Someone diagnosed with bipolar mood disorder (also known as manic depression) may have periods where their mood goes from (deep) depression to periods of overactive, excited behaviour known as mania " target="_blank">bipolar mania or hypomania. Bipolar depression is one of these phases or episodes.

NB. The first UK national Bipolar Awareness Day is on Wednesday 27 June 2012 and is being developed and led by Bipolar UK, Bipolar Scotland and Royal College of Psychiatrists. It will be focusing on the challenges of diagnosing bipolar from both a professional and service user perspective.  The key messages on the Bipolar Awareness Day will be driven by the results from two on-line surveys - one for service users including family members/carers and the other for medical professionals - now available on the Bipolar UK website http://www.bipolaruk.org.uk/surveys/. Please have a go at answering the questions and it will only take a minute or two.

^{Updated 5.12}

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Bipolar depression is the depressed part of having a bipolar disorder. It tends to last longer than "ordinary" (or unipolar) depression and is much more difficult to treat. Any substance misuse can also makes it worse.

Use of some antidepressants (particularly tricyclics or venlafaxine) might switch people to manic phases. Changes in doses should be gradual not sudden. Newer data seems to suggest that antidepressants may help in the short-term but may be less helpful in the long-term. Use of antidepressants with a mood stabiliser is much better.

Some of the symptoms include:

• decreased energy

• fatigue

• sleeping badly

• lethargy (lacking energy)

• doing less

• poor sleep (too much or too little)

• loss of interest in things that used to be enjoyable

• Feelings of wanting to self-harm.

^{Reviewed 3.13}

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of bipolar depression. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the symptoms need to be treated anyway, no matter what causes them.

• Depression (unipolar) - commonly confused early on when bipolar hasn't fully shown e.g. there have been no major highs or manias by that time. GPs are more likely to miss the diagnosis (Øiesvold 2102). Depression is more likely to be due to Bipolar Mood disorders in someone who has had more depressive episodes, it starts at an earlier age, has lots of anxiety symptoms, and suicide attempts. Unipolar depression is more likely to be the cause in people with agitation, suicidal ideation and irritability ^{[Schaffer 2010]}
• See also bipolar mood disorder

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• See also bipolar mood disorder

^{Updated 9.12}

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You can obviously only get bipolar depression if you have bipolar mood disorder (manic depression). However, there are some "risk factors" that make it more likely that someone will get bipolar depression. This is not a complete list but some of the main ones include:

• Having bipolar mood disorder (of course)
• Stopping a mood stabiliser suddenly, especially lithium
• Change in Circadian rhythm e.g. jet-lag, shift work, staying up too late

^{Updated 11.11}

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The list here includes most of the main options for bipolar depression but does not really say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Self help

• Relaxation (e.g. using relaxation tapes and breathing exercises)
• Taking any medicines regularly and reliably
• Eating healthily and taking exercise (“exercise to energise”) or being active
• Putting help from others into practice regularly

Help from others

• Talking therapies e.g. psychotherapy and cognitive behavioural therapy (CBT) – these may be better saved if medicines haven’t worked or if the symptoms are particularly bad
• Reassurances e.g. support, help with problems
• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (click for a review of the 25 studies in mental health by Davidson 2011) (treating like with like) can be used with (but not usually instead of) conventional treatments. Acupuncture is used a lot in many countries and may help anxiety, stress and insomnia. The evidence for these treatments is not very good, especially in bipolar depression. All of these can usually be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines  

• Medicines such as mood stabilisers, quetiapine, antipsychotics or neuroleptics, antidepressants and lamotrigine.

  ^{Reviewed 4.13}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your county)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options in UK are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines

BNF Listed

• Quetiapine, which is licensed specifically for treating acute bipolar depression and for preventing it come back

• Lamotrigine - may be very helpful for some people with bipolar depression, although it is most effective in stopping it returning rather than for actually treating the depression (not least because you have to start it slowly)

Others:

• Antidepressants (see depression) such as the tricyclics, SSRIs, venlafaxine, mirtazapine, may be useful in the short-term. These should mainly be used with a mood stabiliser or they might make "rapid-cycling" and switching to mania or hypomania more likely and can lead to an unstable mood if taken for a long time (Strejilevich, 2011)

• Mood stabilisers (such as lithium, valproate  and carbamazepine) - these are usually better at helping manage mania and prevent relapse to mania but are useful if taken with antidepressants to stop the person being "switched" to going high

• Antimanic agents such as olanzapine although this probably doesn't help bipolar depression

• Other antidepressants - should usually be used with mood stabilisers or antipsychotics/antimanic agents.

There are many medicines in this section, mainly because it is very difficult and expensive to get a license for bipolar depression. Some others have also been tried e.g. Omega-3 fatty acids, which have some good evidence for an effect (Sarris, 2011).

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Download a handy summary chart (PDF format) comparing the main medications for bipolar depression e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

^{Updated 5.12}

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

Bipolar depression is a long-term condition and if it becomes uncontrolled it can have harmful outcomes for the person and their family.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

^{Reviewed 4.13}

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Once you have improved, antidepressants taken for depression should usually be stopped after about six months or so. This helps make sure they don't make you become high or manic. You should usually be taking one of the mood stabilisers as well, and the mood stabiliser should probably be carried on for some time after that, and probably for at least several years.

If you decide to stop, please do it gradually over at least a month or two. You’ve a lot to lose by stopping too quickly and not a lot to lose by taking those few months to stop and not destabilise yourself.

^{Reviewed 4.13}

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, and try to manage the side effects (see the side effects question for each medicine for some ideas on how to reduce or cope with side effects).

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

• Quetiapine – studies show a significant effect in about six weeks. So, if you have no effect after taking 300mg a day for 6 weeks, it probably isn't going to help much

• Lamotrigine – it is not clear how long before you know if it has worked but probably it needs at least about 4-8 weeks at the full dose. Remember that you will need to increase the dose slowly to reduce your risk of getting a (rare but nasty and potentially dangerous) skin rash. Also, if you stop for more than 5 days you should start with a low dose and build up slowly again.

• Antidepressants - generally if antidepressants are effective, it is perhaps at about the same speed as for “unipolar” depression (i.e. depression in someone without bipolar mood disorder), or a bit slower. So, maybe give them 8 weeks before considering a change.

  ^{Reviewed 4.13}

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Antidepressants can be useful for acute depression and for a few months afterwards to prevent it coming back. However, these are probably not a good thing longer-term so mood stabilisers such as lithium or lamotrigine should be taken with the antidepressant to start with and continued afterwards.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the bipolar guidelines, which are being revised and may be available later in 2013 or early 2014)

• Scottish Intercollegiate Guidelines Network (SIGN) where there are guidelines for the Management of Bipolar Affective Disorder (July 2005)

• Northern Ireland  (no guidelines available)

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Reviewed 4.13}

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The resources below provide more information about bipolar depression. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

If you want a more in-depth read, you could no better than visit the BAP (British Association for Psychopharmacology) public web pages, where there are some fairly scientific articles, including about bipolar disorder so click here to get there.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

The British Association for Psychopharmacology has a BAP public area, which has loads of interesting articles, some mentioning bipolar disorder.

The Big White Wall is a 16+ safe, anonymous web-based service for people experiencing emotional or psychological distress provided entirely online. Professionally staffed 24/7 it offers a wide range of services for improving mental wellbeing including tests, peer support, individual and group therapies, articles, tips and creative self expression. Simply click on the link to learn more, or to join for £2.00 a week.

^{Updated 12.12}

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