Understanding Bipolar disorder
Bipolar disorder, formerly called manic depression, causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts in the other direction, you may feel euphoric and full of energy. Mood shifts may occur only a few times a year or as often as several times a week.
Although bipolar disorder is a disruptive, long-term condition, you can keep your moods in check by following a treatment plan. In most cases, bipolar disorder can be controlled with medications and psychological counseling (psychotherapy).
There are several types of bipolar and related disorders. For each type, the exact symptoms of bipolar disorder can vary from person to person. Bipolar I and bipolar II disorders also have additional specific features that can be added to the diagnosis based on your particular signs and symptoms.
Criteria for bipolar disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing bipolar and related disorders. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
Diagnostic criteria for bipolar and related disorders are based on the specific type of disorder:
Bipolar I disorder. You've had at least one manic episode. The manic episode may be preceded by or followed by hypomanic or major depressive episodes. Mania symptoms cause significant impairment in your life and may require hospitalization or trigger a break from reality (psychosis).
Bipolar II disorder. You've had at least one major depressive episode lasting at least two weeks and at least one hypomanic episode lasting at least four days, but you've never had a manic episode. Major depressive episodes or the unpredictable changes in mood and behavior can cause distress or difficulty in areas of your life.
Cyclothymic disorder. You've had at least two years — or one year in children and teenagers — of numerous periods of hypomania symptoms (less severe than a hypomanic episode) and periods of depressive symptoms (less severe than a major depressive episode). During that time, symptoms occur at least half the time and never go away for more than two months. Symptoms cause significant distress in important areas of your life.
Other types. These include, for example, bipolar and related disorder due to another medical condition, such as Cushing's disease, multiple sclerosis or stroke. Another type is called substance and medication-induced bipolar and related disorder.
Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.
Criteria for a manic or hypomanic episode
The DSM-5 has specific criteria for the diagnosis of manic and hypomanic episodes:
A manic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). The episode includes persistently increased goal-directed activity or energy.
A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least four consecutive days.
For both a manic and a hypomanic episode, during the period of disturbed mood and increased energy, three or more of the following symptoms (four if the mood is only irritable) must be present and represent a noticeable change from your usual behavior:
Inflated self-esteem or grandiosity
Decreased need for sleep (for example, you feel rested after only three hours of sleep)
Increased goal-directed activity (either socially, at work or school, or sexually) or agitation
Doing things that are unusual and that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments
To be considered a manic episode:
The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in social activities or relationships; or to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.
To be considered a hypomanic episode:
The episode is a distinct change in mood and functioning that is not characteristic of you when the symptoms are not present, and enough of a change that other people notice.
The episode isn't severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn't require hospitalization or trigger a break from reality.
Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.
Criteria for a major depressive episode
The DSM-5 also lists criteria for diagnosis of a major depressive episode:
Five or more of the symptoms below over a two-week period that represent a change from previous mood and functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure.
Symptoms can be based on your own feelings or on the observations of someone else.
Signs and symptoms include:
Depressed mood most of the day, nearly every day, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
Markedly reduced interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
Either insomnia or sleeping excessively nearly every day
Either restlessness or slowed behavior that can be observed by others
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt, such as believing things that are not true, nearly every day
Decreased ability to think or concentrate, or indecisiveness, nearly every day
Recurrent thoughts of death or suicide, or suicide planning or attempt
To be considered a major depressive episode:
Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships
Symptoms are not due to the direct effects of something else, such as alcohol or drug use, a medication or a medical condition
Symptoms are not caused by grieving, such as after the loss of a loved one
Other signs and symptoms of bipolar disorder
Signs and symptoms of bipolar I and bipolar II disorders may include additional features.
Anxious distress — having anxiety, such as feeling keyed up, tense or restless, having trouble concentrating because of worry, fearing something awful may happen, or feeling you may not be able to control yourself
Mixed features — meeting the criteria for a manic or hypomanic episode, but also having some or all symptoms of major depressive episode at the same time
Melancholic features — having a loss of pleasure in all or most activities and not feeling significantly better, even when something good happens
Atypical features — experiencing symptoms that are not typical of a major depressive episode, such as having a significantly improved mood when something good happens
Catatonia — not reacting to your environment, holding your body in an unusual position, not speaking, or mimicking another person's speech or movement
Peripartum onset — bipolar disorder symptoms that occur during pregnancy or in the four weeks after delivery
Seasonal pattern — a lifetime pattern of manic, hypomanic or major depressive episodes that change with the seasons
Rapid cycling — having four or more mood swing episodes within a single year, with full or partial remission of symptoms in between manic, hypomanic or major depressive episodes
Psychosis — severe episode of either mania or depression (but not hypomania) that results in a detachment from reality and includes symptoms of false but strongly held beliefs (delusions) and hearing or seeing things that aren't there (hallucinations)
Symptoms in children and teens
The same DSM-5 criteria used to diagnose bipolar disorder in adults are used to diagnose children and teenagers. Children and teens may have distinct major depressive, manic or hypomanic episodes, between which they return to their usual behavior, but that's not always the case. And moods can rapidly shift during acute episodes.
Symptoms of bipolar disorder can be difficult to identify in children and teens. It's often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. And children who have bipolar disorder are frequently also diagnosed with other mental health conditions.
The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.
When to see a doctor
If you have any symptoms of depression or mania, see your doctor or mental health provider. Bipolar disorder doesn't get better on its own. Getting treatment from a mental health provider with experience in bipolar disorder can help you get your symptoms under control.
Many people with bipolar disorder don't get the treatment they need. Despite the mood extremes, people with bipolar disorder often don't recognize how much their emotional instability disrupts their lives and the lives of their loved ones.
And if you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out — and perhaps in financial, legal or relationship trouble.
If you're reluctant to seek treatment, confide in a friend or loved one, a health care professional, a faith leader or someone else you trust. He or she may be able to help you take the first steps to successful treatment.
When to get emergency help
Suicidal thoughts and behavior are common among people with bipolar disorder. If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.
Also consider these options:
Reach out to a close friend or loved one.
Contact a minister, spiritual leader or someone in your faith community.
Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor. Use that same number and press 1 to reach the Veterans Crisis Line.
Make an appointment with your doctor, mental health provider or other health care provider.
If you have a loved one who is in danger of committing suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.
The exact cause of bipolar disorder is unknown, but several factors may be involved, such as:
Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a significant role in bipolar disorder and other mood disorders.
Inherited traits. Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.
Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first episode include:
Having a first-degree relative, such as a parent or sibling, with bipolar disorder
Periods of high stress
Drug or alcohol abuse
Major life changes, such as the death of a loved one or other traumatic experiences
Conditions that commonly occur with bipolar disorder
If you have bipolar disorder, you may also have another health condition that's diagnosed before or after your diagnosis of bipolar disorder. Such conditions need to be diagnosed and treated because they may worsen existing bipolar disorder or make treatment less successful. They include:
Anxiety disorders. Examples include social anxiety disorder and generalized anxiety disorder.
Post-traumatic stress disorder (PTSD). Some people with PTSD, a trauma- and stressor-related disorder, also have bipolar disorder.
Attention-deficit/hyperactivity disorder (ADHD). ADHD has symptoms that overlap with bipolar disorder. For this reason, bipolar disorder can be difficult to differentiate from ADHD. Sometimes one is mistaken for the other. In some cases, a person may be diagnosed with both conditions.
Addiction or substance abuse. Many people with bipolar disorder also have alcohol, tobacco or drug problems. Drugs or alcohol may seem to ease symptoms, but they can actually trigger, prolong or worsen depression or mania.
Physical health problems. People diagnosed with bipolar disorder are more likely to have certain other health problems, such as heart disease, thyroid problems or obesity.
Left untreated, bipolar disorder can result in serious problems that affect every area of your life. These may include:
Problems related to drug and alcohol use
Suicide or suicide attempts
Isolation and loneliness
Poor work or school performance
Frequent absences from work or school
Tests and diagnosis
Appointments & care
Learn more. Request an appointment.
When doctors suspect someone has bipolar disorder, they typically do a number of tests and exams. These can help rule out other problems, pinpoint a diagnosis and also check for any related complications. These may include:
Physical exam. A physical exam and lab tests may be done to help identify any medical problems that could be causing your symptoms.
Psychological evaluation. Your doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms and possible episodes of mania or depression.
Mood charting. To identify exactly what's going on, your doctor may have you keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.
Signs and symptoms. Your doctor or mental health professional typically will compare your symptoms with the criteria for bipolar and related disorders in the Diagnostic and Statistical Manual of Mental Disorders to determine a diagnosis.
Diagnosis in children
Although bipolar disorder can occur in young children, typically it's diagnosed in the teenage years or early 20s. It's often hard to tell whether a child's emotional ups and downs are normal for his or her age, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.
Bipolar symptoms in children and teens often have different patterns than they do in adults and may not fit neatly into the categories used for diagnosis. And children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems.
Your child's doctor can help you learn the symptoms of bipolar disorder and how they differ from behavior related to your child's developmental age, the situation and appropriate cultural behavior.
Treatments and drugs
Appointments & care
Treatment is best guided by a psychiatrist skilled in treating bipolar and related disorders. You may have a treatment team that also includes a psychologist, social worker and psychiatric nurse.
Depending on your needs, treatment may include:
Initial treatment. Often, you'll need to start taking medications to balance your moods right away. Once your symptoms are under control, you'll work with your doctor to find the best long-term treatment.
Continued treatment. Bipolar disorder requires lifelong treatment, even during periods when you feel better. Maintenance treatment is used to manage bipolar disorder on a long-term basis. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
Day treatment programs. Your doctor may recommend a day treatment program. These programs provide the support and counseling you need while you get symptoms under control.
Substance abuse treatment. If you have problems with alcohol or drugs, you'll also need substance abuse treatment. Otherwise, it can be very difficult to manage bipolar disorder.
Hospitalization. Your doctor may recommend hospitalization if you're behaving dangerously, you feel suicidal or you become detached from reality (psychotic). Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you're having a manic or major depressive episode.
The primary treatments for bipolar disorder include medications and psychological counseling (psychotherapy), and may include education and support groups.
A number of medications are used to treat bipolar disorder. The types and doses of medications prescribed are based on your particular symptoms.
Medications may include:
Mood stabilizers. Whether you have bipolar I or II disorder, you'll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).
Antipsychotics. If symptoms of depression or mania persist in spite of treatment with other medications, adding an antipsychotic medication such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may help. Your doctor may prescribe some of these medications alone or along with a mood stabilizer.
Antidepressants. Your doctor may add an antidepressant to help manage depression. Because an antidepressant can sometimes trigger a manic episode, it's usually prescribed along with a mood stabilizer or antipsychotic.
Antidepressant-antipsychotic. The medication Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer. Symbyax is approved by the Food and Drug Administration specifically for the treatment of depressive episodes associated with bipolar I disorder.
Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep. Benzodiazepines are generally used for relieving anxiety only on a short-term basis.
Talk to your doctor or mental health provider about side effects. If side effects seem intolerable, you may be tempted to stop taking your medication or to reduce your dose on your own. Don't do it. You may experience withdrawal effects or your symptoms may return.
Side effects often improve as you find the right medications and doses that work for you, and your body adjusts to the medications.
Finding the right medication
Finding the right medication or medications for you will likely take some trial and error. If one doesn't work well for you, there are several others to try.
This process requires patience, as some medications need weeks to months to take full effect. Generally only one medication is changed at a time so that your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. Medications also may need to be adjusted as your symptoms change.
Medications and pregnancy
A number of medications for bipolar disorder can be associated with birth defects. Discuss these issues with your doctor:
Birth control options, as birth control medications may lose effectiveness when taken along with certain bipolar disorder medications
Treatment options if you plan to become pregnant
Breast-feeding, as some bipolar medications can pass through breast milk to your infant
Psychotherapy is a vital part of bipolar disorder treatment and can be provided in individual, family or group settings. Several types of therapy may be helpful. These include:
Cognitive behavioral therapy. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. It can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
Psychoeducation. Counseling to help you learn about bipolar disorder (psychoeducation) can help you and your loved ones understand bipolar disorder. Knowing what's going on can help you get the best support and treatment, and help you and your loved ones recognize warning signs of mood swings.
Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on the stabilization of daily rhythms, such as sleep, wake and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise.
Other therapies. Other therapies have been studied with some evidence of success. Ask your doctor if any other options may be appropriate for you.
Other treatment options
Depending on your needs, other treatments may be added to your depression therapy, such as:
Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. Physical side effects, such as headache, are tolerable. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide. ECT may be an option if you have mania or severe depression when you're pregnant and cannot take your regular medications.
Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, you sit in a reclining chair with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you'll have five treatments each week for up to six weeks.
Treatment in children and teenagers
Treatments for children and teenagers are generally decided on a case-by-case basis, depending on symptoms, medication side effects and other factors.
Medications. Children and teens with bipolar disorder are often prescribed the same types of medications as those used in adults. There's less research on the safety and effectiveness of bipolar medications in children than in adults, so treatment decisions are often based on adult research.
Psychotherapy. Most children diagnosed with bipolar disorder require counseling as part of initial treatment and to keep symptoms from returning. Psychotherapy can help children develop coping skills, address learning difficulties, resolve social problems, and help strengthen family bonds and communication. And, if needed, it can help treat substance abuse problems, common in older children with bipolar disorder.
Support. Working with teachers and school counselors and encouraging support from family and friends can help identify services and encourage success.
Coping and support
Coping with bipolar disorder can be challenging. Here are some strategies that can help:
Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan. Help educate your family and friends about what you're going through.
Stay focused on your goals. Recovery from bipolar disorder can take time. Stay motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
Learn ways to relax and manage stress. Yoga, tai chi, massage, meditation or other relaxation techniques can be helpful.
There's no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.
If you've been diagnosed with bipolar disorder, some strategies can help prevent minor symptoms from becoming full-blown episodes of mania or depression:
Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You and your caregivers may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you're falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.
Avoid drugs and alcohol. Using alcohol or street drugs can worsen your symptoms and make them more likely to come back.
Take your medications exactly as directed. You may be tempted to stop treatment — but don't. This can have immediate consequences — you may become very depressed, feel suicidal, or go into a manic or hypomanic episode. If you think you need to make a change, call your doctor.
Check first before taking other medications. Call the doctor who's treating you for bipolar disorder before you take medications prescribed by another doctor or any over-the-counter supplements or medications. Sometimes other medications trigger episodes of bipolar disorder or may interfere with medications you're already taking to treat bipolar disorder.