Bipolar disorder

Bipolar disorder affects men and women equally. It most often starts between ages 15 and 25. The exact cause is not known, but it occurs more often in relatives of people with bipolar disorder.

In most people with bipolar disorder, there is no clear cause for the periods (episodes) of extreme happiness and high activity or energy (mania) or depression and low activity or energy (depression). The following may trigger a manic episode:

• Childbirth
• Medicines, such as antidepressants or steroids
• Periods of not being able to sleep (insomnia)
• Recreational drug use

The manic phase may last from days to months. It may include these symptoms:

• Easily distracted
• Excess involvement in activities
• Little need for sleep
• Poor judgment
• Poor temper control
• Lack of self-control and reckless behavior, such as drinking or using drugs in excess, having increased and risky sex, gambling, and spending or giving away a lot of money
• Very irritable mood, racing thoughts, talking a lot, and false beliefs about self or abilities
• Rapid speech
• Concerns about things that are not true (delusions)

The depressive episode may include these symptoms:

• Daily low mood or sadness
• Problems concentrating, remembering, or making decisions
• Eating problems such as loss of appetite and weight loss or overeating and weight gain
• Fatigue or lack of energy
• Feelings of worthlessness, hopelessness, or guilt
• Loss of pleasure in activities that were once enjoyed
• Loss of self-esteem
• Thoughts of death or suicide
• Trouble getting to sleep or sleeping too much
• Pulling away from friends or activities that were once enjoyed

People with bipolar disorder are at high risk for suicide. They may use alcohol or other substances. This can make the bipolar symptoms worse and increase the risk for suicide.

Episodes of depression are more common than episodes of mania. The pattern is not the same in all people with bipolar disorder:

• Depression and mania symptoms may occur together. This is called a mixed state.
• Symptoms may also occur right after each other. This is called rapid cycling.

To diagnose bipolar disorder, your health care provider may do some or all of the following:

• Ask whether other family members have bipolar disorder
• Ask about your recent mood swings and for how long you have had them
• Perform a thorough exam and order lab tests to look for other illnesses that may be causing symptoms that resemble bipolar disorder
• Talk to family members about your symptoms and overall health
• Ask about any health problems you have and any medicines you take
• Watch your behavior and mood

The main goal of treatment is to:

• Make the episodes less frequent and severe
• Help you function well and enjoy your life at home and at work
• Prevent self-injury and suicide

MEDICINES

Medicines are a key part of treating bipolar disorder. Most often, the first medicines used are called mood stabilizers. They help you avoid mood swings and extreme changes in activity and energy levels.

With medicines, you may begin to feel better. However, for some people, symptoms of mania may feel good. Some people have side effects from the medicines. As a result, you may be tempted to stop taking your medicines or change the way you are taking them. But stopping your medicines or taking them in the wrong way can cause symptoms to come back or become much worse. Do not stop taking or change the dosages of your medicines. Talk with your provider if you have questions about your medicines.

Ask family members or friends to help you take medicines the right way. This means taking the right dose at the right time. They can also help make sure that episodes of mania and depression are treated as soon as possible.

If mood stabilizers do not help, your provider may suggest other medicines, such as antipsychotics or antidepressants.

You will need regular visits with your provider (often a psychiatrist or psychiatric nurse practitioner) to talk about your medicines and their possible side effects. Blood tests are often needed, too.

OTHER TREATMENTS

Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase if it does not respond to medicine.

People who are in the middle of a severe manic or depressive episode may need to stay in a hospital until they are stable and their behavior is under control.

SUPPORT PROGRAMS AND TALK THERAPY

Joining a support group may help you and your loved ones. Involving family members and caregivers in your treatment may help reduce the chance of symptoms returning.

Important skills you may learn at such programs include how to:

• Cope with symptoms that continue even while you are taking medicines
• Get enough sleep and stay away from recreational drugs
• Take medicines the right way and manage side effects
• Watch for the return of symptoms, and know what to do when they return
• Find out what triggers the episodes and avoid these triggers

Talk therapy with a mental health provider may be helpful for people with bipolar disorder.

Periods of depression or mania return in most people, even with treatment. People may also have issues with alcohol or drug use. They may also have problems with relationships, school, work, and finances.

Suicide is a very real risk during both mania and depression. People with bipolar disorder who think or talk about suicide need emergency attention right away.

Seek help right away if you:

• Have symptoms of mania
• Feel the urge to hurt yourself or others
• Feel hopeless, scared, or overwhelmed
• See or hear things that are not there
• Feel you cannot leave the house
• Are not able to care for yourself

Contact your treating provider if:

• Symptoms are getting worse
• You have side effects from medicines
• You are not taking medicine the right way

If you are thinking about hurting yourself or others, call or text 988 or chat 988lifeline.org. You can also call 1-800-273-8255 (1-800-273-TALK). The 988 Suicide and Crisis Lifeline provides free and confidential support 24/7, anytime day or night.

You can also call 911 or the local emergency number or go to the hospital emergency room. DO NOT delay.

If someone you know has attempted suicide, call 911 or the local emergency number right away. DO NOT leave the person alone, even after you have called for help.

Manic depression; Bipolar affective disorder; Mood disorder - bipolar; Manic depressive disorder

American Psychiatric Association. Bipolar and related disorders. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. Arlington, VA: American Psychiatric Publishing; 2013:123-154.

McIntyre RS, Berk M, Brietzke E, et al. Bipolar disorders. Lancet. 2020;396(10265):1841-1856. PMID: 33278937 pubmed.ncbi.nlm.nih.gov/33278937/.

Perlis RH, Ostacher MJ. Bipolar disorder. In: Stern TA, Fava M, Wilens TE, Rosenbaum JF, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 2nd ed. Philadelphia, PA: Elsevier; 2016:chap 30.

Substance Abuse and Mental Health Services Administration website. Bipolar disorder. www.samhsa.gov/mental-health/bipolar. Updated April 24, 2023. Accessed August 25, 2023.

Updated by: Fred K. Berger, MD, addiction and forensic psychiatrist, Scripps Memorial Hospital, La Jolla, CA. Internal review and update on 07/23/2023 by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.