Bipolar disorder

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Overview

Bipolar disorder is a mental health condition that affects your moods, which can swing from 1 extreme to another. It used to be known as manic depression.

Symptoms of bipolar disorder

People with bipolar disorder have episodes of:

  • depression – feeling very low and lethargic
  • mania – feeling very high and overactive

Symptoms of bipolar disorder depend on which mood you're experiencing.

Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer).

Depression

You may initially be diagnosed with clinical depression before you have a manic episode (sometimes years later), after which you may be diagnosed with bipolar disorder.

During an episode of depression, you may have overwhelming feelings of worthlessness, which can potentially lead to thoughts of suicide.

If you're feeling suicidal, go to your nearest A&E as soon as possible.

If you're feeling very depressed, contact a GP, your care co-ordinator or speak to a local mental health crisis team as soon as possible.

You could also call 111 if you're not sure what to do.

If you want to talk to someone confidentially, call the Samaritans free on 116 123. You can talk to them 24 hours a day, 7 days a week.

Or visit the Samaritans website or email jo@samaritans.org.

Mania

During a manic phase of bipolar disorder, you may:

  • feel very happy
  • have lots of energy, ambitious plans and ideas
  • spend large amounts of money on things you cannot afford and would not normally want

It's also common to:

  • not feel like eating or sleeping
  • talk quickly
  • become annoyed easily

You may feel very creative and view the manic phase of bipolar as a positive experience.

But you may also experience symptoms of psychosis, where you see or hear things that are not there or become convinced of things that are not true.

Living with bipolar disorder

The high and low phases of bipolar disorder are often so extreme that they interfere with everyday life.

But there are several options for treating bipolar disorder that can make a difference.

They aim to control the effects of an episode and help someone with bipolar disorder live life as normally as possible.

The following treatment options are available:

  • medicine to prevent episodes of mania and depression – these are known as mood stabilisers, and you take them every day on a long-term basis
  • medicine to treat the main symptoms of depression and mania when they happen
  • learning to recognise the triggers and signs of an episode of depression or mania
  • psychological treatment – such as talking therapy, which can help you deal with depression, and provides advice about how to improve your relationships
  • lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, as well as advice on improving your diet and getting more sleep

It's thought using a combination of different treatment methods is the best way to control bipolar disorder.

Help and advice for people with a long-term condition or their carers is also available from charities, support groups and associations.

This includes self-help and learning to deal with the practical aspects of a long-term condition.

Find out more about living with bipolar disorder.

Bipolar disorder and pregnancy

Bipolar disorder, like all other mental health problems, can get worse during pregnancy. But specialist help is available if you need it.

What causes bipolar disorder?

The exact cause of bipolar disorder is unknown, although it's believed a number of things can trigger an episode.

These include:

  • extreme stress
  • overwhelming problems
  • life-changing events
  • genetic and chemical factors

Who is affected?

Bipolar disorder is fairly common, and 1 in every 100 people will be diagnosed with it at some point in their life.

Bipolar disorder can occur at any age, although it often develops between the ages of 15 and 19 and rarely develops after 40.

Men and women from all backgrounds are equally likely to develop bipolar disorder.

The pattern of mood swings in bipolar disorder varies widely. For example, some people only have a couple of bipolar episodes in their lifetime and are stable in between, while others have many episodes.

Bipolar disorder and driving

If you have bipolar disorder, it may affect your driving. You must inform the Driver and Vehicle Licensing Agency (DVLA).

Symptoms

Bipolar disorder is characterised by extreme mood swings. These can range from extreme highs (mania) to extreme lows (depression).

Episodes of mania and depression often last for several weeks or months.

Depression

During a period of depression, your symptoms may include:

  • feeling sad, hopeless or irritable most of the time
  • lacking energy
  • difficulty concentrating and remembering things
  • loss of interest in everyday activities
  • feelings of emptiness or worthlessness
  • feelings of guilt and despair
  • feeling pessimistic about everything
  • self-doubt
  • being delusional, having hallucinations and disturbed or illogical thinking
  • lack of appetite
  • difficulty sleeping
  • waking up early
  • suicidal thoughts

Mania

The manic phase of bipolar disorder may include:

  • feeling very happy, elated or overjoyed
  • talking very quickly
  • feeling full of energy
  • feeling self-important
  • feeling full of great new ideas and having important plans
  • being easily distracted
  • being easily irritated or agitated
  • being delusional, having hallucinations and disturbed or illogical thinking
  • not feeling like sleeping
  • not eating
  • doing things that often have disastrous consequences – such as spending large sums of money on expensive and sometimes unaffordable items
  • making decisions or saying things that are out of character and that others see as being risky or harmful

Patterns of depression and mania

If you have bipolar disorder, you may have episodes of depression more regularly than episodes of mania, or vice versa.

Between episodes of depression and mania, you may sometimes have periods where you have a "normal" mood.

The patterns are not always the same and some people may experience:

  • rapid cycling – where a person with bipolar disorder repeatedly swings from a high to a low phase quickly without having a "normal" period in between
  • mixed state – where a person with bipolar disorder experiences symptoms of depression and mania together; for example, overactivity with a depressed mood

If your mood swings last a long time but are not severe enough to be classed as bipolar disorder, you may be diagnosed with a mild form of bipolar disorder called cyclothymia.

Living with bipolar disorder

Bipolar disorder is a condition of extremes. A person with bipolar disorder may be unaware they're in the manic phase.

After the episode is over, they may be shocked at their behaviour. But at the time, they may believe other people are being negative or unhelpful.

Some people with bipolar disorder have more frequent and severe episodes than others. 

The extreme nature of the condition means staying in a job may be difficult and relationships may become strained. There's also an increased risk of suicide.

During episodes of mania and depression, someone with bipolar disorder may experience strange sensations, such as seeing, hearing or smelling things that are not there (hallucinations).

They may also believe things that seem irrational to other people (delusions). These types of symptoms are known as psychosis or a psychotic episode.

Read more about living with bipolar disorder.

Who can get it

The exact cause of bipolar disorder is unknown. Experts believe there are a number of factors that work together to make a person more likely to develop it.

These are thought to be a complex mix of physical, environmental and social factors.

Chemical imbalance in the brain

Bipolar disorder is widely believed to be the result of chemical imbalances in the brain.

The chemicals responsible for controlling the brain's functions are called neurotransmitters, and include noradrenaline, serotonin and dopamine.

There's some evidence that if there's an imbalance in the levels of 1 or more neurotransmitters, a person may develop some symptoms of bipolar disorder.

For example, there's evidence that episodes of mania may occur when levels of noradrenaline are too high, and episodes of depression may be the result of noradrenaline levels becoming too low.

Genetics

It's also thought bipolar disorder is linked to genetics, as it seems to run in families.

The family members of a person with bipolar disorder have an increased risk of developing it themselves.

But no single gene is responsible for bipolar disorder. Instead, a number of genetic and environmental factors are thought to act as triggers.

Triggers

A stressful circumstance or situation often triggers the symptoms of bipolar disorder.

Examples of stressful triggers include:

  • the breakdown of a relationship
  • physical, sexual or emotional abuse
  • the death of a close family member or loved one

These types of life-altering events can cause episodes of depression at any time in a person's life.

Bipolar disorder may also be triggered by:

  • physical illness
  • sleep disturbances
  • overwhelming problems in everyday life, such as problems with money, work or relationships

Diagnosis

If your GP thinks you may have bipolar disorder, they'll usually refer you to a psychiatrist, a doctor who specialises in mental health problems.

If your illness puts you at risk of harming yourself, your GP will arrange an appointment immediately.

Specialist assessment

You'll be assessed by the psychiatrist at your appointment. They'll ask you a few questions to find out if you have bipolar disorder. If you do, they'll decide what treatments are most suitable.

During the assessment, you'll be asked about your symptoms and when you first experienced them.

The psychiatrist will also ask about how you feel leading up to and during an episode of mania or depression, and if you have thoughts about harming yourself.

The psychiatrist will also want to know about your medical background and family history, especially whether any of your relatives have had bipolar disorder.

If someone else in your family has the condition, the psychiatrist may want to talk to them. But they'll ask for your agreement before doing so.

Other tests

Depending on your symptoms, you may also need tests to see whether you have a physical problem, such as an underactive thyroid or an overactive thyroid.

If you have bipolar disorder, you'll need to visit your GP regularly for a physical health check.

Advanced directives

If you're diagnosed with the condition, it's important to talk to your psychiatrist so you're fully involved in the decisions about your treatment and care.

But a person is sometimes not able to make an informed decision about their care or communicate their needs, especially if their symptoms become severe.

If this happens, it may be possible to draw up an advance decision. An advance decision is a set of written instructions that state what treatments and help you want (or do not want) in advance in case you cannot communicate your decisions at a later stage.

Your GP or psychiatrist can give you further help and advice.

Treatment

Treatment for bipolar disorder aims to reduce the severity and number of episodes of depression and mania to allow as normal a life as possible.

Treatment options for bipolar disorder

If a person is not treated, episodes of bipolar-related mania can last for between 3 and 6 months.

Episodes of depression tend to last longer, often 6 to 12 months.

But with effective treatment, episodes usually improve within about 3 months.

Most people with bipolar disorder can be treated using a combination of different treatments.

These can include 1 or more of the following:

  • medicine to prevent episodes of mania and depression – these are known as mood stabilisers, and you take them every day on a long-term basis
  • medicine to treat the main symptoms of depression and mania when they happen
  • learning to recognise the triggers and signs of an episode of depression or mania
  • psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
  • lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.

But hospital treatment may be needed if your symptoms are severe or you're being treated under the Mental Health Act, as there's a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medicines for bipolar disorder

Several medicines are available to help stabilise mood swings.

These are commonly called mood stabilisers and include:

  • lithium
  • anticonvulsant medicines
  • antipsychotic medicines

If you're already taking medicine for bipolar disorder and you develop depression, your GP will check you're taking the correct dose. If you're not, they'll change it.

Episodes of depression are treated slightly differently in bipolar disorder, as taking antidepressants alone may lead to a relapse.

Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabiliser.

But antidepressants are commonly used alongside a mood stabiliser or antipsychotic.

Find out more about antidepressants.

If your GP or psychiatrist recommends you stop taking bipolar disorder medicine, the dose should be gradually reduced over at least 4 weeks, and up to 3 months if you're taking an antipsychotic or lithium.

If you have to stop taking lithium for any reason, talk to your GP about taking an antipsychotic or valproate instead.

Lithium

In the UK, lithium is the main medicine used to treat bipolar disorder.

Lithium is a long-term treatment for episodes of mania and depression. It's usually prescribed for at least 6 months.

If you're prescribed lithium, stick to the prescribed dose and do not stop taking it suddenly unless told to by your doctor.

For lithium to be effective, the dosage must be correct. If it's incorrect, you may get side effects such as diarrhoea and getting sick.

Tell your doctor immediately if you have side effects while taking lithium.

You'll need regular blood tests at least every 3 months while taking lithium. This is to make sure your lithium levels are not too high or too low.

Your kidney and thyroid function will also need to be checked every 2 to 3 months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you're taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they're prescribed by your GP. 

In the UK, lithium and the antipsychotic medicine aripiprazole are currently the only medicines that are officially approved for use in teenagers with bipolar disorder.

But the Royal College of Paediatrics and Child Health says that other bipolar medicines may be prescribed for children if recommended by their doctor.

Anticonvulsant medicines

Anticonvulsant medicines include:

  • valproate 
  • carbamazepine
  • lamotrigine

These medicines are sometimes used to treat episodes of mania. They're also long-term mood stabilisers.

Anticonvulsant medicines are often used to treat epilepsy, but they're also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used, or they may be used in combination with lithium when bipolar disorder does not respond to lithium on its own.

Valproate

Valproate is not usually prescribed for women of childbearing age because there's a risk of physical defects in babies, such as spina bifida, heart abnormalities and cleft lip.

There may also be an increased risk of developmental problems, such as lower intellectual abilities, poor speaking and understanding, memory problems, autistic spectrum disorders, and delayed walking and talking.

In women, your GP may decide to use valproate if there's no alternative or you have been assessed and it's unlikely you'll respond to other treatments.

They'll need to check you're using a reliable contraception and will advise you on the risks of taking the medicine during pregnancy.

Carbamazepine

Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.

Your progress will be carefully monitored if you're taking other medication, including the contraceptive pill.

Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine and again after 6 months.

You'll also need to have a blood count at the start and after 6 months, and you may also have your weight and height monitored.  

Lamotrigine

If you're prescribed lamotrigine, you'll usually be started on a low dose, which will be increased gradually.

See your GP straight away if you're taking lamotrigine and develop a rash. You'll need to have an annual health check, but other tests are not usually needed.

Women who are taking the contraceptive pill should talk to their GP about switching to a different method of contraception.

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania.

They include:

  • aripiprazole
  • olanzapine
  • quetiapine
  • risperidone

They may also be used as a long-term mood stabiliser. Quetiapine may also be used for long-term bipolar depression.

Antipsychotic medicines can be particularly useful if symptoms are severe or behaviour is disturbed.

As antipsychotics can cause side effects, such as blurred vision, a dry mouth, constipation and weight gain, the initial dose will usually be low.

If you're prescribed an antipsychotic medicine, you'll need to have regular health checks at least every 3 months, but possibly more often, particularly if you have diabetes.

If your symptoms do not improve, you may be offered lithium and valproate as well.

Rapid cycling

You may be prescribed a combination of lithium and valproate if you experience rapid cycling, where you quickly change from highs to lows without a "normal" period in between.

If this does not help, you may be offered lithium on its own, or a combination of lithium, valproate and lamotrigine.

But you will not usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.

Learning to recognise triggers

If you have bipolar disorder, you can learn to recognise the warning signs of an approaching episode of mania or depression.

A community mental health worker, such as a psychiatric nurse, may be able to help you identify your early signs of relapse from your history.

This will not prevent the episode occurring, but it'll allow you to get help in time.

This may mean making some changes to your treatment, perhaps by adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you're already taking.

Your GP or specialist can advise you on this.

Psychological treatment

Some people find psychological treatment helpful when used alongside medicine in between episodes of mania or depression.

This may include:

  • psychoeducation – to find out more about bipolar disorder
  • cognitive behavioural therapy (CBT) – this is most useful when treating depression
  • family therapy – a type of talking therapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of 6 to 9 months.

Pregnancy and bipolar disorder

One of the main problems is that the risks of taking bipolar medicines during pregnancy are not well understood.

If you're pregnant and you have bipolar disorder, a written plan for your treatment should be developed as soon as possible.

The plan should be drawn up with you, your partner, your obstetrician (pregnancy specialist), midwife, GP and health visitor.

The following medicines are not routinely prescribed for pregnant women with bipolar disorder, as they may harm the baby:

  • valproate
  • carbamazepine
  • lithium
  • lamotrigine
  • paroxetine
  • benzodiazepines (tranquillisers), such as diazepam (Valium) and lorazepam (Ativan)

If you become pregnant while taking medicine that's been prescribed for bipolar disorder, it's important that you do not stop taking it until you have discussed it with your doctor.

If bipolar medicine is prescribed for bipolar disorder after the baby's born, it may also affect your decision whether to breastfeed.

Your pharmacist, midwife or mental health team can give you advice based on your circumstances.

Living with

Although it is usually a long-term condition, effective treatments for bipolar disorder combined with self-help techniques can limit the condition's impact on your everyday life.

Staying active and eating well

Eating well and keeping fit can help reduce the symptoms of bipolar disorder, particularly the depressive symptoms.

It may also give you something to focus on and provide a routine, which is important for many people.

A healthy diet, combined with exercise, may also help limit weight gain, which is a common side effect of medical treatments for bipolar disorder.

Some treatments also increase the risk of developing diabetes, or worsen the illness in people that already have it.

Maintaining a healthy weight and exercising are an important way of limiting that risk.

Annual health check

You should have a check-up at least once a year to monitor your risk of developing cardiovascular disease or diabetes.

This will include recording your weight, checking your blood pressure and having any appropriate blood tests.

Use self-management programmes

Self-management programmes aim to help you take an active part in your own recovery so you're not controlled by your illness.

Courses like those run by Self Management UK for mild to moderate mental health conditions may be helpful if you feel distressed and uncertain about bipolar disorder.

Talking about it

Some people with bipolar disorder find it easy to talk to family and friends about their condition and its effects.

Other people find it easier to turn to charities and support groups.

Many organisations run self-help groups that can put you in touch with other people with the condition.

This enables you to share helpful ideas and helps you realise you're not alone in feeling the way you do.

These organisations also provide online support in forums and blogs.

Some useful charities, support groups and associations include:

Talking therapies are useful for managing bipolar disorder, particularly during periods of stability.

Services that can help

You may be involved with many different services during treatment for bipolar disorder.

Some are accessed through referral from your GP, others through your local authority.

Community mental health teams (CMHT)

These provide the main part of local specialist mental health services.

They offer assessment, treatment and social care.

Early intervention teams 

These provide early identification and treatment if you have the first symptoms of psychosis.

Your GP may be able to refer you directly to an early intervention team.

Crisis services

Crisis services allow you to be treated at home, instead of in hospital, for a sudden episode.

These are specialist mental health teams that deal with crises that occur outside normal office hours.

Acute day hospital

These are an alternative to inpatient care in a hospital. You can visit every day or as often as you need.

Assertive outreach teams

These deliver intensive treatment and rehabilitation in the community, providing rapid help in a crisis.

Staff often visit you at home and liaise with other services, such as your GP or social services.

They can also help with practical problems, such as helping to find housing and work, or doing your shopping and cooking.

Avoiding drugs and alcohol

Some people with bipolar disorder use alcohol or illegal drugs to try to ease their distress.

Both have well-known harmful physical and social effects, and are not a substitute for treatment and good healthcare.

Some people with bipolar disorder find they can stop misusing alcohol and drugs once they're using effective treatment.

Others may have separate but related problems of alcohol and drug misuse, which may need to be treated separately.

Avoiding alcohol and illegal drugs is an important part of recovery from episodes of manic or depressive symptoms, and can help you gain stability.

Read more information about alcohol misuse.

Money and benefits

It's important to avoid too much stress, including work-related stress.

If you're employed, you may be able to work shorter hours or in a more flexible way, particularly if job pressure triggers your symptoms.

Employers must make reasonable adjustments to make the employment of people with disabilities possible. This includes people with bipolar disorder.

A range of benefits is available to you if you cannot work as a result of bipolar disorder.

These may include:

Living with or caring for someone with bipolar disorder

People living with or caring for someone with bipolar disorder can have a tough time.

During episodes of illness, the personalities of people with bipolar disorder may change, and they may become abusive or even violent.

Sometimes social workers and the police may become involved. Relationships and family life are likely to feel the strain.

If you're the nearest relative of a person with bipolar disorder, you have certain rights that can be used to protect the person's interests.

These include requesting that the local social services authority asks an approved mental health professional to consider whether the person with bipolar disorder should be detained in hospital, also known as sectioning.

You may feel at a loss if you're caring for someone with bipolar disorder. Finding a support group and talking to other people in a similar situation might help.

If you're having relationship or marriage difficulties, you can contact specialist relationship counsellors, who can talk things through with you and your partner.

Want to know more?

Dealing with suicidal feelings

Having suicidal thoughts is a common depressive symptom of bipolar disorder. Without treatment, these thoughts may get stronger.

Some research has shown the risk of suicide for people with bipolar disorder is 15 to 20 times greater than the general population.

Studies have also shown that as many as half of all people with bipolar disorder attempt suicide at least once.

The risk of suicide seems to be higher earlier in the illness, so early recognition and help may prevent it.

If you're feeling suicidal, go to your nearest A&E department as soon as possible.

If you're feeling very depressed, contact your GP, care co-ordinator or local mental health crisis team as soon as possible.

You could also call 111 for an immediate assessment. 111 is available 24 hours a day, every day. For patients' safety, all calls are recorded. 111 is free to call.

If you cannot or do not want to contact these people, contact the Samaritans on 116 123. You can call them 24 hours a day, 7 days a week. 

Alternatively, visit the Samaritans website or email jo@samaritans.org.

The Community Advice & Listening Line (CALL) is a mental health helpline for Wales offering a confidential listening and support service - 0800 132 737 or text 'help' to 81066. CALL are available 24 hours a day, 7 days a week.

Self-harm

Self-harm is often a symptom of mental health problems like bipolar disorder.

For some people, self-harm is a way of gaining control over their lives or temporarily distracting themselves from mental distress.

It may not be related to suicide or attempted suicide.

Want to know more? 

Recommended communities

Online communities help you talk to people, share your experiences and learn from others.

The SANE Support Forum allows people to share their feelings and provide mutual support for anyone with mental health issues, as well as their friends and family.

Bipolar UK, a national charity, also runs an online discussion forum for people with bipolar disorder, their families and carers.



The information on this page has been adapted by NHS Wales from original content supplied by NHS UK NHS website nhs.uk
Last Updated: 20/05/2022 09:51:52