Bipolar mood disorder (also known as manic-depression) is where the person suffers from periods of being high (mania or hypomania) or low (depression). There are also times when mood is fairly normal. Mania or hypomania is almost always part of a bipolar mood disorder. Mania can be a seriously harmful, and hypomania is the less severe form of mania.

Someone with mania will be elated, over-confident and full of energy, 'on top of the world' but also can get frustrated and irritable. They may sleep very little, talk very fast, and do things impulsively that are out of character e.g. spend lots of money, be sexually disinhibited. These mood swings can be very unpleasant and destructive.

Medication can be used to treat mania once it has started, or to prevent it from starting.

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.

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Hypomania is the more common and less severe form of mania. Mania or hypomania are nearly always part of a bipolar mood disorder. The symptoms include:

• elated mood, alternating with irritability (the person gets frustrated very easily)

• lots of energy

• may be overactive and be intrusive

• poor concentration

• flight of ideas (rapid changing of the subject, but with some obscure connections)

• lack of sleep or need for sleep.

There can be an obsessive preoccupation with some thought, idea, plan or desire. The person will appear high and full of energy, but with a changeable mood (can be irritable or angry), have a bright or untidy appearance, not need much sleep, not realise they are a bit high, and may spend money on things they don't need.

Mania can threaten the person's life as they may become completely exhausted but still keep on going.

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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 mania. 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 mania needs to be treated anyway, no matter what causes it.

• Schizophrenia - which has less improvement or normality between episodes

• Schizoaffective - having both bipolar disorder and schizophrenia

• ADHD (Attention Deficit Hyperactivity Disorder) - where hyperactivity, distractibility and irritability can seem like mania

• Organic causes e.g. brain tumours

• Dementia or delirium - tends to have brain changes as well

• Unipolar mania - mania with no depression, which is probably very rare indeed

• Prescribed medicine-induced e.g. antidepressants (especially if not used with a mood stabiliser), some anticonvulsants, and steroids

• Seasonal Affective Disorder causing mania

• See also bipolar mood disorder

Although it is quite possible to have both bipolar mood disorder and other illnesses, mania can be life-threatening (due to physical exhaustion), so it needs to be treated. Any other problems are secondary.

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

• Bipolar mood disorder (obviously)
• Sudden stopping of lithium
• Being on an antidepressant without a mood stabiliser if bipolar I (although this is still not proven and not everyone thinks it is true) (Proudfoot, 2010)
• Having ECT for depression
• Spring and summer (Proudfoot, 2010)
• "Goal attainment events"  (Proudfoot, 2010)
• Disrupted Circadian rhythms, such as shift-working, flying to a different time zone  (Proudfoot, 2010)
• Some medications (see next question)

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The list here includes most of the main options but does not 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. 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).

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

• Avoiding risks e.g. not getting too tired by trying to get regular sleep, not taking antidepressants longer than needed, not abusing or taking excess alcohol or other drugs
• Taking any medicines regularly and reliably

Help from others

• Stopping the person accidentally harming themselves or others is also vital
• Noticing the warning signs of someone going high and getting treatment early - going a bit high can be highly pleasurable for the person, but the problems come when it goes too far
• Talking therapies have not been shown to be particularly helpful (for obvious reasons) but trying to calm the person is very helpful

Medicines

• Medicines such as antimanic medicines, often in combination with mood stabilisers, are the main treatment. Sleeping tablets can have very useful role. It is also important to stop any antidepressants in case they are causing the mania.

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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 area)
• 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 in "BNF" 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:

• Carbamazepine (Tegretol ®) - not often used in the UK for mania

• Lithium - difficult to use in acute mania so it is not often used for mania, although it is good at preventing it coming back

• Olanzapine  - can be sedative to start with, can be given by injection and can prevent relapse

• Quetiapine (Seroquel ® and Seroquel XL ®) - this is sedative to start with, and the dose can be built up over 2 days with the XL tablets

• Risperidone - dose has to be built up over a few days, and it may help reduce relapse

• Aripiprazole (Abilify®)

• Other antipsychotics  (such as haloperidol)

• Valproate semisodium (Depakote ®) - can be used at a higher dose to start with and can help prevent relapse

• Asenapine (Sycrest® or Saphris®) - is available in many countries but not launched in UK yet

• Benzodiazepines (such as lorazepam, clonazepam and diazepam) - can be used in combination with other medicines as sedatives and calming agents over the first few weeks

Others:

• Hypnotics (such as those below) to try to help the person sleep and becoming too exhausted e.g. the Benzodiazepines (such as flunitrazepam, flurazepam, loprazolam, lormetazepam, nitrazepam and temazepam or the 'Z' hypnotics (such as zaleplon, zolpidem and zopiclone).

Sometimes the symptoms of mania or hypomania can become very severe. This can result in the person becoming very distressed and too difficult to cope with and needs to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

Many medicines have been tried but not all have been successful e.g. Omega-3 fatty acids (an analysis of 5 studies showed no effect; Sarris 2011)

Updated 5.12  

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

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

Since mania can be life-threatening, medicines are vital to help the person and avoid harm. Psychological therapies are usually not very helpful if someone is manic or hypomanic, although they can be very useful when the person is no longer manic or hypomanic.  

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

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Most of the antimanic medication (except the benzodiazepines) may also help prevent relapse so you might want to take it for at least 6-12 months to get yourself stable.

Whatever you do, if you decide to stop, please do it gradually over at least several weeks or months. You’ve a lot to lose by stopping too quickly and not a lot to lose by taking those few months and not destabilise you.

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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, manage side effects etc.

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).

Most people start to get an effect from medication in the first few days or week. With an antimanic, about 1 in 2 people stop being manic in 3 weeks, and 3 in 4 people after 12 weeks. If an antimanic medicine is combined with a mood stabiliser then about 3 in 4 people will respond at 3 weeks and 9 in 10 people after 12 weeks. Sometimes higher doses (loading doses) are used at the start (eg with valproate and antipsychotics), which can speed the recovery.

• Carbamazepine – most trials show an effect in three weeks

• Lithium – most trials show an effect in a couple of weeks, but stopping too soon might make things worse and increase the risk of relapse. It is also difficult to get the dose right.  

• Olanzapine, aripiprazole, asenapine and risperidone – generally these have an effect in the first week or so

• Quetiapine - this seems to be effective at 400-800mg/d after 4 days (Cutler 2011)

• Valproate – again within first week or so, especially if high starting doses are used

• Benzodiazepines - these are very reliable for mania and if they are not working, then a higher dose will almost always help within a few days.

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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.

In bipolar mania, combinations of different types of medicine are usually best until the person settles. A mood stabiliser and an antimanic are much better than one by itself, and shorten the time until the person is well again.

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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 their own 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, including mania, published 2006). These are to be reviewed soon, with a new set of guidelines due in 2012 or 2013.

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

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).

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The resources below provide specialist information on mania or hypomania. 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

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