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Bipolar disorder is a recurring psychiatric illness with often devastating symptoms of depression and mania. The disorder, which has been described in highly accomplished individuals such as Theodore Roosevelt, Robert Schumann, Vincent van Gogh, and Sylvia Plath, is highly treatable, however. Despite the chronicity of the illness, effective drugs such as lithium have enabled persons diagnosed with bipolar illness to lead productive lives.

Diagnostic Criteria

Bipolar illness has two distinct forms. Bipolar I disorder, previously called manic-depressive illness, characterizes patients who experience episodes of mania and depression or mania only. Any single episode can be manic, depressive, or mixed. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) gives specific criteria for both mania and depression. A diagnosis of mania does not require a set duration of illness or impairment. For a diagnosis of depression, however, the symptoms must last at least two weeks.

For a diagnosis of mania, the patient’s mood can be either elated or irritable. The most common symptoms are grandiosity, racing thoughts, and pressured speech. The patient is also distractible. These symptoms lead to inattention, impatience, inflated self-confidence, grand schemes, excessive spending, impulsive traveling, and reckless driving.

Bipolar I illness occurs in about 1% of the population and is equally prevalent in men and women. Women, however, are more likely to have depressive episodes.

A patient who has mainly depressions and a few hypomanic episodes (the same symptoms as for mania but without social impairment) would receive a diagnosis of bipolar II, a form much more common in women. These illnesses typically start with a depressive episode.

Thirty percent of patients who have bipolar I illness first experience symptoms as teenagers. In the usual course, episodes of illness are followed by periods of wellness (euthymia), at first punctuated by years but later settling into a pattern that’s often seasonal. The depression can become very chronic and unremitting; suicide is the most serious potential consequence. Despite new and successful treatments, about 12% of manic-depressives commit suicide, almost always during the depressive stage of the illness.

Other symptoms of bipolar disorder are delusions and hallucinations. These symptoms are often overlooked, even by psychiatrists. In patients who have mania, the delusions are consistent with their grandiose ideas and schemes but may also be paranoid. In patients with bipolar depression, delusions occur about 20% of the time (consistent with their inappropriate sense of low self-worth, low productivity, feeling of being a burden, and pessimism, e.g., the family is sinking into poverty).

Research has shown that genetic factors play a significant role in the etiology of bipolar disorder. Biochemical, neurophysiologic, and sleep abnormalities also have been reported, but none seems specific to bipolar disorder. It is not known how recurrent unipolar depression, bipolar I disorder, and bipolar II disorder are related. In addition, many studies identify bipolar patients but do not specify whether the patient is in the depressive, manic, or mixed state, much less whether the patient is manic or hypomanic when studied.

Bipolar disorder is a recurring illness. A few people are lucky enough to have only two or three episodes, but the average patient has more than 10. Studies have found that the depressive episodes in bipolar disorder are shorter than the depressive episodes in unipolar illness. Unfortunately, however, some bipolar patients have chronic depressions. Between 15% and 20% of bipolar patients experience rapid cycling, defined as four or more episodes of depression, mania, or hypomania in a year.

Related to these two distinct illnesses is cyclothymia, a condition in which patients have mood swings, but the swings are not as extreme as those in mania and depression. Another related condition is hyperthymic temperament, seen in patients who have recurrent depression. Such patients have baseline personalities that are cheerful and exuberant. They are extroverted, highly energetic, and short sleepers. Unlike the other conditions, which demand treatment, hyperthymia is associated with desirable traits and should not be treated.

Drug Treatment

Bipolar illness is underdiagnosed and undertreated. A 1999 hospital study from a university center confirmed that 40% of the bipolar patients in the study were previously diagnosed as unipolar. Only 38% were taking mood stabilizers on admission to the hospital (96% on discharge). Psychological autopsies on persons who have committed suicide show that the majority of patients who are diagnosed as bipolar are not taking any mood stabilizers.

Psychological treatment cannot be accomplished when a patient with bipolar illness is in a manic state. The patient will be highly talkative, irritating, sexually aroused, overconfident, expansive, and completely lacking in insight and good judgment. Because of the uplifted mood, the patient will feel no need for treatment and will vehemently refuse assistance. This is particularly evident with respect to a spouse. If in your practice you see a spouse who suddenly becomes extremely derogatory and accusatory toward the partner, consider the possibility of mania. A history of depressive episodes will help you make the diagnosis. Treatment, usually on an inpatient basis, is imperative for a patient with mania.

The best treatment for a manic episode is lithium, the oldest mood stabilizer. Neuroleptics also are extremely helpful for treating mania. How to treat the depression, how-ever, is still open to question. Although most experts agree that it is best to try to avoid antidepressants, or to use them short term, this is difficult to do in practice. The monoamine oxidase inhibitor tranylcypromine has been shown to be more efficacious than the tricyclic antidepressant imipramine. The other MAO drugs, phenelzine and isocarboxazid, also seem useful. Patients need to be on a special diet with these drugs. Clearly, patients do better in the treatment of their depressive episode if they also take a mood stabilizer.

In addition to treatment for the mania and depression, a mood stabilizer is indicated for long-term maintenance. A recent 40-year longitudinal study of bipolar illness found that mood stabilizers and atypical antipsychotics (in this case, mostly clozapine) proved to be the best combination to prevent suicide.

Although perhaps the best known, lithium is not the only effective mood stabilizer. Valproate is another, and a third but less often used drug for stabilizing mood is carbamazepine. These drugs can be used alone or in combination and must be monitored.

Before starting lithium, the patient needs a complete physicial, ECG, and thyroid and kidney (BUN, creatinine) tests. After stabilization, lithium levels should be monitored every six months, and thyroid levels and creatinine levels every year. Unfortunately, this drug has annoying, ongoing side effects, including acne, diarrhea, difficulty concentrating, increased urination, muscle weakness, thirst, tremors, upset stomach, and weight gain. The only long-term concern (besides low thyroid, which is easily treated), however, is kidney dysfunction. If the latter occurs, lithium must be discontinued.

Valproate has side effects that are often better tolerated than those of lithium. For that reason, more patients are now being started on valproate than on lithium. Valproate also causes the fewest side effects in long-term treatment. However, it can have life-threatening effects on bone marrow and liver.

With both carbamazepine and valproate, patients’ blood levels should be monitored, and their blood counts and liver enzymes should be checked twice a year. The usefulness of newer mood stabilizers such as lamotrigine and gabapentin, which are also new anticonvulsants, has not been clearly established.

Although patients with bipolar illness should usually be diagnosed and started on treatment by a psychiatrist, many other physicians could adequately treat the maintenance phase of this disorder, particularly if the patient has been stable for a year or more.

Pregnancy and Mood Stabilizers

In a woman who may become pregnant, lithium is the only safe mood stabilizer. Although lithium has been associated with a rare congenital malformation, the decision to discontinue or continue lithium in the event of pregnancy must be made by the patient and physician together. Both carbamazepine and valproate have teratogenic effects and should not be used by women who are trying to become pregnant or who become pregnant. It is important to be aware, however, that the sudden discontinuation of any of these mood stabilizers frequently causes a manic relapse. Discontinuation of a drug must be done gradually over a week or more.

It is also extremely important to consider using low doses of the newer atypical neuroleptics, such as risperidone, olanzapine, and clozapine. Clozapine is probably superior to the other two, but it has more serious side effects and requires frequent monitoring of white blood counts. Electroconvulsive therapy remains a treatment option for both mania and depression and may be the treatment of choice for pregnant women.


Bipolar illness frequently has its onset in the teenage years, when much of life is unfolding: completing high school, choosing a college, developing personal relationships, and separating from the family. Because of these often stressful life events, psychotherapy is probably indicated for the adolescent. No specific psychotherapy has been tested on teenagers, although all evidence indicates that behavioral therapies are effective in mild and moderate depression.

For older patients, supportive psychotherapy is indicated. It is important to give patients feedback about current symptoms, identify early symptoms of an episode, help solve problems, and repair relationships damaged by the illness. It is also important to teach patients how to control their symptoms better. For instance, because lack of sleep can precipitate an episode of mania, patients should take additional medication to stabilize their sleep when they are under stress and sleeping less. Changing the dose of a mood stabilizer during periods of stress is not as important as ensuring a good night’s sleep.

Patients can also help themselves through self-help groups. The National Depressive and Manic Depressive Association, for example, meets regularly in cities throughout the country and teaches patients how to live with their illness.

Substance Abuse and Bipolar Illness

Substance abuse is a problem in bipolar illness. About 60% of patients with this diagnosis have superimposed substance abuse at some point in their life. Therefore, the use of alcohol and illicit drugs needs to be examined and monitored. When a patient is not doing well or not responding to treatment, the physician should suspect substance abuse.

Most patients with bipolar illness (about 80%) are able to stabilize their mood and be highly productive. The others, especially those with chronic depression, are severely disabled. Still, they can live outside the hospital for long periods, especially with the help of family, friends, and a knowledgeable, sympathetic physician.

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