BipolarDisorder

National Institute of Mental Health

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health





Contents
What is bipolar disorder? _____________________________________________ 1
What are the symptoms of bipolar disorder? ____________________________ 1
How does bipolar disorder affect someone over time? ___________________ 4
What illnesses often co-exist with bipolar disorder? _____________________ 6
What are the risk factors for bipolar disorder? __________________________ 6
Genetics _________________________________________________________ 6
Brain structure and functioning ___________________________________ 8
How is bipolar disorder diagnosed? ____________________________________ 8
How is bipolar disorder treated? _______________________________________ 9
Medications ______________________________________________________ 9
Psychotherapy __________________________________________________ 16
Other treatments ________________________________________________ 17
What can people with bipolar disorder expect from treatment? __________ 19
How can I help a friend or relative who has bipolar disorder? ____________ 19
Support for caregivers _______________________________________________ 20
How can I help myself if I have bipolar disorder? _______________________ 20
Where can I go for help? _____________________________________________ 21
What if I or someone I know is in crisis? _______________________________ 21
Citations ___________________________________________________________ 22
For more information on bipolar disorder ______________________________ 26

Thisbookletdiscussesbipolardisorderin
adults.Forinformationonbipolardisorder
inchildrenandadolescents,seetheNIMH
booklet,BipolarDisorderinChildrenand
Teens:AParentsGuide.

BipolarDisorder 1
Whatisbipolardisorder?
Bipolardisorder,alsoknownasmanic-depressive
illness,isabraindisorderthatcausesunusual
shiftsinmood,energy,activitylevels,andthe
abilitytocarryoutday-to-daytasks.Symptoms
ofbipolardisorderaresevere.Theyaredifferent
fromthenormalupsanddownsthateveryone
goesthroughfromtimetotime.Bipolardisorder
symptomscanresultindamagedrelationships,
poorjoborschoolperformance,andevensuicide.Butbipolardisordercanbe
treated,andpeoplewiththisillnesscanleadfullandproductivelives.
Bipolardisorderoftendevelopsinapersonslateteensorearlyadultyears.At
leasthalfofallcasesstartbeforeage25.
1
Somepeoplehavetheirrstsymptoms
duringchildhood,whileothersmaydevelopsymptomslateinlife.
Bipolardisorderisnoteasytospotwhenitstarts.Thesymptomsmayseemlike
separateproblems,notrecognizedaspartsofalargerproblem.Somepeoplesuf-
ferforyearsbeforetheyareproperlydiagnosedandtreated.Likediabetesorheart
disease,bipolardisorderisalong-termillnessthatmustbecarefullymanaged
throughoutapersonslife.
Whatarethesymptomsofbipolardisorder?
Peoplewithbipolardisorderexperienceunusuallyintenseemotionalstatesthat
occurindistinctperiodscalledmoodepisodes.Anoverlyjoyfuloroverexcited
stateiscalledamanicepisode,andanextremelysadorhopelessstateiscalled
adepressiveepisode.Sometimes,amoodepisodeincludessymptomsofboth
maniaanddepression.Thisiscalledamixedstate.Peoplewithbipolardisorder
alsomaybeexplosiveandirritableduringamoodepisode.
Extremechangesinenergy,activity,sleep,andbehaviorgoalongwiththese
changesinmood.Itispossibleforsomeonewithbipolardisordertoexperiencea
long-lastingperiodofunstablemoodsratherthandiscreteepisodesofdepression
ormania.
Apersonmaybehavinganepisodeofbipolardisorderifheorshehasanumber
ofmanicordepressivesymptomsformostoftheday,nearlyeveryday,foratleast
oneortwoweeks.Sometimessymptomsaresoseverethatthepersoncannot
functionnormallyatwork,school,orhome.

2 NationalInstituteofMentalHealth
Symptomsofbipolardisorderaredescribedbelow.
Symptomsofmaniaoramanic
episodeinclude:
MoodChanges
Alongperiodoffeelinghigh,or
anoverlyhappyoroutgoingmood
Extremelyirritablemood,agita-
tion,feelingjumpyorwired.
BehavioralChanges
Talkingveryfast,jumpingfrom
oneideatoanother,havingracing
thoughts
Beingeasilydistracted
Increasinggoal-directedactivities,
suchastakingonnewprojects
Beingrestless
Sleepinglittle
Havinganunrealisticbeliefin
onesabilities
Behavingimpulsivelyandtaking
partinalotofpleasurable,high-
riskbehaviors,suchasspending
sprees,impulsivesex,andimpul-
sivebusinessinvestments.
Symptomsofdepressionora
depressiveepisodeinclude:
MoodChanges
Alongperiodoffeelingworriedor
empty
Lossofinterestinactivitiesonce
enjoyed,includingsex.
BehavioralChanges
Feelingtiredorsloweddown
Havingproblemsconcentrat-
ing,remembering,andmaking
decisions
Beingrestlessorirritable
Changingeating,sleeping,or
otherhabits
Thinkingofdeathorsuicide,or
attemptingsuicide.

BipolarDisorder 3
Inadditiontomaniaanddepression,bipolardisordercancausearangeofmoods,
asshownonthescale.

normalor
severedepression,
balancedmood
hypomaniaand
moderatedepression,and severemania
mildlowmood
Onesideofthescaleincludesseveredepression,moderatedepression,andmild
lowmood.Moderatedepressionmaycauselessextremesymptoms,andmildlow
moodiscalleddysthymiawhenitischronicorlong-term.Inthemiddleofthescale
isnormalorbalancedmood.
Attheotherendofthescalearehypomaniaandseveremania.Somepeoplewith
bipolardisorderexperiencehypomania.Duringhypomanicepisodes,apersonmay
haveincreasedenergyandactivitylevelsthatarenotassevereastypicalmania,
orheorshemayhaveepisodesthatlastlessthanaweekanddonotrequire
emergencycare.Apersonhavingahypomanicepisodemayfeelverygood,be
highlyproductive,andfunctionwell.Thispersonmaynotfeelthatanythingis
wrongevenasfamilyandfriendsrecognizethemoodswingsaspossiblebipolar
disorder.Withoutpropertreatment,however,peoplewithhypomaniamaydevelop
severemaniaordepression.

4 NationalInstituteofMentalHealth
Duringamixedstate,symptomsoftenincludeagitation,troublesleeping,major
changesinappetite,andsuicidalthinking.Peopleinamixedstatemayfeelvery
sadorhopelesswhilefeelingextremelyenergized.
Sometimes,apersonwithsevereepisodesofmaniaordepressionhaspsychotic
symptomstoo,suchashallucinationsordelusions.Thepsychoticsymptomstend
toreectthepersonsextrememood.Forexample,psychoticsymptomsforaper-
sonhavingamanicepisodemayincludebelievingheorsheisfamous,hasalotof
money,orhasspecialpowers.Inthesameway,apersonhavingadepressiveepi-
sodemaybelieveheorsheisruinedandpenniless,orhascommittedacrime.As
aresult,peoplewithbipolardisorderwhohavepsychotic
symptomsaresometimeswronglydiagnosedashaving
schizophrenia,anotherseverementalillnessthatislinked
withhallucinationsanddelusions.
Peoplewithbipolardisordermayalsohavebehavioral
problems.Theymayabusealcoholorsubstances,have
relationshipproblems,orperformpoorlyinschoolorat
work.Atrst,itsnoteasytorecognizetheseproblems
assignsofamajormentalillness.
Howdoesbipolardisorderaffectsomeone
overtime?
Bipolardisorderusuallylastsalifetime.Episodesofmaniaanddepressiontypically
comebackovertime.Betweenepisodes,manypeoplewithbipolardisorderare
freeofsymptoms,butsomepeoplemayhavelingeringsymptoms.
DoctorsusuallydiagnosementaldisordersusingguidelinesfromtheDiagnostic
and Statistical Manual of Mental Disorders,orDSM.AccordingtotheDSM,there
arefourbasictypesofbipolardisorder:
1. BipolarIDisorderismainlydenedbymanicormixedepisodesthatlastat
leastsevendays,orbymanicsymptomsthataresoseverethattheperson
needsimmediatehospitalcare.Usually,thepersonalsohasdepressiveepi-
sodes,typicallylastingatleasttwoweeks.Thesymptomsofmaniaordepres-
sionmustbeamajorchangefromthepersonsnormalbehavior.

BipolarDisorder 5
2. BipolarIIDisorderisdenedbyapatternofdepres-
siveepisodesshiftingbackandforthwithhypomanic
episodes,butnofull-blownmanicormixedepisodes.
3. BipolarDisorderNotOtherwiseSpecied
(BP-NOS)isdiagnosedwhenapersonhassymp-
tomsoftheillnessthatdonotmeetdiagnosticcriteria
foreitherbipolarIorII.Thesymptomsmaynotlast
longenough,orthepersonmayhavetoofewsymp-
toms,tobediagnosedwithbipolarIorII.However,
thesymptomsareclearlyoutofthepersonsnormal
rangeofbehavior.
4. CyclothymicDisorder,orCyclothymia,isamildformofbipolardisorder.
Peoplewhohavecyclothymiahaveepisodesofhypomaniathatshiftbackand
forthwithmilddepressionforatleasttwoyears.However,thesymptomsdonot
meetthediagnosticrequirementsforanyothertypeofbipolardisorder.
Somepeoplemaybediagnosedwithrapid-cyclingbipolardisorder.Thisiswhen
apersonhasfourormoreepisodesofmajordepression,mania,hypomania,or
mixedsymptomswithinayear.
2
Somepeopleexperiencemorethanoneepisode
inaweek,orevenwithinoneday.Rapidcyclingseemstobemorecommonin
peoplewhohaveseverebipolardisorderandmaybemorecommoninpeople
whohavetheirrstepisodeatayoungerage.Onestudyfoundthatpeoplewith
rapidcyclinghadtheirrstepisodeaboutfouryearsearlier,duringmidtolateteen
years,thanpeoplewithoutrapidcyclingbipolardisorder.
3
Rapidcyclingaffects
morewomenthanmen.
4
Bipolardisordertendstoworsenifitisnottreated.Overtime,apersonmaysuffer
morefrequentandmoresevereepisodesthanwhentheillnessrstappeared.
5
Also,delaysingettingthecorrectdiagnosisandtreatmentmakeapersonmore
likelytoexperiencepersonal,social,andwork-relatedproblems.
6
Properdiagnosisandtreatmenthelpspeoplewithbipolardisorderleadhealthy
andproductivelives.Inmostcases,treatmentcanhelpreducethefrequencyand
severityofepisodes.

6 NationalInstituteofMentalHealth
Whatillnessesoftenco-exist
withbipolardisorder?
Substanceabuseisverycommonamongpeople
withbipolardisorder,butthereasonsforthislinkare
unclear.
7
Somepeoplewithbipolardisordermaytryto
treattheirsymptomswithalcoholordrugs.However,
substanceabusemaytriggerorprolongbipolarsymp-
toms,andthebehavioralcontrolproblemsassociated
withmaniacanresultinapersondrinkingtoomuch.
Anxietydisorders,suchaspost-traumaticstressdisorder(PTSD)andsocial
phobia,alsoco-occuroftenamongpeoplewithbipolardisorder.
8-10
Bipolardisor-
deralsoco-occurswithattentiondecithyperactivitydisorder(ADHD),whichhas
somesymptomsthatoverlapwithbipolardisorder,suchasrestlessnessandbeing
easilydistracted.
Peoplewithbipolardisorderarealsoathigherriskforthyroiddisease,migraine
headaches,heartdisease,diabetes,obesity,andotherphysicalillnesses.
10,11
Theseillnessesmaycausesymptomsofmaniaordepression.Theymayalsoresult
fromtreatmentforbipolardisorder(seeLithiumandThyroidFunctionsectionon
page10).
Otherillnessescanmakeithardtodiagnoseandtreatbipolardisorder.People
withbipolardisordershouldmonitortheirphysicalandmentalhealth.Ifasymptom
doesnotgetbetterwithtreatment,theyshouldtelltheirdoctor.
Whataretheriskfactorsforbipolardisorder?
Scientistsarelearningaboutthepossiblecausesofbipolardisorder.Mostscien-
tistsagreethatthereisnosinglecause.Rather,manyfactorslikelyacttogetherto
producetheillnessorincreaserisk.
Genetics
Bipolardisordertendstoruninfamilies,soresearchersarelookingforgenesthat
mayincreaseapersonschanceofdevelopingtheillness.Genesarethebuild-
ingblocksofheredity.Theyhelpcontrolhowthebodyandbrainworkandgrow.
Genesarecontainedinsideapersonscellsthatarepasseddownfromparentsto
children.

BipolarDisorder 7
Childrenwithaparentorsiblingwhohasbipolardisorderarefourtosixtimes
morelikelytodeveloptheillness,comparedwithchildrenwhodonothaveafamily
historyofbipolardisorder.
12
However,mostchildrenwithafamilyhistoryofbipolar
disorderwillnotdeveloptheillness.
Geneticresearchonbipolardisorderisbeinghelpedby
advancesintechnology.Thistypeofresearchisnow
muchquickerandmorefar-reachingthaninthepast.One
exampleisthelaunchoftheBipolarDisorderPhenome
Database,fundedinpartbyNIMH.Usingthedatabase,
scientistswillbeabletolinkvisiblesignsofthedisorder
withthegenesthatmayinuencethem.Sofar,researchers
usingthisdatabasefoundthatmostpeoplewithbipolar
disorderhad:
13
Missedworkbecauseoftheirillness
Otherillnessesatthesametime,especiallyalcoholand/orsubstanceabuse
andpanicdisorders
Beentreatedorhospitalizedforbipolardisorder.
Theresearchersalsoidentiedcertaintraitsthatappearedtoruninfamilies,
including:
Historyofpsychiatrichospitalization
Co-occurringobsessive-compulsivedisorder(OCD)
Ageatrstmanicepisode
Numberandfrequencyofmanicepisodes.
Scientistscontinuetostudythesetraits,whichmayhelpthemndthegenesthat
causebipolardisordersomeday.
Butgenesarenottheonlyriskfactorforbipolardisorder.Studiesofidenticaltwins
haveshownthatthetwinofapersonwithbipolarillnessdoesnotalwaysdevelop
thedisorder.Thisisimportantbecauseidenticaltwinsshareallofthesamegenes.
Thestudyresultssuggestfactorsbesidesgenesarealsoatwork.Rather,itis
likelythatmanydifferentgenesandapersonsenvironmentareinvolved.However,
scientistsdonotyetfullyunderstandhowthesefactorsinteracttocausebipolar
disorder.

8 NationalInstituteofMentalHealth
Brainstructureandfunctioning
Brain-imagingstudiesarehelpingscientistslearnwhat
happensinthebrainofapersonwithbipolardisorder.
14,15
Newerbrain-imagingtools,suchasfunctionalmagnetic
resonanceimaging(fMRI)andpositronemissiontomogra-
phy(PET),allowresearcherstotakepicturesoftheliving
brainatwork.Thesetoolshelpscientistsstudythebrains
structureandactivity.
Someimagingstudiesshowhowthebrainsofpeoplewithbipolardisordermay
differfromthebrainsofhealthypeopleorpeoplewithothermentaldisorders.
Forexample,onestudyusingMRIfoundthatthepatternofbraindevelopmentin
childrenwithbipolardisorderwassimilartothatinchildrenwithmulti-dimensional
impairment,adisorderthatcausessymptomsthatoverlapsomewhatwithbipolar
disorderandschizophrenia.
16
Thissuggeststhatthecommonpatternofbrain
developmentmaybelinkedtogeneralriskforunstablemoods.
Learningmoreaboutthesedifferences,alongwithinformationgainedfromgenetic
studies,helpsscientistsbetterunderstandbipolardisorder.Somedayscientists
maybeabletopredictwhichtypesoftreatmentwillworkmosteffectively.They
mayevenndwaystopreventbipolardisorder.
Howisbipolardisorderdiagnosed?
Therststepingettingaproperdiagnosisisto
talktoadoctor,whomayconductaphysical
examination,aninterview,andlabtests.Bipolar
disordercannotcurrentlybeidentiedthrough
abloodtestorabrainscan,butthesetestscan
helpruleoutothercontributingfactors,suchas
astrokeorbraintumor.Iftheproblemsarenot
causedbyotherillnesses,thedoctormayconductamentalhealthevaluation.The
doctormayalsoprovideareferraltoatrainedmentalhealthprofessional,suchas
apsychiatrist,whoisexperiencedindiagnosingandtreatingbipolardisorder.
Thedoctorormentalhealthprofessionalshouldconductacompletediagnostic
evaluation.Heorsheshoulddiscussanyfamilyhistoryofbipolardisorderorother
mentalillnessesandgetacompletehistoryofsymptoms.Thedoctorormental
healthprofessionalsshouldalsotalktothepersonscloserelativesorspouseand
notehowtheydescribethepersonssymptomsandfamilymedicalhistory.

BipolarDisorder 9
Peoplewithbipolardisorderaremorelikelytoseekhelpwhentheyaredepressed
thanwhenexperiencingmaniaorhypomania.
17
Therefore,acarefulmedicalhistory
isneededtoassurethatbipolardisorderisnotmistakenlydiagnosedasmajor
depressivedisorder,whichisalsocalledunipolardepression.Unlikepeoplewith
bipolardisorder,peoplewhohaveunipolardepressiondonotexperiencemania.
Wheneverpossible,previousrecordsandinputfromfamilyandfriendsshouldalso
beincludedinthemedicalhistory.
Howisbipolardisordertreated?
Todate,thereisnocureforbipolardisorder.Butpropertreatmenthelpsmost
peoplewithbipolardisordergainbettercontroloftheirmoodswingsandrelated
symptoms.
18-20
Thisisalsotrueforpeoplewiththemostsevereformsoftheillness.
Becausebipolardisorderisalifelongandrecurrentillness,peoplewiththedisor-
derneedlong-termtreatmenttomaintaincontrolofbipolarsymptoms.Aneffective
maintenancetreatmentplanincludesmedicationandpsychotherapyforpreventing
relapseandreducingsymptomseverity.
21
Medications
Bipolardisordercanbediagnosedandmedicationspre-
scribedbypeoplewithanM.D.(doctorofmedicine).
Usually,bipolarmedicationsareprescribedbyapsychia-
trist.Insomestates,clinicalpsychologists,psychiatric
nursepractitioners,andadvancedpsychiatricnursespecial-
istscanalsoprescribemedications.Checkwithyourstates
licensingagencytondoutmore.
Noteveryonerespondstomedicationsinthesameway.Severaldifferentmedica-
tionsmayneedtobetriedbeforethebestcourseoftreatmentisfound.
Keepingachartofdailymoodsymptoms,treatments,sleeppatterns,andlife
eventscanhelpthedoctortrackandtreattheillnessmosteffectively.Sometimes
thisiscalledadailylifechart.Ifapersonssymptomschangeorifsideeffects
becomeserious,thedoctormayswitchoraddmedications.
Someofthetypesofmedicationsgenerallyusedtotreatbipolardisorderarelisted
onthenextpage.Informationonmedicationscanchange.Forthemostuptodate
informationonuseandsideeffectscontacttheU.S.FoodandDrugAdministration
(FDA)athttp://www.fda.gov.

10 NationalInstituteofMentalHealth
1. Moodstabilizingmedicationsareusuallytherstchoicetotreatbipolar
disorder.Ingeneral,peoplewithbipolardisordercontinuetreatmentwithmood
stabilizersforyears.Exceptforlithium,manyofthesemedicationsareanti-
convulsants.Anticonvulsantmedicationsareusuallyusedtotreatseizures,but
theyalsohelpcontrolmoods.Thesemedicationsarecommonlyusedasmood
stabilizersinbipolardisorder:
Lithium(sometimesknownasEskalithorLithobid)wastherstmood-stabilizing
medicationapprovedbytheU.S.FoodandDrugAdministration(FDA)inthe
1970sfortreatmentofmania.Itisoftenveryeffectiveincontrollingsymptoms
ofmaniaandpreventingtherecurrenceofmanicanddepressiveepisodes.
Valproicacidordivalproexsodium(Depakote),approvedbytheFDAin1995
fortreatingmania,isapopularalternativetolithiumforbipolardisorder.Itis
generallyaseffectiveaslithiumfortreatingbipolardisorder.
23,24
Alsoseethe
sectioninthisbooklet,Shouldyoungwomentakevalproicacid?
Morerecently,theanticonvulsantlamotrigine(Lamictal)receivedFDA
approvalformaintenancetreatmentofbipolardisorder.
Otheranticonvulsantmedications,includinggabapentin(Neurontin),topi-
ramate(Topamax),andoxcarbazepine(Trileptal)aresometimesprescribed.
Nolargestudieshaveshownthatthesemedicationsaremoreeffectivethan
moodstabilizers.
Valproicacid,lamotrigine,andotheranticonvulsantmedicationshaveanFDA
warning.Thewarningstatesthattheirusemayincreasetheriskofsuicidal
thoughtsandbehaviors.Peopletakinganticonvulsantmedicationsforbipolaror
otherillnessesshouldbecloselymonitoredforneworworseningsymptomsof
depression,suicidalthoughtsorbehavior,oranyunusualchangesinmoodor
behavior.Peopletakingthesemedicationsshouldnotmakeanychangeswith-
outtalkingtotheirhealthcareprofessional.
LithiumandThyroidFunction
People with bipolar disorder often have thyroid gland problems. Lithium treatment may also
cause low thyroid levels in some people.
22
Low thyroid function, called hypothyroidism, has been
associated with rapid cycling in some people with bipolar disorder, especially women.
Because too much or too little thyroid hormone can lead to mood and energy changes, it is
important to have a doctor check thyroid levels carefully. A person with bipolar disorder may
need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid
levels balanced.

BipolarDisorder 11
Shouldyoungwomentakevalproicacid?
Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to
polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20.
25, 26
PCOS causes a womans eggs to develop into cysts, or uid lled sacs that collect in the ovaries
instead of being released by monthly periods. This condition can cause obesity, excess body hair,
disruptions in the menstrual cycle, and other serious symptoms. Most of these symptoms will
improve after stopping treatment with valproic acid.
27
Young girls and women taking valproic acid
should be monitored carefully by a doctor.
2. Atypicalantipsychoticmedicationsaresometimesusedtotreatsymptoms
ofbipolardisorder.Often,thesemedicationsaretakenwithothermedica-
tions.Atypicalantipsychoticmedicationsarecalledatypicaltosetthemapart
fromearliermedications,whicharecalledconventionalorrst-generation
antipsychotics.
Olanzapine(Zyprexa),whengivenwithanantidepressantmedication,may
helprelievesymptomsofseveremaniaorpsychosis.
28
Olanzapineisalso
availableinaninjectableform,whichquicklytreatsagitationassociated
withamanicormixedepisode.Olanzapinecanbeusedformaintenance
treatmentofbipolardisorderaswell,evenwhenapersondoesnothave
psychoticsymptoms.However,somestudiesshowthatpeopletaking
olanzapinemaygainweightandhaveothersideeffectsthatcanincrease
theirriskfordiabetesandheartdisease.Thesesideeffectsaremorelikely
inpeopletakingolanzapinewhencomparedwithpeopleprescribedother
atypicalantipsychotics.
Aripiprazole(Abilify),likeolanzapine,isapprovedfortreatmentofamanic
ormixedepisode.Aripiprazoleisalsousedformaintenancetreatmentafter
asevereorsuddenepisode.Aswitholanzapine,aripiprazolealsocanbe
injectedforurgenttreatmentofsymptomsofmanicormixedepisodesof
bipolardisorder.
Quetiapine(Seroquel)relievesthesymptomsofsevereandsuddenmanic
episodes.Inthatway,quetiapineislikealmostallantipsychotics.In2006,it
becametherstatypicalantipsychotictoalsoreceiveFDAapprovalforthe
treatmentofbipolardepressiveepisodes.
Risperidone(Risperdal)andziprasidone(Geodon)areotheratypicalantipsy-
choticsthatmayalsobeprescribedforcontrollingmanicormixedepisodes.

12 NationalInstituteofMentalHealth
3. Antidepressantmedicationsaresometimesusedtotreatsymptomsof
depressioninbipolardisorder.Peoplewithbipolardisorderwhotakeantide-
pressantsoftentakeamoodstabilizertoo.Doctorsusuallyrequirethisbecause
takingonlyanantidepressantcanincreaseapersonsriskofswitchingto
maniaorhypomania,orofdevelopingrapidcyclingsymptoms.
29
Topreventthis
switch,doctorswhoprescribeantidepressantsfortreatingbipolardisorderalso
usuallyrequirethepersontotakeamood-stabilizingmedicationatthesame
time.
Recently,alarge-scale,NIMH-fundedstudyshowedthatformanypeople,add-
inganantidepressanttoamoodstabilizerisnomoreeffectiveintreatingthe
depressionthanusingonlyamoodstabilizer.
30
Fluoxetine(Prozac),paroxetine(Paxil),sertraline(Zoloft),andbupropion
(Wellbutrin)areexamplesofantidepressantsthatmaybeprescribedtotreat
symptomsofbipolardepression.
Somemedicationsarebetterattreatingonetypeofbipolarsymptomsthan
another.Forexample,lamotrigine(Lamictal)seemstobehelpfulincontrolling
depressivesymptomsofbipolardisorder.
What are the side effects of these medications?
Beforestartinganewmedication,peoplewithbipolar
disordershouldtalktotheirdoctoraboutthepossible
risksandbenets.
Thepsychiatristprescribingthemedicationorphar-
macistcanalsoanswerquestionsaboutsideeffects.
Overthelastdecade,treatmentshaveimproved,and
somemedicationsnowhavefewerormoretolerable
sideeffectsthanearliertreatments.However,everyone
respondsdifferentlytomedications.Insomecases,
sideeffectsmaynotappearuntilapersonhastakena
medicationforsometime.
Ifthepersonwithbipolardisorderdevelopsanyseveresideeffectsfromamedi-
cation,heorsheshouldtalktothedoctorwhoprescribeditassoonaspossible.
Thedoctormaychangethedoseorprescribeadifferentmedication.Peoplebeing
treatedforbipolardisordershouldnotstoptakingamedicationwithouttalkingto
adoctorrst.Suddenlystoppingamedicationmayleadtorebound,orworsen-
ingofbipolardisordersymptoms.Otheruncomfortableorpotentiallydangerous
withdrawaleffectsarealsopossible.

BipolarDisorder 13
FDAWarningonAntidepressants
Antidepressants are safe and popular, but some studies have suggested that they may have unin-
tentional effects on some people, especially in adolescents and young adults. The FDA warning
says that patients of all ages taking antidepressants should be watched closely, especially during
the rst few weeks of treatment. Possible side effects to look for are depression that gets worse,
suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping,
agitation, or withdrawal from normal social situations. Families and caregivers should report any
changes to the doctor. The latest information from the FDA can be found at http://www.fda.gov.
Thefollowingsectionsdescribesomecommonsideeffectsofthedifferenttypes
ofmedicationsusedtotreatbipolardisorder.
1. Mood Stabilizers
Insomecases,lithiumcancausesideeffectssuchas:
Restlessness
Drymouth
Bloatingorindigestion
Acne
Unusualdiscomforttocoldtemperatures
Jointormusclepain
Brittlenailsorhair.
31
Lithiumalsocausessideeffectsnotlistedhere.Ifextremelybothersomeor
unusualsideeffectsoccur,tellyourdoctorassoonaspossible.
Ifapersonwithbipolardisorderisbeingtreatedwithlithium,itisimportantto
makeregularvisitstothetreatingdoctor.Thedoctorneedstocheckthelevelsof
lithiuminthepersonsblood,aswellaskidneyandthyroidfunction.

14 NationalInstituteofMentalHealth
Commonsideeffectsofothermoodstabilizing
medicationsinclude:
Drowsiness
Dizziness
Headache
Diarrhea
Constipation
Heartburn
Moodswings
Stuffedorrunnynose,orothercold-likesymptoms.
32-37
These medications may
also be linked with rare
but serious side effects.
Talk with the treating
doctor or a pharmacist to
make sure you under-
stand signs of serious
side effects for the medi-
cations youre taking.
2. Atypical Antipsychotics
Somepeoplehavesideeffectswhentheystarttakingatypicalantipsychotics.
Mostsideeffectsgoawayafterafewdaysandoftencanbemanagedsuccess-
fully.Peoplewhoaretakingantipsychoticsshouldnotdriveuntiltheyadjustto
theirnewmedication.Sideeffectsofmanyantipsychoticsinclude:
Drowsiness
Dizzinesswhenchangingpositions
Blurredvision
Rapidheartbeat
Sensitivitytothesun
Skinrashes
Menstrualproblemsforwomen.
Atypicalantipsychoticmedicationscancausemajorweightgainandchangesin
apersonsmetabolism.Thismayincreaseapersonsriskofgettingdiabetesand
highcholesterol.
38
Apersonsweight,glucoselevels,andlipidlevelsshouldbe
monitoredregularlybyadoctorwhiletakingthesemedications.
Inrarecases,long-termuseofatypicalantipsychoticdrugsmayleadtoacon-
ditioncalledtardivedyskinesia(TD).Theconditioncausesmusclemovements
thatcommonlyoccuraroundthemouth.ApersonwithTDcannotcontrolthese
moments.TDcanrangefrommildtosevere,anditcannotalwaysbecured.Some
peoplewithTDrecoverpartiallyorfullyaftertheystoptakingthedrug.

BipolarDisorder 15
3. Antidepressants
Theantidepressantsmostcommonlyprescribedfortreatingsymptomsofbipolar
disordercanalsocausemildsideeffectsthatusuallydonotlastlong.Thesecan
include:
Headache,whichusuallygoesawaywithinafewdays.
Nausea(feelingsicktoyourstomach),whichusuallygoesawaywithinafewdays.
Sleepproblems,suchassleeplessnessordrowsiness.Thismayhappenduring
therstfewweeksbutthengoaway.Tohelplessentheseeffects,sometimes
themedicationdosecanbereduced,orthetimeofdayitistakencanbe
changed.
Agitation(feelingjittery).
Sexualproblems,whichcanaffectbothmenandwomen.Theseinclude
reducedsexdriveandproblemshavingandenjoyingsex.
Someantidepressantsaremorelikelytocausecertainsideeffectsthanother
types.Yourdoctororpharmacistcananswerquestionsaboutthesemedications.
Anyunusualreactionsorsideeffectsshouldbereportedtoadoctorimmediately.
Forthemostup-to-dateinformationonmedicationsfortreat-
ingbipolardisorderandtheirsideeffects,pleaseseethe
onlineNIMHMedicationsbookletathttp://www.nimh.nih.gov/
health/publications/medications/complete-publication.shtml.
Shouldwomenwhoarepregnantormaybecome
pregnanttakemedicationforbipolardisorder?
Women with bipolar disorder who are pregnant or may become pregnant
face special challenges. The mood stabilizing medications in use today
can harm a developing fetus or nursing infant.
39
But stopping medica-
tions, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur
during pregnancy.
40
Scientists are not sure yet, but lithium is likely the preferred mood-stabilizing medication for
pregnant women with bipolar disorder.
40, 41
However, lithium can lead to heart problems in the
fetus. Women need to know that most bipolar medications are passed on through breast milk.
41
Pregnant women and nursing mothers should talk to their doctors about the benets and risks of
all available treatments.

16 NationalInstituteofMentalHealth
Psychotherapy
Inadditiontomedication,psychotherapy,ortalktherapy,canbeaneffective
treatmentforbipolardisorder.Itcanprovidesupport,education,andguidanceto
peoplewithbipolardisorderandtheirfamilies.Somepsychotherapytreatments
usedtotreatbipolardisorderinclude:
1. Cognitivebehavioraltherapy(CBT)helpspeoplewithbipolardisorderlearnto
changeharmfulornegativethoughtpatternsandbehaviors.
2. Family-focusedtherapyincludesfamilymembers.Ithelpsenhancefamily
copingstrategies,suchasrecognizingnewepisodesearlyandhelpingtheir
lovedone.Thistherapyalsoimprovescommunicationandproblem-solving.
3. Interpersonalandsocialrhythmtherapy
helpspeoplewithbipolardisorderimprove
theirrelationshipswithothersandmanagetheir
dailyroutines.Regulardailyroutinesandsleep
schedulesmayhelpprotectagainstmanic
episodes.
4. Psychoeducationteachespeoplewithbipo-
lardisorderabouttheillnessanditstreatment.
Thistreatmenthelpspeoplerecognizesignsof
relapsesotheycanseektreatmentearly,before
afull-blownepisodeoccurs.Usuallydoneinagroup,psychoeducationmay
alsobehelpfulforfamilymembersandcaregivers.
Alicensedpsychologist,socialworker,orcounselortypicallyprovidesthese
therapies.Thismentalhealthprofessionaloftenworkswiththepsychiatristto
trackprogress.Thenumber,frequency,andtypeofsessionsshouldbebasedon
thetreatmentneedsofeachperson.Aswithmedication,followingthedoctors
instructionsforanypsychotherapywillprovidethegreatestbenet.
Formoreinformation,seetheSubstanceAbuseandMentalHealth
ServicesAdministrationWebpageonchoosingamentalhealththerapistat
http://mentalhealth.samhsa.gov/publications/allpubs/KEN98-0055/default.asp.

BipolarDisorder 17
Recently,NIMHfundedaclinicaltrialcalledtheSystematicTreatmentEnhancement
ProgramforBipolarDisorder(STEP-BD).Thiswasthelargesttreatmentstudyever
conductedforbipolardisorder(informationathttp://www.nimh.nih.gov/health/trials/
practical/step-bd/index.shtml).Inastudyonpsychotherapies,STEP-BDresearch-
erscomparedpeopleintwogroups.Therstgroupwastreatedwithcollabora-
tivecare(threesessionsofpsychoeducationoversixweeks).Thesecondgroup
wastreatedwithmedicationandintensivepsychotherapy(30sessionsovernine
monthsofCBT,interpersonalandsocialrhythmtherapy,orfamily-focusedther-
apy).Researchersfoundthatthesecondgrouphadfewerrelapses,lowerhospital-
izationrates,andwerebetterabletostickwiththeirtreatmentplans.
42
Theywere
alsomorelikelytogetwellfasterandstaywelllonger.
NIMHissupportingmoreresearchonwhichcombinationsofpsychotherapy
andmedicationworkbest.Thegoalistohelppeoplewithbipolardisorderlive
symptom-freeforlongerperiodsandtorecoverfromepisodesmorequickly.
Researchersalsohopetodeterminewhetherpsychotherapyhelpsdelaythestart
ofbipolardisorderinchildrenathighriskfortheillness.
Formoreinformationonpsychotherapy,visittheNIMHWebsiteat
http://www.nimh.nih.gov/health/topics/treatment/index.shtml.
Othertreatments
1. ElectroconvulsiveTherapy(ECT)Forcasesinwhichmedicationand/orpsy-
chotherapydoesnotwork,electroconvulsivetherapy(ECT)maybeuseful.ECT,
formerlyknownasshocktherapy,oncehadabadreputation.Butinrecent
years,ithasgreatlyimprovedandcanprovidereliefforpeoplewithsevere
bipolardisorderwhohavenotbeenabletofeelbetterwithothertreatments.
BeforeECTisadministered,apatienttakesamusclerelaxantandisputunder
briefanesthesia.Heorshedoesnotconsciouslyfeeltheelectricalimpulse
administeredinECT.Onaverage,ECTtreatmentslastfrom3090seconds.
PeoplewhohaveECTusuallyrecoverafter515minutesandareabletogo
homethesameday.
43
SometimesECTisusedforbipolarsymptomswhenothermedicalconditions,
includingpregnancy,maketheuseofmedicationstoorisky.ECTisahighly
effectivetreatmentforseverelydepressive,manic,ormixedepisodes,butis
generallynotarst-linetreatment.

18 NationalInstituteofMentalHealth
ECTmaycausesomeshort-termsideeffects,includingconfusion,disorientation,
andmemoryloss.Butthesesideeffectstypicallyclearsoonaftertreatment.
PeoplewithbipolardisordershoulddiscusspossiblebenetsandrisksofECT
withanexperienceddoctor.
44
2. SleepMedicationsPeoplewithbipolardisorderwhohavetroublesleep-
ingusuallysleepbetteraftergettingtreatmentforbipolardisorder.However,if
sleeplessnessdoesnotimprove,thedoctormaysuggestachangeinmedica-
tions.Iftheproblemsstillcontinue,thedoctormayprescribesedativesorother
sleepmedications.
Peoplewithbipolardisordershouldtelltheirdoctoraboutallprescriptiondrugs,
over-the-countermedications,orsupplementstheyaretaking.Certainmedications
andsupplementstakentogethermaycauseunwantedordangerouseffects.
HerbalSupplements
In general, there is not much research about herbal or natural supplements. Little is known about
their effects on bipolar disorder. An herb called St. Johns wort (Hypericum perforatum ), often
marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar
disorder.
45
St. Johns wort can also make other medications less effective, including some antide-
pressant and anticonvulsant medications.
46
Scientists are also researching omega-3 fatty acids
(most commonly found in sh oil) to measure their usefulness for long-term treatment of bipolar
disorder.
47
Study results have been mixed.
48
It is important to talk with a doctor before taking any
herbal or natural supplements because of the serious risk of interactions with other medications.

BipolarDisorder 19
Whatcanpeoplewithbipolardisorderexpect
fromtreatment?
Bipolardisorderhasnocure,butcanbeeffectivelytreatedoverthelong-term.
Itisbestcontrolledwhentreatmentiscontinuous,ratherthanonandoff.Inthe
STEP-BDstudy,alittlemorethanhalfofthepeopletreatedforbipolardisorder
recoveredoveroneyearstime.Forthisstudy,recoverymeanthavingtwoorfewer
symptomsofthedisorderforatleasteightweeks.
However,evenwithpropertreatment,moodchangescan
occur.IntheSTEP-BDstudy,almosthalfofthosewho
recoveredstillhadlingeringsymptoms.Thesepeople
experiencedarelapseorrecurrencethatwasusuallya
returntoadepressivestate.
49
Ifapersonhadamental
illnessinadditiontobipolardisorder,heorshewasmore
likelytoexperiencearelapse.
49
Scientistsareunsure,
however,howtheseotherillnessesorlingeringsymp-
tomsincreasethechanceofrelapse.Forsomepeople,
combiningpsychotherapywithmedicationmayhelpto
preventordelayrelapse.
42
Treatmentmaybemoreeffectivewhenpeopleworkcloselywithadoctorandtalk
openlyabouttheirconcernsandchoices.Keepingtrackofmoodchangesand
symptomswithadailylifechartcanhelpadoctorassessapersonsresponseto
treatments.Sometimesthedoctorneedstochangeatreatmentplantomakesure
symptomsarecontrolledmosteffectively.Apsychiatristshouldguideanychanges
intypeordoseofmedication.
HowcanIhelpafriendorrelativewhohas
bipolardisorder?
Ifyouknowsomeonewhohasbipolardisorder,itaffectsyoutoo.Therstand
mostimportantthingyoucandoishelphimorhergettherightdiagnosisand
treatment.Youmayneedtomaketheappointmentandgowithhimorhertosee
thedoctor.Encourageyourlovedonetostayintreatment.
Tohelpafriendorrelative,youcan:
Offeremotionalsupport,understanding,patience,andencouragement
Learnaboutbipolardisordersoyoucanunderstandwhatyourfriendorrelative
isexperiencing
Talktoyourfriendorrelativeandlistencarefully

20 NationalInstituteofMentalHealth
Listentofeelingsyourfriendorrelativeexpressesbe
understandingaboutsituationsthatmaytriggerbipolar
symptoms
Inviteyourfriendorrelativeoutforpositivedistractions,
suchaswalks,outings,andotheractivities
Remindyourfriendorrelativethat,withtimeandtreat-
ment,heorshecangetbetter.
Neverignorecommentsaboutyourfriendorrelativeharminghimselforherself.
Alwaysreportsuchcommentstohisorhertherapistordoctor.
Supportforcaregivers
Likeotherseriousillnesses,bipolardisordercanbedifcultforspouses,family
members,friends,andothercaregivers.Relativesandfriendsoftenhavetocope
withthepersonsseriousbehavioralproblems,suchaswildspendingspreesduring
mania,extremewithdrawalduringdepression,poorworkorschoolperformance.
Thesebehaviorscanhavelastingconsequences.
Caregiversusuallytakecareofthemedicalneedsoftheirlovedones.Thecaregiv-
ershavetodealwithhowthisaffectstheirownhealth.Thestressthatcaregiversare
undermayleadtomissedworkorlostfreetime,strainedrelationshipswithpeople
whomaynotunderstandthesituation,andphysicalandmentalexhaustion.
Stressfromcaregivingcanmakeithardtocopewithalovedonesbipolarsymp-
toms.Onestudyshowsthatifacaregiverisunderalotofstress,hisorherloved
onehasmoretroublefollowingthetreatmentplan,whichincreasesthechancefor
amajorbipolarepisode.
50
Itisimportantthatpeoplecaringforthosewithbipolar
disorderalsotakecareofthemselves.
HowcanIhelpmyselfifIhavebipolardisorder?
Itmaybeveryhardtotakethatrststeptohelpyourself.Itmaytaketime,butyou
cangetbetterwithtreatment.
Tohelpyourself:
Talktoyourdoctorabouttreatmentoptionsandprogress
Keeparegularroutine,suchaseatingmealsatthesametimeeverydayand
goingtosleepatthesametimeeverynight
Trytogetenoughsleep
Stayonyourmedication

BipolarDisorder 21
Learnaboutwarningsignssignalingashiftintodepressionormania
Expectyoursymptomstoimprovegradually,notimmediately.
WherecanIgoforhelp?
Ifyouareunsurewheretogoforhelp,askyourfamilydoctor.Otherswhocan
helparelistedbelow.
Mentalhealthspecialists,suchaspsychiatrists,psychologists,socialwork-
ers,ormentalhealthcounselors
Healthmaintenanceorganizations
Communitymentalhealthcenters
Hospitalpsychiatrydepartmentsandoutpatientclinics
Mentalhealthprogramsatuniversitiesormedicalschools
Statehospitaloutpatientclinics
Familyservices,socialagencies,orclergy
Peersupportgroups
Privateclinicsandfacilities
Employeeassistanceprograms
Localmedicaland/orpsychiatricsocieties.
Youcanalsocheckthephonebookundermentalhealth,health,social
services,hotlines,orphysiciansforphonenumbersandaddresses.An
emergencyroomdoctorcanalsoprovidetemporaryhelpandcantellyou
whereandhowtogetfurtherhelp.
WhatifIorsomeoneIknowisincrisis?
Ifyouarethinkingaboutharmingyourself,orknowsomeonewhois,tellsomeone
whocanhelpimmediately.
Callyourdoctor.
Call911orgotoahospitalemergencyroomtogetimmediatehelporaska
friendorfamilymembertohelpyoudothesethings.
Callthetoll-free,24-hourhotlineoftheNationalSuicidePreventionLifelineat
1800273TALK(18002738255);TTY:18007994TTY(4889)totalktoa
trainedcounselor.
Makesureyouorthesuicidalpersonisnotleftalone.

22 NationalInstituteofMentalHealth
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26 NationalInstituteofMentalHealth
Formoreinformationonbipolardisorder
VisittheNationalLibraryofMedicines:
MedlinePlus
http://medlineplus.gov
EnEspaol
http://medlineplus.gov/spanish
Forinformationonclinicaltrialsforbipolardisorder:
NIMHsupportedclinicaltrials
http://www.nimh.nih.gov/health/trials/index.shtml
NationalLibraryofMedicineClinicalTrialsDatabase:
http://www.clinicaltrials.gov
ClinicaltrialsatNIMHinBethesda,MD
http://patientinfo.nimh.nih.gov
InformationfromNIMHisavailableinmultipleformats.Youcanbrowseonline,
downloaddocumentsinPDF,andordermaterialsthroughthemail.Checkthe
NIMHWebsiteathttp://www.nimh.nih.govforthelatestinformationonthistopic
andtoorderpublications.
IfyoudonothaveInternetaccesspleasecontacttheNIMHInformationResource
Centeratthenumberslistedbelow.
NationalInstituteofMentalHealth
ScienceWriting,Press&DisseminationBranch
6001ExecutiveBoulevard
Room8184,MSC9663
Bethesda,MD20892-9663
Phone:301-443-4513or
1-866-615-NIMH(6464)toll-free
TTY:301-443-8431or
1-866-415-8051toll-free
FAX:301-443-4279
E-mail:nimhinfo@nih.gov
Website:http://www.nimh.nih.gov

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 09-3679
Revised 2008
Reprinted 2009