Bipolar disorder--which is also known as manic-depressive illness and will be called by both names throughout this publication--is a mental illness involving episodes of serious mania and depression. The person's mood usually swings from overly "high" and irritable to sad and hopeless, and then back again, with periods of normal mood in between.

Bipolar disorder typically begins in adolescence or early adulthood and continues throughout life. It is often not recognized as an illness, and people who have it may suffer needlessly for years or even decades.

Effective treatments are available that greatly alleviate the suffering caused by bipolar disorder and can usually prevent its devastating complications. These include marital break-ups, job loss, alcohol and drug abuse, and suicide.

Here are some facts about bipolar disorder.

Manic-depressive illness has a devastating impact on many people.

• At least 2 million Americans suffer from manic-depressive illness. For those afflicted with the illness, it is extremely distressing and disruptive.
  
• Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
  
• Family members of people with bipolar disorder often have to cope with serious behavioral problems (such as wild spending sprees) and the lasting consequences of these behaviors.
  
• Bipolar disorder tends to run in families and is believed to be inherited in many cases. Despite vigorous research efforts, a specific genetic defect associated with the disease has not yet been detected.
  
• Bipolar illness has been diagnosed in children under age 12, although it is not common in this age bracket. It can be confused with attention deficit/hyperactivity disorder, so careful diagnosis is necessary.

Bipolar disorder involves cycles of mania and depression.

Signs and symptoms of mania include discrete periods of:

• Increased energy, activity, restlessness, racing thoughts, and rapid talking
  
• Excessive "high" or euphoric feelings
  
• Extreme irritability and distractibility
  
• Decreased need for sleep
  
• Unrealistic beliefs in one's abilities and powers
  
• Uncharacteristically poor judgment
  
• A sustained period of behavior that is different from usual
  
• Increased sexual drive
  
• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
  
• Provocative, intrusive, or aggressive behavior
  
• Denial that anything is wrong

Signs and symptoms of depression include discrete periods of:

• Persistent sad, anxious, or empty mood
  
• Feelings of hopelessness or pessimism
  
• Feelings of guilt, worthlessness, or helplessness
  
• Loss of interest or pleasure in ordinary activities, including sex
  
• Decreased energy, a feeling of fatigue or of being "slowed down"
  
• Difficulty concentrating, remembering, making decisions
  
• Restlessness or irritability
  
• Sleep disturbances
  
• Loss of appetite and weight, or weight gain
  
• Chronic pain or other persistent bodily symptoms that are not caused by physical disease
  
• Thoughts of death or suicide; suicide attempts

It may be helpful to think of the various mood states in manic-depressive illness as a spectrum or continuous range. At one end is severe depression, which shades into moderate depression; then come mild and brief mood disturbances that many people call "the blues," then normal mood, then hypomania (a mild form of mania), and then mania.

Some people with untreated bipolar disorder have repeated depressions and only an occasional episode of hypomania (bipolar II). In the other extreme, mania may be the main problem and depression may occur only infrequently. In fact, symptoms of mania and depression may be mixed together in a single "mixed" bipolar state.

Descriptions provided by patients themselves offer valuable insights into the various mood states associated with bipolar disorder:

Depression:

Hypomania:

Mania:

Recognition of the various mood states is essential so that the person who has manic-depressive illness can obtain effective treatment and avoid the harmful consequences of the disease, which include destruction of personal relationships, loss of employment, and suicide.

Manic-depressive illness is often not recognized by the patient, relatives, friends, or even physicians.

• An early sign of manic-depressive illness may be hypomania--a state in which the person shows a high level of energy, excessive moodiness or irritability, and impulsive or reckless behavior.
  
• Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong.
  
• In its early stages, bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work performance.
  
• If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression.

Most people with manic-depressive illness can be helped with treatment.

• Almost all people with bipolar disorder--even those with the most severe forms--can obtain substantial stabilization of their mood swings.
  
• One medication, lithium, is usually very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.
  
• Most recently, the mood stabilizing anticonvulsants carbamazepine and valproate have also been found useful, especially in more refractory bipolar episodes. Often these medications are combined with lithium for maximum effect.
  
• Some scientists have theorized that the anticonvulsant medications work because they have an effect on kindling, a process in which the brain becomes increasingly sensitive to stress and eventually begins to show episodes of abnormal activity even in the absence of a stressor. It is thought that lithium acts to block the early stages of this kindling process and that carbamazepine and valproate act later.
  
• Children and adolescents with bipolar disorder are generally treated with lithium, but carbamazepine and valproate are also used.
  
• Valproate has recently been approved by the Food and Drug Administration for treatment of acute mania.
  
• The high potency benzodiazepines clonazepam and lorazepam may be helpful adjuncts for insomnia.
  
• Thyroid augmentation may also be of value.
  
• For depression, several types of antidepressants can be useful when combined with lithium, carbamazepine, or valproate.
  
• Electroconvulsive therapy (ECT) is often helpful in the treatment of severe depression and/or mixed mania that does not respond to medications.
  
• As an adjunct to medications, psychotherapy is often helpful in providing support, education, and guidance to the patient and his or her family.
  
• Constructing a life chart of mood symptoms, medications, and life events may help the health care professional to treat the illness optimally.
  
• Because manic-depressive illness is recurrent, long-term preventive (prophylactic) treatment is highly recommended and almost always indicated.

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