There is a tendency to romanticize bipolar
disorder. Many artists, musicians, and writers have suffered from its mood
swings. But in truth, many lives are ruined by this disease; and without
effective treatment, the illness is associated with an increased risk of
suicide.1
Bipolar disorder, also known as manic-depressive illness, is a serious brain
disease that causes extreme shifts in mood, energy, and functioning. It affects
approximately 2.3 million adult Americans—about 1.2 percent of the population.2
Men and women are equally likely to develop this disabling illness. The disorder
typically emerges in adolescence or early adulthood, but in some cases appears
in childhood.3 Cycles, or episodes, of depression, mania, or "mixed" manic and
depressive symptoms typically recur and may become more frequent, often
disrupting work, school, family, and social life.
Depression: Symptoms include a persistent sad mood; loss of interest or pleasure
in activities that were once enjoyed; significant change in appetite or body
weight; difficulty sleeping or oversleeping; physical slowing or agitation; loss
of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking
or concentrating; and recurrent thoughts of death or suicide.
Mania: Abnormally and persistently elevated (high) mood or irritability
accompanied by at least three of the following symptoms: overly-inflated
self-esteem; decreased need for sleep; increased talkativeness; racing thoughts;
distractibility; increased goal-directed activity such as shopping; physical
agitation; and excessive involvement in risky behaviors or activities.
"Mixed" state: Symptoms of mania and depression are present at the same time.
The symptom picture frequently includes agitation, trouble sleeping, significant
change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies
manic activation.
Especially early in the course of illness, the episodes may be separated by
periods of wellness during which a person suffers few to no symptoms. When four
or more episodes of illness occur within a 12-month period, the person is said
to have bipolar disorder with rapid cycling. Bipolar disorder is often
complicated by co-occurring alcohol or substance abuse.4
Severe depression or mania may be accompanied by symptoms of psychosis. These
symptoms include: hallucinations (hearing, seeing, or otherwise sensing the
presence of stimuli that are not there) and delusions (false personal beliefs
that are not subject to reason or contradictory evidence and are not explained
by a person's cultural concepts). Psychotic symptoms associated with bipolar
typically reflect the extreme mood state at the time.
Treatments
A variety of medications are used to treat bipolar disorder.5 But even with
optimal medication treatment, many people with the illness have some residual
symptoms. Certain types of psychotherapy or psychosocial interventions, in
combination with medication, often can provide additional benefit. These include
cognitive-behavioral therapy, interpersonal and social rhythm therapy, family
therapy, and psychoeducation.6,7
Lithium has long been used as a first-line treatment for bipolar disorder.
Approved for the treatment of acute mania in 1970 by the U.S. Food and Drug
Administration (FDA), lithium has been an effective mood-stabilizing medication
for many people with bipolar disorder.
Anticonvulsant medications, particularly valproate and carbamazepine, have been
used as alternatives to lithium in many cases. Valproate was FDA approved for
the treatment of acute mania in 1995. Newer anticonvulsant medications,
including lamotrigine, gabapentin, and topiramate, are being studied to
determine their efficacy as mood stabilizers in bipolar disorder. Some research
suggests that different combinations of lithium and anticonvulsants may be
helpful.
According to studies conducted in Finland in patients with epilepsy, valproate
may increase testosterone levels in teenage girls and produce polycystic ovary
syndrome in women who began taking the medication before age 20.8 Increased
testosterone can lead to polycystic ovary syndrome with irregular or absent
menses, obesity, and abnormal growth of hair. Therefore, young female patients
taking valproate should be monitored carefully by a physician.
During a depressive episode, people with bipolar disorder commonly require
additional treatment with antidepressant medication. Typically, lithium or
anticonvulsant mood stabilizers are prescribed along with an antidepressant to
protect against a switch into mania or rapid cycling. The comparative efficacy
of various antidepressants in bipolar disorder is currently being studied.
In some cases, the newer, atypical antipsychotic drugs such as clozapine or
olanzapine may help relieve severe or refractory symptoms of bipolar disorder
and prevent recurrences of mania. More research is needed to establish the
safety and efficacy of atypical antipsychotics as long-term treatments for this
disorder.
Research Findings
More than two-thirds of people with bipolar disorder have at least one close
relative with the disorder or with unipolar major depression, indicating that
the disease has a heritable component.9 Studies seeking to identify the genetic
basis of bipolar disorder indicate that susceptibility stems from multiple
genes. Scientists are continuing their search for these genes using advanced
genetic analytic methods and large samples of families affected by the illness.
The researchers are hopeful that identification of susceptibility genes for
bipolar disorder, and the brain proteins they code for, will make it possible to
develop better treatments and preventive interventions targeted at the
underlying illness process.
Researchers are using advanced imaging techniques to examine brain function and
structure in people with bipolar disorder.10,11 An important area of imaging
research focuses on identifying and characterizing networks of interconnected
nerve cells in the brain, interactions among which form the basis for normal and
abnormal behaviors. Researchers hypothesize that abnormalities in the structure
and/or function of certain brain circuits could underlie bipolar and other mood
disorders. Better understanding of the neural circuits involved in regulating
mood states will influence the development of new and better treatments, and
will ultimately aid in diagnosis.
New Clinical Trial
NIMH has initiated a large-scale study at 20 sites across the U.S. to determine
the most effective treatment strategies for people with bipolar disorder. This
study, the Systematic Treatment Enhancement Program for Bipolar Disorder
(STEP-BD), will follow patients and document their treatment outcome for 5 to 8
years. For more information, visit the Clinical Trials page of the NIMH Web
site.
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For More Information
Please visit the following link for more information about organizations that
focus on bipolar disorder.
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All material in this fact sheet is in the public domain and may be copied or
reproduced without permission from the Institute. Citation of the source is
appreciated.
NIH Publication No. 01-4595
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References
1 Brown GK, Beck AT, Steer RA, et al. Risk factors for suicide in psychiatric
outpatients: a 20-year prospective study. Journal of Consulting and Clinical
Psychology, 2000; 68(3): 371-7.
2 Narrow WE. One-year prevalence of depressive disorders among adults 18 and
over in the U.S.: NIMH ECA prospective data. Population estimates based on U.S.
Census estimated residential population age 18 and over on July 1, 1998.
Unpublished.
3 Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past
10 years. Journal of the American Academy of Child and Adolescent Psychiatry,
1997; 36(9): 1168-76.
4 Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic
Catchment Area Study. New York: The Free Press, 1991.
5 Sachs GS, Printz DJ, Kahn DA, et al. The expert consensus guideline series:
medication treatment of bipolar disorder 2000. Postgraduate Medicine, 2000; Spec
No: 1-104.
6 American Psychiatric Association. Practice guideline for the treatment of
patients with bipolar disorder. American Journal of Psychiatry, 1994; 151(12
Suppl): 1-36.
7 Frank E, Hlastala S, Ritenour A, et al. Inducing lifestyle regularity in
recovering bipolar disorder patients: results from the maintenance therapies in
bipolar disorder protocol. Biological Psychiatry, 1997; 41(12): 1165-73.
8 Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism
during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999;
45(4): 444-50.
9 NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No.
98-4268. Rockville, MD: National Institute of Mental Health, 1998.
10 Soares JC, Mann JJ. The anatomy of mood disorders-review of structural
neuroimaging studies. Biological Psychiatry, 1997; 41(1): 86-106.
11 Soares JC, Mann JJ. The functional neuroanatomy of mood disorders. Journal of
Psychiatric Research, 1997; 31(4): 393-432.
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