Bipolar Disorder (Manic Depression)
Someone with bipolar disorder will have severe mood swings involving low mood or depression on one end and a high mood on the other extreme. These usually last several weeks or months and are far beyond what most people experience. They are:
- Low or “depressive” feelings of intense depression and despair;
- High or “manic”—feelings of extreme or excessive happiness and overactivity;
- Mixed despair—for example, depressed mood with the restlessness and over activity of a manic episode.
There are Four Types of Mood Disorder 1. Bipolar I
There has been at least one high, or manic episode, which has lasted for longer than one week. Some people with bipolar I will have only manic episodes, although most will also have periods of depression. If untreated, manic episodes generally last three to six months. Depressive episodes last rather longer—6 to12 months without treatment.
- Bipolar II
There has been more than one episode of severe depression, but only mild manic episodes. A
mild manic episode is called “hypomania.”
- Rapid cycling
More than four mood swings happen in a 12-month period. This affects around one in 10 people with bipolar disorder, and can happen with both types I and II.
The mood swings are not as severe as those in full bipolar disorder, but can be longer. This can develop into full bipolar disorder.
Bipolar disorder runs in families, and therefore suggests a strong genetic predisposition. It is a disease that involves those areas of the brain which control our moods. It is often controlled with medication. Episodes can sometimes be brought on by stressful experiences or physical illness. The symptoms of a mood disorder depend on which way your mood has swung, whether it is in a depressive or manic phase.
The symptoms are the same as those described for depression but in bipolar disorder, the feeling of depression is worse. It goes on for longer and makes it difficult or impossible to deal with the normal things of life. If you become depressed, you will notice some of these changes.
This is the extreme opposite of depression. It is characterized by an extreme sense of wellbeing, energy, and optimism. If these symptoms are intense, they can affect thinking and judgment, and make one believe that they are more worthy than they really are. A person in this phase tends to make bad poorly thought-out decisions. They become disinhibited in thought and behaviour. Because of disinhibition, they behave in embarrassing, harmful and–occasionally—dangerous ways such as engaging in irresponsible sexual behaviour and creating disruptions in both relationships and work. Bipolar disorders are cyclic and in between the depressive and manic phase there is a “normal” period which can last from months to years.
- Classification of Manic Symptoms:
- very happy and excited
- irritated with other people who do not share the patient’s optimistic outlook feeling more important than usual
- full of new and exciting ideas
- moving quickly from one idea to another
- hearing voices that other people can’t hear
- full of energy
- unable or unwilling to sleep
- more interested in sex
- making plans that are grandiose and unrealistic
- very active, moving around very quickly
- behaving unusually, that is, uncharacteristic behaviour because of disinhibition
- talking very quickly—other people may find it hard to understand what they are talking about
- making odd decisions on the spur of the moment, sometimes with disastrous consequences
- recklessly spending money
- over-familiar or recklessly critical with other people
- less inhibited in general and more specifically in sexual behaviour and social relations and alcohol indulgence. This places them at a high risk for sexually transmitted disease, including HV/AIDS.
- Lack of insight: Especially during the first manic attack, the person does not think or believe that there is anything the matter with them although familiar acquaintances can see that there is something wrong. The person may even take offence at such a suggestion, and they are indifferent to other people’s feelings.
- Psychotic symptoms
In severe manic episode the person tends to have grandiose beliefs about him/herself—that they are on an important mission or that they have special powers and abilities. They may even experience hearing voices which other people do not hear. However, these experiences are in agreement with or can be understood since they are as a result of the emotional symptoms. For example, the person may hear a voice saying they are important and they will easily agree with those voices because they are already feeling important.
Many people with bipolar disorder continue to experience mild depressive symptoms and problems in thinking in between mood swings even when they seem to be better.
Treatment of Bipolar Disorders
Since bipolar disorders involve mood swings, the drugs that are used are meant to prevent the swings and maintain the person in between. They are therefore aptly referred to as mood stabilizers. There are several in the market.
When to Start on Mood Stabilizer and for How Long
The more manic episodes one has had, the more likely one is to have another one. The risks for relapse do not change much with age. After just one episode, it is difficult to predict how likely and when another one will take place. There is therefore no need to start on a mood stabilizer unless the episode was very severe and disruptive. If there is a second episode, there is an 80% chance of further episodes. A mood stabilizer is usually recommended at this point. The mood stabilizer should be for at least two years after one episode of bipolar disorder, and for up to five years if there have been frequent previous relapses, psychotic episodes, alcohol or substance misuse, and continuing stress at home or at work. If there are frequent and troublesome mood swings, then the mood stabilizer should be continued for much longer.
The Use of Antipsychotic in Manic illness
In the initial stages when the patient comes for treatment, he/she may be very excited and restless. There is need to calm him/her down by using medicines such as haloperidol and other antipsychotic drugs. He/she may need to be sedated with other drugs such as chlorpromazine and diazepam. The scenario of a manic patient being brought to hospital can be dramatic—a very active and talkative person with endless energy being escorted by several exhausted and tired relatives, often with the assistance of police. The patient may be restrained by ropes or handcuffs.
In between episodes of mania or depression, psychological treatment can be helpful.
This should include:
- Psychoeducation—finding out and learning more about bipolar disorder;
- Mood monitoring—helps one to pick up when the mood is swinging;
- Mood strategies—to help stop mood swinging into a full-blown manic or depressive episode;
- Help to develop general coping skills;
- Cognitive Behavioural Therapy (CBT) for depression.
Pregnancy and Mood Stabilizers
Pregnancy is a very important consideration for people who have bipolar disorder especially if they are on a mood stabilizer. The decision about whether or not to remain on the mood stabilizer during pregnancy will have to be based on careful considerations which the patient must go through with her doctor. These considerations include:
- Lithium is still safer than all the other mood stabilizer and is safer after 29 weeks of pregnancy;
- The highest risk is during the first three months of pregnancy;
- A baby should breastfeed when the mother is on lithium;
- The decision on whether or not to take lithium or any mood stabilizer during pregnancy would have to be weighed carefully against the risks for relapse and the risks to the baby associated with lithium. The final decision lies with the woman.
- Bipolar on the Depression Phase
If a patient is on a mood stabilizer and gets depressed, an antidepressant is usually added. However, the following are taken into account:
- There is the possibility that the antidepressant can push the patient to a manic phase. However, SSRIs are less likely to do this than TCAs;
- The person who has had a recent manic episode or is a rapid cycling bipolar is the more likely to be pushed to a manic phase and therefore a mood stabilizer alone is a safer option.
- If there is history of manic episode, any added antidepressant should be for a relatively shorter time than when there has never been history of a manic episode;
- If there have been repeated attacks of depressive episodes without a manic episode, then both the mood stabilizer and the antidepressant can be continued on a long term to prevent relapse of the depressive phase;
- In the event it is considered necessary to put a patient on an antidepressant in spite of the history of manic episodes, the patient and the relative must be informed of the risks and much closer follow-up prescribed so that the antidepressant can be stopped at the earliest sign of manic features.
In mixed affective disorder—where features of mania coexist with depressive symptoms:
- Do not use antidepressants;
- Use either a mood stabilizer or an antipsychotic drug or both of them depending on the clinical picture;
- The antipsychotic drugs help to reduce the overactivity, grandiosity, sleeplessness, and the agitation associated with the mania. The choice of which antipsychotic will depend on the availability and cost, but where these are not an issue, then the newer generation antipsychotics such as olanzapine and risperidone are to be preferred to chlorpromazine and haloperidol. This is because the latter have more short-term side-effects such as stiffness, shakiness, and muscular contractions.
Personal Tips for a Person with Mood Swings
- Learn how to recognize all the symptoms of mania, and diarise them as they appear. This will assist you to seek help before they get out of control and in the process prevent destructive episodes or hospital admissions.
- Read as much as possible about the condition. Be in charge.
- Learn about stress and how to manage it so that stresses that are part of daily life do not overwhelm you and possibly precipitate a manic episode.
- Improve personal relationships, especially with close confidantes by telling them of your condition and how it can adversely affect relationships. This will enable them to understand and be supportive of you when under attack.
- Occupy yourself (without overworking yourself) with activities that take your focus away from the illness.
- Exercise regularly.
- Involve yourself in activities that are relaxing and nondestructive.
- Keep regular check-ups with your healthcare provider and do not change or stop medication without consulting with him/her. This is more so with lithium which initially requires regular monitoring of levels in your kidneys and thyroid. When stable, these check-ups can be done every three to six months.
- Your relatives and close confidantes need to be educated as well so that they can recognize early symptoms, the need for maintenance, appreciate and handle both the manic and depressive episode and the suicidal risks.
- Discuss with your relatives and your healthcare provider how to handle your finances and treatment in the event you go into a manic or depressive episode. Make plans as to what should be done about your family and especially your children should you become manic or severely depressed.
Tips for Relatives and Friends
- When in the depressive phase the same tips as discussed under depression apply.
- When in the manic phase:
- Manic patients can be highly disruptive and argumentative. Avoid direct confrontations.
- Manic patient tends to over-indulge in pleasurable activities such as drugs (alcohol included), irresponsible sexual behaviour, extravagance, and unplanned spending. Help to persuade them against those.
- Educate yourself on the early symptoms of the condition and read as much as possible about the condition.
- Make sure the patient keeps appointments
- Make sure you know in advance where to seek for help in the event you could not handle the situation of the patient.
- Children of manic or depressed people will not understand the condition. They react with anxiety and confusion. It is at this time that the children will need the support of the adults around them, which will include a gentle explanation of what is going on with the sick relative or patient. Assurance that they are not to blame is necessary.
- Looking after a manic patient can be energy-draining. Make sure you get help from the rest of the family members and if need be, take him to hospital.
Source: Africa Mental Health Foundation