Bipolar disorder

Overview

• Bipolar disorder, also known as bipolar affective disorder, is a mood disorder. It used to be called manic depression.
• Bipolar disorder can cause your mood to swing from an extreme high to an extreme low.
• Manic symptoms can include increased energy, excitement, impulsive behaviour, and agitation.
• Depressive symptoms can include lack of energy, feeling worthless, low self-esteem and suicidal thoughts.
• You can also have psychotic symptoms. Psychotic symptoms can mean that you see and hear things that feel real, but they don’t exist.
• There are different types of bipolar disorder.
• We don’t know what causes bipolar. But it is thought to be a combination of genetic and environmental causes.
• Bipolar disorder is treated with medication or talking therapies.

About & symptoms

What is bipolar disorder?

Bipolar disorder can be a life-long mental health problem that mainly affects your mood. It affects how you feel, and your mood can change massively. You can experience episodes of:

• mania, and
• depression.

You may feel well between these times. When your mood changes, you might see changes in your energy levels or how you act.

Symptoms of bipolar disorder can be severe. They can affect areas of your life, such as work, school and relationships.

You usually develop bipolar disorder before you are 20. It can develop in later life, but it rarely develops after the age of 40.

You could have symptoms of bipolar disorder for some time before a doctor diagnoses you. A doctor might say you have something else such as depression before you get a bipolar disorder diagnosis. This is because diagnosing mental illnesses can be sometimes difficult for doctors. They usually can’t do things like blood tests and scans to help them.

Bipolar disorder used to be called manic depression.

What are the symptoms of bipolar disorder?

Bipolar disorder symptoms can make it difficult to deal with day-to-day life. It can have a bad effect on your relationships and work. The different types of symptoms are described below.

Mania

Symptoms of mania can include:

• feeling happy or excited, even if things aren’t going well for you,
• being full of new and exciting ideas,
• moving quickly from one idea to another,
• racing thoughts,
• talking very quickly,
• hearing voices that other people can’t hear,
• being more irritable than normal,
• feeling much better about yourself than usual,
• being easily distracted and struggle to focus on one topic,
• not being able to sleep, or feel that you don’t want to sleep,
• thinking you can do much more than you actually can,
• make unusual, or big decisions without thinking them through, and
• doing things you normally wouldn’t do which can cause problems. Such as:
  
  • spending a lot of money,
  • having casual sex with different people,
  • using drugs or alcohol,
  • gambling, or
  • making unwise decisions.

Hypomania

Hypomania is like mania but you will have milder symptoms.

Depression

Symptoms of depression can include:

• low mood,
• having less energy and feeling tired,
• feeling hopeless or negative,
• feeling guilty, worthless or helpless,
• being less interested in things you normally like doing,
• difficulty concentrating, remembering or making decisions,
• feeling restless or irritable,
• sleeping too much or not being able to sleep,
• eating less or over eating,
• losing or gaining weight, when you don’t mean to, and
• thoughts of death or suicide, or suicide attempts.

Psychosis

Sometimes you can have psychotic symptoms during a severe episode of mania or depression. Symptoms of psychosis can be:

• hallucinations. This means that you may hear, see, or feel things that are not there, and
• delusions. This means you may believe things that aren’t true. Other people will usually find your beliefs unusual.

Psychotic symptoms in bipolar disorder can reflect your mood. For example, if you have a manic episode you may believe that you have special powers or are being monitored by the government. If you have depressive episode, you may feel very guilty about something you think you have done. You may feel that you are worse than anybody else or feel that you don't exist.

You can find more information about:

• Depression by clicking here.
• Psychosis by clicking here.

Types & causes

What are the different types of bipolar disorder?

There are different types of bipolar disorder.

What is bipolar disorder I disorder?

A diagnosis of bipolar I disorder means you will have had at least 1 episode of mania that lasts longer than 1 week. You may also have periods of depression. Manic episodes will generally last 3-6 months if left untreated. Depressive episodes will generally last 6-12 months without treatment.

What is bipolar II disorder?

A diagnosis of bipolar II disorder means it is common to have symptoms of depression. You will have had at least 1 period of major depression. And at least 1 period of hypomania instead of mania.

What is bipolar I or II disorder with mixed features?

You will experience symptoms of mania or hypomania and depression at the same time. You may hear this being called ‘mixed bipolar state’. You may feel very sad and hopeless at the same time as feeling restlessness and being overactive.

What is bipolar I or II disorder with rapid cycling?

Rapid cycling means you have had 4 or more depressive, manic or hypomanic episodes in a 12-month period.

What is bipolar I or II with seasonal pattern?

Seasonal pattern means that either your depression, mania or hypomania is regularly affected in the same way by the seasons. For example, you may find that each winter you have a depressive episode, but your mania doesn’t regularly follow a pattern.

There can be some similarities between bipolar I or II with seasonal pattern and another conditional called seasonal affective disorder.

What is cyclothymia?

A diagnosis of cyclothymic disorder means you will have experienced regular episodes of hypomania and depression for at least 2 years. You won’t be diagnosed with bipolar because your symptoms will be milder. But they can last longer. Cyclothymia can develop into bipolar disorder.

What causes bipolar disorder?

Experts don’t know for sure why some people experience bipolar disorder. Your genetics can play a part and your experiences too.

If any of your family members have experienced bipolar disorder, you’ve more chance of developing it too. But scientists say no single gene can be linked to bipolar disorder.

Someone in your immediate family might live with bipolar disorder, like a parent, brother, or sister. If they do, there’s a 13 in 100 chance you will develop it too. The risk is higher if both of your parents or your twin live with the condition.

For some people symptoms of bipolar disorder can be triggered by stressful things in their lives. These things can include:

• relationship problems,
• physical, sexual or emotional abuse,
• the death of a loved one,
• physical illness,
• losing your job or other work issues,
• problems with sleep disturbances,
• being in debt or money issues.

You can find more information about ‘Does mental illness run in families’ by clicking here.

Getting help

How do I get help if I think I have bipolar disorder?

The usual first step to getting help is to speak to your GP.

It can help to keep a record of your moods. This can help you and your GP to understand your mood swings. Bipolar UK have a mood diary and a mood scale on their website. You can find their details in the Useful contacts section at the bottom of this page.

Your GP can’t diagnose bipolar disorder. Only a psychiatrist can make a formal diagnosis. Your GP may arrange an appointment with a psychiatrist if you have:

• depression, and
• ever felt very excited or not in control of your mood or behaviour for at least 4 days in a row.

They might refer you to a psychiatrist at your local NHS community mental health team (CMHT).

Your GP should make an urgent referral to the CMHT if they think that you might have mania or severe depression. Or there is a chance that you are a danger to yourself or someone else.

Your GP should refer you to your local NHS early intervention team if you have an episode of psychosis and it’s your first one.

Bipolar disorder can be difficult to diagnose because it affects everyone differently. Also, the symptoms of bipolar disorder can be experienced by people who have other mental illness diagnoses. It can take a long time to get a diagnosis of bipolar disorder.

You can find more information about:

• NHS mental health teams (MHTs) by clicking here.

Treatment and management 

What is the treatment for mania, hypomania and depression?

You can check what treatment and care is recommended for bipolar disorders on the National Institute for Health and Care Excellence (NICE) website.

NICE produce guidelines for how health professionals should treat certain conditions. You can download these from their website at:
www.nice.org.uk.

The NHS doesn’t have to follow these recommendations. But they should have a good reason for not following them.

What medications are recommended?

Mood stabilisers are usually used to manage mania, hypomania and depressive symptoms.

The mood stabilisers we talk about in this factsheet are:

• Lithium
• Certain antipsychotic medication
• Certain anticonvulsive medication
• Certain benzodiazepine medication

Mania and hypomania
You should be offered a mood stabiliser to help manage your mania or hypomania. Your doctor may refer to your medication as ‘antimanic’ medication.

If you are taking antidepressants your doctor may advise you to withdraw from taking them.

You will usually be offered an antipsychotic first. The common antipsychotics used for the treatment of bipolar disorder are:

• Haloperidol
• Olanzapine
• Quetiapine
• Risperidone

If the first antipsychotic you are given doesn’t work, then you should be offered a different antipsychotic medication from the list above.

If a different antipsychotic doesn’t work, then you may be offered lithium to take alongside it. If the lithium doesn’t work you may be offered sodium valproate to take with an antipsychotic. Sodium valproate is an anticonvulsive medication.

Sodium Valproate shouldn’t be given to girls or young women who might want to get pregnant.

Your doctor should think about giving you benzodiazepine medication short term.

Your doctor will suggest different dosages and combinations to you depending on what works best for you. Your personal preferences should be listened to.

Depression
Your doctor should offer you medication to treat depressive symptoms. You may be offered the following medication:

• Fluoxetine with Olanzapine
• Quetiapine
• Olanzapine or
• Lamotrigine

Fluoxetine is an antidepressant. Lamotrigine is an anticonvulsant medication.

Your doctor can prescribe the above medication alongside:

• Lithium, and
• Sodium valproate.

If you would like to take medication, doctors will use different dosages and combinations depending on what works best for you. Your personal preferences should be listened to.

You can find more information about:

• Mood stabilisers by clicking here.
• Antipsychotics by clicking here.
• Antidepressants by clicking here.
• Benzodiazepines by clicking here.
• Medication – choice and managing problems by clicking here.

What psychological treatments are recommended?

If you have an episode of depression you should be offered medication and a high intensity talking therapy, such as:

• cognitive behavioural therapy (CBT), or
• interpersonal therapy.

What is cognitive behavioural therapy (CBT)?
CBT is a talking therapy that can help you manage your problems by changing the way you think and behave.

What is interpersonal therapy?
Interpersonal therapy is a talking therapy that focuses on you and your relationships with other people.

You can find more information about ‘Talking therapies’ by clicking here.

What are the long-term treatments for bipolar disorder?

Bipolar disorder is a life-long and often recurring illness. You may need long term support to help manage your condition.

What medication options are there?

Your doctor will look at what medication worked for you during episodes of mania or depression. They should ask you whether you want to continue this treatment or if you want to change to lithium.

Lithium usually works better than other types of medication for long-term treatment. Your doctor should give you information about how to take lithium safely. If lithium doesn't work well enough or causes you problems, you may be offered:

• Valproate,
• Olanzapine, or
• Quetiapine.

Your doctor should monitor your health. Physical health checks should be done at least once a year. These checks will include:

• measuring your weight,
• blood and urine tests,
• checking your liver and heart, and
• checking your pulse and blood pressure.

What psychological treatments are recommended?

You should be offered a psychological therapy that is specially designed for bipolar disorder. You could have individual or group therapy.

The aim of your therapy is to stop you from becoming unwell again. This is known as ‘relapse.’ Your therapy should help you to:

• understand your condition,
• think about the effect that your thoughts and behaviour have on your mood,
• monitor your mood, thoughts and behaviour,
• think about risk and distress,
• make plans to stay well,
• make plans to follow if you start to become unwell,
• be aware of how you communicate, and
• manage difficulties you may have in day to day life.

If you live with your family or are in close contact with them, you should also be offered ‘family intervention.’

Family intervention is where you and your family work with mental health professionals to help to manage relationships. This should be offered to people who you live with or who you are in close contact with.

The support that you and your family are given will depend on what problems there are and what preferences you all have. This could be group family sessions or individual sessions. Your family should get support for 3 months to 1 year and should have at least 10 planned sessions.

Is there any other support?

Your mental health team should give you advice about exercise and healthy eating.

If you want to return to work, you should be offered support with that including training. You should get this support if your care is managed by your GP or by your community mental health team.

You might not be able to work or to find any. Your healthcare professionals should think about other activities that could help you back to employment in the future.

Your healthcare team should help you to make a recovery plan. The plan should help you to identify early warning signs and triggers that may make you unwell again and ways of coping. Your plan should also have people to call if you become very distressed.

You should be encouraged to make an ‘advance statement.’ This is an instruction to health professionals about what you would like to happen with your care if you ever lack mental capacity to make your own decisions.

What is the Care Programme Approach?

You may be assessed under the Care Programme Approach (CPA) if you have complex needs or you are vulnerable.

CPA is a package of care that is used by secondary mental health services. You will have a care plan and someone to coordinate your care. All care plans should include a crisis plan.

CPA aims to support your mental health recovery by helping you to understand your:

• strengths,
• goals,
• support needs, and
• difficulties.

CPA should be available if you have a wide range of needs from different services or you are thought to be a high risk. Both you and your GP should be given a copy of your care plan.

Your carers can be involved in your care plan and given a copy if you give your consent for this to happen.

You can find more information about:

• Care Programme Approach by clicking here.
• Planning your care. Advance statements and advance decisions by clicking here.
• Mood stabilisers by clicking here.
• Antipsychotics by clicking here.
• Antidepressants by clicking here.
• Medication. Choice and managing problems by clicking here.
• Talking therapies by clicking here.

What if I’m not happy with my treatment?

If you aren’t happy with your treatment you can:

• talk to your doctor about your treatment options,
• ask for a second opinion,
• get an advocate to help you speak to your doctor,
• contact Patient Advice and Liaison Service (PALS), or
• make a complaint.

There is more information about these options below.

How can I speak to my doctor about my treatment options?

You can speak to your doctor about your treatment. Explain why you aren’t happy with it. You could ask what other treatments you could try.

Tell your doctor if there is a type of treatment that you would like to try. Doctors should listen to your preference. If you aren’t given this treatment, ask your doctor to explain why it isn’t suitable for you.

What’s a second opinion?

A second opinion means that you would like a different doctor to give their opinion about what treatment you should have. You can also ask for a second opinion if you disagree with your diagnosis.

You don’t have a right to a second opinion. But your doctor should listen to your reason for wanting a second opinion.

What is advocacy?

An advocate is independent from the mental health service. They are free to use. They can be useful if you find it difficult to get your views heard.

There are different types of advocates available. Community advocates can support you to get a health professional to listen to your concerns. And help you to get the treatment that you would like. NHS complaints advocates can help you if you want to complain about the NHS.

You can search online to search for a local advocacy service.

What is the Patient Advice and Liaison Service (PALS)?

PALS is part of the NHS. They give information and support to patients and a good place to start if you’re not happy with any aspect of the NHS.

You can find your local PALS’ details through this website link:
www.nhs.uk/Service-Search/Patient-advice-and-liaison-services-(PALS)/LocationSearch/363.

How can I complain?

You can complain about your treatment or any other aspect of the NHS verbally or in writing. See our information on ‘Complaining about the NHS or social services’ for more information.

You can find out more about:

• Medication. Choice and managing problems by clicking here.
• Second opinions by clicking here.
• Advocacy by clicking here.
• Complaining about the NHS or social services by clicking here.

What can I do to manage my symptoms?

You can learn to manage your symptoms by looking after yourself. Selfcare is how you take care of your diet, sleep, exercise, daily routine, relationships and how you are feeling.

What lifestyle changes can I make?

Making small lifestyle changes can improve your wellbeing and can help your recovery.

Routine helps many people with their mental wellbeing. It will help to give a structure to your day and may give you a sense of purpose. This could be a simple routine such as eating at the same time each day, going to bed at the same time each day and buying food once per week.

Your healthcare professionals should offer you a combined healthy eating, exercise and sleep programme.

You can find more information about wellbeing any physical health at:
www.rethink.org/advice-and-information/living-with-mental-illness/wellbeing-physical-health/.

What are support groups?

You could join a support group. A support group is where people come together to share information, experiences and give each other support.

You might be able to find a local group by searching online. The charity Bipolar UK have an online support group. They also have face to face support groups in some areas of the country. Their contact details are in the Useful contacts at the bottom of this page.

Rethink Mental Illness have support groups in some areas. You can find out what is available in your area if you follow this link: www.rethink.org/about-us/our-support-groups. Or you can contact our General Enquiries team on 0121 522 7007 or info@rethink.org for more information.

What are recovery colleges?

Recovery colleges are part of the NHS. They offer free courses about mental health to help you manage your symptoms. They can help you to take control of your life and become an expert in your own wellbeing and recovery. You can usually self-refer to a recovery college. But the college may inform your care team.

Unfortunately, recovery colleges aren’t available in all areas. To see if there is a recovery college in your area you can use a search engine such as Google.

What is a Wellness Recovery Action Plan (WRAP)?

Learning to spot early signs of mania or depression is important in self-management. The idea of the WRAP is to help you stay well and achieve what you would like to. The WRAP looks at areas like how you are affected by your illness and what you could do to manage them.

There are guides that can help with this. You can ask your healthcare professional to make one with you or ask them for a template of one. There is more information about the WRAP in the further reading section at the bottom of this page.

Rethink Mental Illness has created a guide called ‘Staying well with bipolar’. This is a guide based on information from people who have or support someone with bipolar disorder. You can download it here:
www.rethink.org/living-with-mental-illness/staying-well-with-bipolar.

You can find more information about ‘Recovery’ by clicking here.

Risks

What risks and complications can bipolar disorder cause?

There can be complications and risks for people who live with bipolar disorder. But these risks can be lessened with the right support and treatment.

What about suicide and self-harm?

You might have an illness where you experience psychosis, such as schizophrenia or bipolar disorder. Your risk of suicide is estimated to be between 5% and 6% higher than the general population.

You are more likely to try to take your own life if you have a history of attempted suicide and depression. It is important that you get the right treatment for your symptoms of depression and have an up to date crisis plan.

There is also research that suggests you are 30% - 40% more likely to self-harm if you live with bipolar disorder.

What about financial risk?

If you have mania or hypomania you may struggle to manage your finances. You may spend lots of money without thinking about the effect that it may have on your life.

You could make a ‘Lasting Power of Attorney.’ This is a legal process. This means that you pick someone that you trust to manage your finances if you lack mental capacity to manage them by yourself.

You can work with your carer and mental health team. You can form an action plan. This can say what they can do if you have a period of mania or hypomania and you start to make poor financial decisions.

What about physical health risk?

People with bipolar disorder have a higher rate of physical illnesses such as diabetes and heart disease. You should have a physical health check at least once every year to help manage these risks.

What about alcohol and drugs risk?

Just over 30% of people with bipolar disorder misuse drugs or alcohol. Drinking alcohol, smoking or taking other drugs while taking medication could stop your medication working properly and make your symptoms worse.

If you want advice or help with alcohol or drug use contact your GP.

What about driving risk?

You must tell the Drivers and Vehicle Licensing Agency (DVLA) that you have bipolar disorder. You must stop driving if you have an episode of severe depression, hypomania, mania or psychosis.

You can find out more about:

• Suicidal thoughts – how to cope by clicking here.
• Self-harm by clicking here.
• Mental capacity and mental illness by clicking here.
• Cannabis and mental health by clicking here.
• Drugs, alcohol and mental health by clicking here.
• Driving and mental illness by clicking here.

Family, carer's and friends

Information for family, carers and friends

How can I get support?

You can speak to your GP. You should be given your own assessment through NHS mental health services to work out what effect your caring role is having on your health. And what support you need. Such as practical support and emergency support.

These are some other options for you:

• Join a carers service
• Join a carers support group
• Ask your local authority for a carer’s assessment
• Read about the condition
• Apply for welfare benefits for carers

Rethink Mental Illness run carers’ support groups in some areas. You can also search for groups on the Carers Trust website:

• Rethink Mental Illness: www.rethink.org/about-us/our-support-groups
• Carers Trust: www.carers.org/search/network-partners;

How can I support the person I care for?

You might find it easier to support someone with bipolar disorder if you understand their symptoms, treatment and self-management skills.

You should be aware of what you can do if you are worried about their mental state. It can be helpful to know contact information for their mental health team or GP.

You could find out from your relative if they have a crisis plan. You could help your relative to make a crisis plan if they don’t have one.

As a carer you should be involved in decisions about care planning. But you don’t have a legal right to this. The medical team should encourage the person that you care for to allow information to be shared with you.

You can find out more information about:

• Supporting someone with a mental illness by clicking here.
• Carers assessment – Under the Care Act 2014 by clicking here.
• Getting help in a crisis by clicking here.
• Suicidal thoughts - How to support someone by clicking here.
• Responding to unusual behaviour by clicking here.
• Confidentiality and information sharing - For carers, friends and family by clicking here.

Further reading

Wellness Recovery Action Plan (WRAP) Plus. Formerly living without Depression and Manic Depression - Mary Ellen Copeland, PhD.

The Wellness Recovery Action Plan® or WRAP® is a self-designed wellness process. You can use a WRAP to get well, stay well and make your life your own. It was developed in 1997 by a group of people who were searching for ways to overcome their own mental health issues and move on to fulfilling their life dreams and goals.

Website: www.mentalhealthrecovery.com

Useful contacts

Bipolar UK
This is a user led charity working to enable people affected by bipolar disorder to take control of their lives. You can email or leave a voicemail to arrange a call back with a staff member.

Telephone: 0333 323 3880
Address: Bipolar UK, 11 Belgrave Road, London, SW1V 1RB
Email: info@bipolaruk.org.uk
Website: www.bipolaruk.org.uk

The Hearing Voices Network
This service gives support and understanding for those who hear voices or experience other types of hallucination.

Address: c/o Sheffield Hearing Voices Network, Limbrick Day Service, Limbrick Road, Sheffield, S6 2PE
Email: nhvn@hotmail.co.uk
Website: www.hearing-voices.org