong illness, but long-term, ongoing treatment can help control symptoms and enable you to live a healthy life.

What is bipolar disorder?

Bipolar disorder is when people experience serious extremes of mood, to the point where their moods interfere with their daily life. If you have bipolar disorder, your mood is likely to go through extreme highs (known as mania or hypomania) and lows (known as depression). However, what you experience during each mood, and how quickly or slowly you move between high and low moods, is different for everyone. There are also different types of bipolar disorder.

People with bipolar disorder can experience moods that don’t necessarily make sense in the context of what’s going on around them. The moods can be very disruptive and make it difficult to function in day-to-day life.

When you’re experiencing a high or low mood with bipolar disorder, one specific mood extreme can last for weeks or even months.

What are the signs and symptoms?

Someone with bipolar disorder will experience mood changes ranging between manic and depressive episodes.

It’s also common to feel or experience:

  • high self-esteem
  • increased energy
  • a reduced need for sleep
  • an increase in goal-directed behaviour (e.g. staying up all night to get something done)
  • racing thoughts
  • irritability
  • agitation
  • increased sexual activity
  • excessive spending.

During a manic episode, people can also become out of control, feel very anxious, and become frustrated and angry. They can become reckless without realising it, engage in dangerous behaviour and take huge risks. Mania can also cause psychotic thoughts and actions.

When experiencing a depressed episode, it’s common to feel or experience:

  • loss of interest in activities
  • changes in appetite
  • weight loss or gain
  • changes in sleeping patterns
  • a loss of energy
  • difficulties with concentration
  • feelings of worthlessness or guilt.

Bipolar disorder is caused by a combination of things, including your genes, and it can be brought on by stress, certain brain chemicals and/or your environment. However, significant use of alcohol and other drugs may trigger symptoms of the disorder or worsen existing symptoms.

People with bipolar disorder are more likely to engage in risky behaviour such as drinking heavily or taking drugs. It’s also been known for people with bipolar disorder to self-medicate and to try and regulate their extreme moods using drugs or alcohol.

What are the different types of bipolar disorder?

There are several different types of bipolar disorder, and the type you’re diagnosed with often depends on your individual experience of mood changes, including how quickly your mood changes.

  • Bipolar I. People with bipolar I usually experience extreme highs (mania) that may be long-lasting, plus depressive episodes, and possibly psychotic episodes.
  • Bipolar II. People with bipolar II usually experience highs that are less extreme than mania (called hypomania) and only last for a few hours or days. They also have depressive episodes. Between extreme moods, they might have times when their mood is relatively normal.
  • Cyclothymic disorder. A milder form of bipolar in which moods are not as extreme.
  • Bipolar disorder otherwise not specified. The mood changes that are experienced by people with bipolar disorder are different for everyone; this diagnosis is for those people who don’t fit into the above three categories.

What to do if this sounds like you?

Bipolar disorder can only be diagnosed by your GP or mental health professional. Medication is usually a large part of a successful treatment plan for bipolar disorder, in conjunction with other treatments such as therapy and self-help strategies. Often a diagnosis of bipolar disorder takes time, as your moods will need to be monitored over a period of weeks or months. If you can relate to some of the signs and symptoms described above, make sure you seek help. The good news is that bipolar disorder can be managed with the right treatment and support.

Hotline Information

There are several kinds of bipolar disorder. Each kind is defined by the length, frequency and pattern of episodes of mania and depression.

Bipolar I Disorder

Bipolar I is characterized by one or more manic episodes or mixed episodes (which is when you experience symptoms of both a mania and a depression). Typically a person will experience periods of depression as well. Bipolar I disorder is marked by extreme manic episodes.

Bipolar II Disorder

Bipolar II disorder is diagnosed after one or more major depressive episodes and at least one episode of hypomania, with possible periods of level mood between episodes.

The highs in bipolar II, called hypomanias, are not as high as those in bipolar I (manias). Bipolar II disorder is sometimes misdiagnosed as major depression if hypomanic episodes go unrecognized or unreported. If you have recurring depressions that go away periodically and then return, ask yourself if you have also:

  • Had periods (lasting four or more days) when your mood was especially or abnormally energetic or irritable?
  • Were you:
    • Feeling abnormally self-confident or social?
    • Needing less sleep or more energetic?
    • Unusually talkative or hyper?
    • Irritable or quick to anger?
    • Thinking faster than usual?
    • More easily distracted/having trouble concentrating?
    • More goal-directed or productive at work, school or home?
    • More involved in pleasurable activities, such as spending or sex?
  • Did you feel or did others say that you were doing or saying things that were unusual, abnormal or not like your usual self?

If so, talk to your health care provider about these energetic episodes, and find out if they might be hypomania. Getting a correct diagnosis of bipolar II disorder can help you find treatment that may also help lift your depression.

Not Otherwise Specified (NOS)

Bipolar disorder that does not follow a particular pattern (for example, re-occuring hypomanic episodes without depressive symptoms, or very rapid swings between some symptoms of mania and some symptoms of depression) is called bipolar disorder Not Otherwise Specified (NOS).

Cyclothymia

Cyclothymia is a milder form of bipolar disorder characterized by several hypomanic episodes and less severe episodes of depression that alternate for at least two years. The severity of this illness may change over time.

Rapid Cycling

Bipolar disorder with rapid cycling is diagnosed when a person experiences four or more manic, hypomanic, or depressive episodes in any 12-month period. Rapid cycling can occur with any type of bipolar disorder, and may be a temporary condition for some people.

Diagnosis

DBSA has found that nearly 7 of every 10 people with bipolar disorder are misdiagnosed at least once, and that the average length of time from a person’s first bipolar symptoms to correct diagnosis and treatment is 10 years. One of the reasons for this is that many people don’t report all of their symptoms. It is important for people to share all symptoms, even those not present during a health care appointment, as well as their family history to help health care providers make a correct diagnosis.

Sometimes symptoms of hypomania (a milder form of mania) are mistaken for “a really good day.” Many people don’t report symptoms of mania or hypomania because they feel good and it often doesn’t feel like an illness.

What is the difference between bipolar disorder and ordinary mood swings?

The three main things that make bipolar disorder different from ordinary mood swings are:

  • Intensity: Mood swings that come with bipolar disorder are usually more severe than ordinary mood swings.
  • Length: A bad mood is usually gone in a few days but mania or depression can last weeks or months. With rapid cycling, moods last a short time but change quickly from one extreme to another. With rapid cycling, “level” (euthymic) moods do not last long.
  • Interference with life: The extremes in mood that come with bipolar disorder can severely disrupt your life. For example, depression can make a person unable to get out of bed or go to work or mania can cause a person to go for days without sleep.

For more detailed information on the types of bipolar disorder and their symptoms, read the Mood Disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which may be available at your local library.

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *