Article updated and reviewed by Christos Ballas, MD, Attenting Psychiatrist, Inpatient and Consult/Liaison Psychiatry, Hospital of the University of Pennsylvania on April 11, 2005.
There are two basic mood disorder categories are unipolar and bipolar.
Bipolar disorder is a disorder characterized by extreme shifts in mood, energy, and functioning. About one percent of the population in any given year suffers from this disorder. Bipolar disorder (also called manic-depressive illness) is marked by periods of manic, greatly elated moods, or excited states interspersed with periods of depression.
Unipolar (i.e., no mania) depression is more common than bipolar illness, though there is some controversy about the extent to which the two disorders overlap.
Some people who experience clinical depression also have periods of euphoria, elation, sleeplessness, excessive energy, and/or excitement known as mania. Though the diagnosis formally requires only one mania per year, in actuality, patients can fluctuate from depression to mania several times a year. More than four manic episodes in a year is considered “rapid cycling bipolar disorder.”
During a euphoric, manic phase, some people go on spending sprees or stints of sexual activity, act impulsively, or display exhibitionistic behavior. Though the person may feel euphoric, they may also feel irritable or upset. This is called dysphoric mania.
The depression of bipolar disorder is indistinguishable from the unipolar varieties. The pattern of mild or severe mania in addition to depression is what may warrant the diagnosis of bipolar disorder. Many people experience a predominance of episodes of one mood over the other, with occasional shifts to the opposite state. Rare individuals experience elevated mood alone.
Rapid-cycling bipolar disorder is characterized by four or more episodes of significant mood changes within a single 12-month period. Less severe manic episodes are known as hypomania, and when these episodes are interspersed with periods of depression it is known as bipolar disorder type II.
Most scientists agree there is no single cause of bipolar. Genetic factors (involving more than one gene) are involved in the transmission of the disorder. People with a first degree relative (a parent, sibling, or child) who have the disease have a 20% higher chance of developing it themselves. The disorder is found equally in patients of varying socioeconomic backgrounds. Genetic research is continuing, as is research involving brain imaging.
Usually the illness appears suddenly (sometimes precipitated by life stresses), although onset may be gradual. Episodes of mania, which can last from days to weeks or months, are generally briefer than episodes of depression. It typically emerges in adolescence or early adulthood, but may begin in childhood. Bipolar disorder most often manifests itself between the ages of 15 – 24, with 90% of cases diagnosed by the age of 30.
Without treatment, symptoms usually become more severe, unpleasant, and disruptive, and can lead to suicide in about 15 percent of cases of note, long term treatment with lithium may substantially reduce the suicide rate.
Some people cycle either rapidly or more slowly from one mood to the other, while others experience ‘normal’ moods (mixed state) between episodes. Some people go for years without a recurrence, while others suffer from increasingly frequent episodes. As in depression, a small percentage suffer impaired mood chronically.
The diagnosis is made by a clinician based on the clinical findings, after a complete medical history and physical examination. Several types of medications, such as steroids and some antibiotic medications, may cause symptoms resembling mania. The use of illicit substances like amphetamines and cocaine may also mimic a manic phase, as can certain medical and organic causes, such as strokes or infections.
Most people with bipolar disorder, even the very severe forms, can achieve substantial stabilization of mood swings and other symptoms with the proper treatment.
To treat acute episodes of mania and depression, to reduce the cycling, and to prevent relapse, doctors often use medications known as “mood stabilizers.”
Acute mania: This may require hospitalization to protect the individual or others from impulsiveness. Lithium is generally the drug of choice to stabilize the person and is usually very effective in controlling mania and preventing new episodes. Response to lithium treatment may take several days. Several medications are approved for the treatment of acute mania, including:
Anticonvulsant drugs may also be used. These include:
Clinicians may use other medications which do not have formal FDA approval, based on available evidence and clinical experience.
Acute depression: Lithium can be a very effective treatment for the depression that occurs in bipolar disorder. To date, only the anticonvulsant lamotrigine (Lamictal) is indicated for maintenance treatment of the depression of bipolar disorder. Antidepressants are often used to treat bipolar depression, though some controversy exists as to whether these could worsen mania. These antidepressants include the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). These act specifically on serotonin, making it more available for nerve cells. Effexor and Cymbalta affect two neurotransmitters, serotonin and norepinephrine. Bupropion (Wellbutrin) affects dopamine and norepinephrine. Other antidepressants include the monoamine oxidase inhibitors (MAOIs), including phenelzine (Nardil) and tranylcypromine (Parnate), and the tricyclic antidepressants (TCAs), such as amitriptyline (Elavil).
Prevention of manic episodes: Currently, only lithium and olanzapine (Zyprexa) are indicated for the maintenance treatment of bipolar disorder. Symbyax, a combination of fluoxetine and olanzapine, is also indicated for bipolar disorder.
Lithium is the only medication shown to decrease the rate of suicide in bipolar disorder. (Clozapine (clozaril) may have anti-suicide properties as well, though it is not specifically indicated for maintenance in bipolar disorder.) However, lithium carries numerous risks. It is fatal in overdose and requires regular monitoring of blood levels to ensure safety. Chronic lithium therapy has an associated risk of kidney damage. Many patients also experience difficulties with their thyroid function with long term lithium use, therefore regular evaluation of kidney and thyroid function through blood tests is recommended. Patients taking lithium should not take non-steroidal anti-inflammatory medications such as ibuprofen, or diuretics such as hydrochlorthiazide without consulting with their doctor, as there can be serious drug interactions.
Was there a specific incident that may have caused this disorder?
What treatment do you recommend?
Will you be prescribing any medications?
What are the side effects?
Are there any side effects that I should report right away?
What testing is required while on lithium and how often is the testing required?
What if the medication is skipped?
If antidepressants are used, can they trigger a manic episode?
What signs would indicate severe, dangerous depression, such as suicide?
Are there any signs that indicate immediate contact of the medical staff?
Do you recommend family therapy?
How can the family learn ways to handle the mood swings and behavior?
Is diet important and can it affect the behavior and drugs?
Editorial review provided by VeriMed Healthcare Network.