Bipolar mood disorder (also known as manic-depression or bipolar affective disorder) 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.

Bipolar disorder is a fairly common condition with at least 1% (1 in 100 people) being diagnosed with the condition, possibly up to 5% (1 in 20 people).  Bipolar disorder can occur at any age, although it often develops in people who are between 18-24 years of age. Both men and women, and people from all backgrounds, can develop bipolar disorder.

^{Updated 3.13}

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Basically, anyone can get bipolar mood disorder. However, there are some "risk factors" that make it more likely that someone will get the symptoms of bipolar mood disorder. This is not a complete list but some of the main ones include:

• Family history and genetics - in identical twins, if one has bipolar mood disorder, 40% of the other twins will also have bipolar; whereas it is only 10% of non-identical twins. However, it is likely to be a combination of many genes, not just one

• Being male (only very slight increase over women)

• Some life events may trigger episodes e.g. trauma, physical, sexual, or emotional abuse, breakdown of a relationship, death of a family member or loved one, moving house, transatlantic flights  

^{Updated 4.13}

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Bipolar mood disorder is a potentially life-long illness. It has a strong genetic link, so if you've got it, there's a good chance a close relative also has or has had it too. It has a number of different phases e.g. bipolar mania or hypomania and bipolar depression. There are a number of medical classifications, but probably the best one is as follows:

Bipolar I (classical manic-depression)

• Includes mania and severe depression, or mania alone
• Usually starts by around the early twenties
• Occurs in about 4-16 in 1000 adults (1 in 60-250 people, according to NICE)

Bipolar II

• includes depression with at least one hypomanic episode (i.e. not as severe as "mania")
• Occurs in about 1 in 200 US adults, is slightly more common in women and slightly more common than Bipolar I
• Usually starts by around the mid-twenties

Bipolar III (Pseudounipolar Bipolar Disorder)

• Includes less severe depression that keeps coming back, and mixed states (i.e. depressed mood but with a manic drive)
• antidepressants may easily switch the person from depression to hypomania (or a mixed state)

Cyclothymic disorder

• this is defined as two years of mild hypomania and milder depression

Rapid-cycling

• four or more mood episodes of depression or hypomania in one year

This section deals with maintenance (ie long-term) treatment for bipolar mood disorder, i.e. preventing relapses. There are separate pages for bipolar mania or hypomania and bipolar depression.

^{Reviewed 4.13}

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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 mood disorder. 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, although the treatments may be different depending on the actual cause. Several studies have show that up to 7 in 10 people (70%) with bipolar get the wrong diagnosis to start with and that the correct diagnosis can take up to 10 years.

• Schizophrenia - psychotic symptoms can appear in bipolar mood disorder as well, and may share some of the same genes (about 1 in 6 people [18%] get this as the wrong diagnosis)

• Depression - unipolar depression i.e. depression with no mania. It is almost impossible to tell to start with if the depression is unipolar or bipolar (Øiesvold 2102 ) and this is the most common misdiagnosis. As the medicines to treat bipolar depression and unipolar depression are different this is an important thing to get right (about 2 in 3 people [60%] with bipolar depression get this as the wrong diagnosis)

• Substance misuse e.g. drug dependence or addiction, giving erratic behaviour, may be partially self-medication to help control e.g. manic symptoms

• ADHD (Attention Deficit Hyperactivity Disorder) can sometimes look like hypomania

• Borderline Personality Disorder - about 1 in 6 people [17%] get this as the wrong diagnosis

• Seasonal Affective Disorder

• Post-Traumatic Stress Disorder (PTSD)

• Social anxiety or phobia or other anxiety disorders - about 1 in 4 people (26%) get this as the wrong diagnosis

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.

• Alcohol dependence - sometimes to self-medicate and especially if the person has poor impulse control and is a risk-taker

• Phobias

• Panic disorder

• GAD or Generalised Anxiety Disorder

• Agoraphobia

• PTSD (Post-Traumatic Stress Disorder)

• OCD (Obsessive Compulsive Disorder)

• Eating disorders -  1 in 7 people with bipolar have an eating disorder, especially in women, with an earlier onset and more severe illness ^{(McElroy et al, 2010)}

• ADHD (Attention Deficit Hyperactivity Disorder) - a third of people (32%) with bipolar also can be diagnosed as ADHD, although this might just be similar symptoms

• Schizoaffective disorder - about 1 in 500 people can get the worst of both worlds i.e. both schizophrenia and bipolar

^{Updated 1.13}

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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.

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 the risk factors for relapse e.g. loss of sleep, change in time zone, other medicines or drugs that might make it worse, not taking medicines regularly
• Taking any medicines regularly and reliably (stopping and starting can be unhelpful to the brain)  
• Eating healthily and taking exercise  (“exercise to energise”) or being active
• Regular sleep patterns (not getting over-tired or jet-lagged)

Medicines

• Medication such as mood stabilisers are the main treatment. They include lithium carbonate, lithium citrate, valproate and carbamazepine
• Antidepressants, antipsychotics (such as quetiapine), and antimanic agents (e.g. olanzapine) are also used. Often medicines are used in combination e.g. cognitive behavioural therapy (CBT) reduces relapse when used in combination with medicines in people if they’ve only had a few episodes.
• St. John's Wort and SAMe (S-adenosyl-l-methionine) may help bipolar depression but can switch people to being high (manic) so be careful 

Help from others

• Psychological treatments i.e. talking therapies such as psychotherapy, cognitive behavioural therapy (CBT) and family therapy are very useful for some people, especially early on in treatment, when used with medicines and perhaps in people with difficult-to-treat symptoms
• Psychosocial interventions have an important part to play. They can help reduce stress and help manage symptoms
• 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 instead of) conventional treatments. There is really no evidence that acupuncture, omega-3-fatty acids, massage, aromatherapy or yoga in bipolar mood disorder.  All of these can 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).

  ^{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 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 "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

• Lithium (better at preventing relapse of mania)

• Quetiapine (known to help bipolar depression and mania, treating an acute episode and help stop it coming back)

• Carbamazepine (for people who didn’t do well on lithium)

• Olanzapine (to prevent relapse of mania in someone who got better with olanzapine when manic)

• Aripiprazole (to prevent relapse of mania in someone who got better with aripiprazole when manic)

• Valproate - to prevent mania coming back; about 1 in 6 people do better on valproate than nothing (NNT=6, Bond 2010)

• Lamotrigine - for stopping bipolar depression coming back

Others (for mood stabilisation or preventing relapse):

• Other antipsychotics (such as risperidone)

• Of course, antimanic medicines are used too for the lows and highs. Antidepressants are also used but they probably don't help much in the long-term, and going into "rapid-cycling" (more than 4 mood changes a year) is a little more likely

Others

For the main medicines for bipolar depression and bipolar mania click the links.

^{Reviewed 4.13}

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Download a handy summary chart (PDF format) comparing the main medications for bipolar mood disorder 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 1.13}

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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!

Talking therapies can be really useful for many people, especially when used with medicines. A recent analysis of the 12 studies carried out so far shows that Talking Therapies are good treatments for bipolar disorder and for stopping it coming back, when used with medicines. However, generally they are not enough for most people when used without medicines ^{(Szentagotai and David, 2010).} In people whose symptoms are difficult to manage, having psychotherapy and medicines can reduce symptoms and lead to less time in hospital ^{(Gonzalez 2010)}.

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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If you have bipolar disorder, you also have a genetic disposition (susceptability) and it is likely to be life-long. Every time you get ill it increases the chances of you getting ill another time. Medicines clearly reduce the chance of getting ill again in many people. It's a bit like a broken leg - each time it breaks the more likely it is to get broken again.

If a medicine or combination seems to be working for you, the chances of becoming ill again may be high if you stop so you might want to consider at least 5 years to get yourself stable.

Taking lithium for less than 2 years is thought to be harmful in its own right and increases the chance of relapse, so you should take it for at least 2 years, if not longer.

Whatever you do, if you decide to stop, please do it gradually over at least several 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 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, 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).

It is very difficult to come up with clear advice about how long to keep taking a mood stabiliser. Probably you would want to think about at least 6-12 months, but this would depend on how often you relapse. If you have been becoming ill every few months, then a year might probably be enough to see if it is working. If you only get ill every few years then a trial of a medicine would need to be longer. Then, what becomes important is the balance between side effects and the effect of a relapse on you and your family, friends and colleagues. Clearly if your relapses become more common or more severe then the medicine isn’t working.

If lithium isn't working (or even if it is) then stopping it quickly or even after less than 2 years is likely to make matters worse.

^{Updated 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.

Generally the aim is one drug to help prevent you becoming ill again. However, this can be difficult to do in bipolar disorder and many people need to take two (or more) to prevent a relapse. Some combinations of medicines have a logic and possible advantages. It will be an individual's decision. Finding a drug that stops both highs AND lows is difficult, and so one to help stop highs and one to stop lows may be the best option.

^{Updated 4.13}

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The resources below provide specialist information on bipolar disorder. 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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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)

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

• Northern Ireland

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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