Bipolar disorder

What this diagnosis means

Bipolar disorder is a medical condition. It causes big shifts in mood, energy, activity, and thinking. These shifts go far beyond the ordinary ups and downs that everyone has. They come in stretches called episodes. An episode can last days or weeks. Between episodes, many people feel like themselves for months or even years.¹

There are two main kinds of episodes. A manic episode, or mania, is a stretch of unusually high energy and mood. The person may feel elated, wired, or extremely irritable. A depressive episode is a stretch of deep sadness, low energy, and lost interest. A milder form of mania is called hypomania. It is shorter and less disruptive, and the person can often keep working and socializing. Some people also have mixed features, which means manic and depressive symptoms at the same time.¹

The psychiatrist may name a type. Bipolar I means the person has had at least one full manic episode. Bipolar II means depressive episodes plus hypomania, but never a full manic episode. Cyclothymic disorder means milder highs and lows that keep coming for at least two years.⁵

Bipolar disorder is common. NAMI reports that about 2.8 percent of people in the United States have been diagnosed with it.⁴ Symptoms most often begin in the late teens or early twenties. It can also start in childhood or later in life.⁶ It is not a character flaw. It is not a failure of faith, willpower, or parenting. It often runs in families, and genes play a large role. Most people with bipolar disorder have a relative with bipolar disorder or depression. The American Psychiatric Association puts that at 80 to 90 percent.⁵ Stress, loss, and lack of sleep can set off episodes. They do not cause the illness on their own.¹

Diagnosis can take time. There is no blood test or brain scan for it. The psychiatrist looks at the pattern of moods over time, and at family history.⁶ Hypomania often goes unnoticed because it can feel good. So some people are first treated for depression alone.⁴ The diagnosis may be revised as the picture becomes clearer. That is normal. Bipolar disorder is treatable, and ongoing treatment helps many people.¹

What you may notice at home

Families are often the first to see an episode coming. The person usually does not see it, especially with mania, which can feel wonderful at first. Below are things families commonly notice.¹² They do not prove anything on their own. They are worth mentioning to the psychiatrist.

During mania or hypomania, families often notice:

• Very little sleep, sometimes for days, without seeming tired.
• Fast talking that jumps between topics and is hard to interrupt.
• Big plans, sudden projects, and a feeling of being unusually gifted or important.
• Spending sprees, big purchases, and new debts.
• Risky driving, sexual risk-taking, or more alcohol or drug use.
• Irritability that flares into anger over small things.
• Not seeing any problem, and pushing back hard when family raises concern.

During depression, families often notice:

• Trouble getting out of bed. Sleeping far more or far less than usual.
• Slow speech, trouble finding words, and forgetfulness.
• Small decisions, like what to eat, feeling impossible.
• Pulling away from people and from activities the person used to enjoy.
• Talk of guilt, worthlessness, or being a burden.
• Changes in appetite and weight.
• Talk of death or of not wanting to be here. Take this seriously every time.

In severe episodes, some people lose touch with what is real. This is called psychosis, which means having false beliefs or seeing or hearing things others do not. The beliefs usually match the mood. In mania, a person may believe they are famous or chosen. In depression, they may believe they have ruined the family.²

Early warning signs are often small and specific to the person.⁹ Two nights of shorter sleep, or a phrase the person starts repeating, can be a red flag. Families often find it helps to learn their family member’s own pattern.

In children and teens, AACAP explains that the picture can look different. Mania may show up as long stretches of intense silliness, or as a very short temper. A child may feel like a superhero with special powers. Depression may show up as boredom, headaches, or stomachaches.⁷ Many of these signs overlap with ADHD, substance use, or plain depression. So a diagnosis in a young person takes careful observation over time.³ A child and adolescent psychiatrist usually leads this.

What treatment usually involves

Bipolar disorder is a long-term condition. NIMH explains that it usually needs ongoing treatment and does not go away on its own.¹ Treatment helps many people manage symptoms and prevent new episodes. Starting treatment early tends to help.¹

Treatment almost always includes medicine. The main class is mood stabilizers, medicines that even out the highs and lows. They also help prevent new episodes. Another class is antipsychotics, which are often used for manic or mixed episodes and sometimes for long-term care. Antidepressants, medicines for depression, are sometimes added, but with care. NIMH notes they are not used alone in bipolar disorder because they can set off mania.¹ Some of these medicines need regular blood tests. Side effects vary. It may take several tries to find the right fit. The psychiatrist chooses and adjusts medicines with the person, and changes along the way are normal.¹

Talk therapy, called psychotherapy, is a core part of treatment too. One common kind is cognitive behavioral therapy, which works on negative thinking. Another is family-focused therapy, which teaches the whole family about the illness and the treatment plan. A third helps the person keep steady daily rhythms of sleep, meals, and activity.¹ In a large NIMH study, people on medicine who also got intensive therapy got well faster and stayed well longer.²

For very severe episodes that have not responded to other treatment, the psychiatrist may discuss brain stimulation treatments. One is electroconvulsive therapy, or ECT, a procedure done under anesthesia in a hospital.¹

Daily habits matter a great deal in bipolar disorder. A regular sleep schedule, regular meals, exercise, and avoiding alcohol and drugs all help protect against episodes.¹

For children and teens, AACAP describes treatment as education for the child and family, mood-stabilizing medicines, and psychotherapy.⁷ NAMI adds that children usually receive therapy and family support before medicines are considered.⁴ A child and adolescent psychiatrist guides these choices.

How to support without taking over

Your family member is an adult, or a young person growing into one. NAMI puts it simply: support is not control. You can offer ideas and encouragement. You cannot make treatment decisions for them. Respecting their right to decide keeps the relationship intact, and that relationship matters.⁸

Privacy laws mean the treatment team cannot share details with you unless your family member gives permission. But even without permission, you can always give information to the team. If you notice sleep dropping or spending climbing, you can call the psychiatrist’s office and say so. Ask ahead of time how to reach them.⁸

With your family member’s consent, going to appointments together can help. You can help remember what was said and ask about side effects. NAMI cautions that daily nagging about medicine can insult an adult and backfire.⁹ Ask your family member what kind of reminders they want, and set up a simple system together.

Mania raises hard questions about money. Families often find it helps to talk, during a calm stretch, about what to do if spending takes off. Put that plan in writing as part of the crisis plan. The treatment team can help. Do it with the person, not to them.

Spread the load. NAMI advises against leaving all the caregiving to one person.⁸ Keep normal routines going. Life should not revolve around the illness.

Take care of yourself. NAMI compares it to putting on your own oxygen mask first.⁸ Sleep, eat, move, and keep your own friendships. Feeling frustrated or resentful at times is normal. It does not make you a bad parent, partner, or child.

You do not have to learn this alone. NAMI Family-to-Family is a free eight-session class for relatives, taught by family members who have been through it.¹⁰ NAMI also runs free family support groups.⁸ Faith and family traditions of care can be real strengths here. NAMI classes add to them. They do not replace them.

Questions worth asking the psychiatrist

Bring these to the next visit, with your family member’s agreement. Ask them together.

• Which type of bipolar disorder do you think this is, and how sure are you right now?
• What are the early warning signs of mania and of depression for this person in particular?
• What should we do, and whom should we call, if we see those signs?
• What is each medicine for, and what side effects should we watch for?
• Are there blood tests or check-ups that need to happen regularly?
• What kind of therapy would you recommend, and is family therapy an option?
• How long before we should expect to see improvement?
• Can we set up a plan now for money and driving during a manic episode?
• Can my family member sign a release so I can talk with the team?
• How can I give you information between visits if I am worried?