Understanding bipolar disorder (manic depression)

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What is bipolar disorder (manic depression)?
What causes bipolar disorder?
What sort of treatment can I get?
What other support can I get?
What can I do to help myself?
What can friends and relatives do?
Useful organisations
Useful websites
Further reading

'When I'm in a manic phase, I feel as though I am capable of anything and everything. This can be an amazing feeling, but I sometimes get frustrated and angry with people. Ideas flow constantly and quickly, as if my brain is on fast-forward. Everything happening in the world has significance in my life.

But when I'm depressed, it's as if I'm completely crushed and living in slow motion. I feel capable of nothing.'

This booklet is for anyone who has been given a diagnosis of bipolar disorder (manic depression), and for their family and friends. It describes the possible causes and discusses the consequences of the diagnosis and where they can get help. It also looks at what people can do to help themselves.

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What is bipolar disorder (manic depression)?

Someone diagnosed with bipolar disorder (formerly known as manic depression) may swing from moods of deep depression to periods of overactive, excited behaviour known as mania. Between these severe highs and lows can be stable times. Some people also see or hear things that others around them don't (known as having visual or auditory hallucinations or delusions).

Everybody has their ups and downs in daily life, but with bipolar disorder these changes are extreme. During the manic phase, people may feel euphoric, full of a sense of their own importance and brimming with ambitious schemes and ideas. They may spend money extravagantly, and build up debts. They may eat and sleep very little, and talk so quickly that it's difficult to understand them. They may be easily irritable and angry. Their libido can go into overdrive.

A person may be quite unaware of these changes in their attitude or behaviour. After a manic phase is over, they may be quite shocked at what they've done and the effect that it has had. Sometimes, people experience a milder form of mania known as hypomania. During these periods people can actually become very productive and creative and so see these experiences as positive and valuable. (However, hypomania, if left untreated, can become more severe, and may be followed by an episode of depression.)

Mania may flare up periodically, but depression is the most consistent symptom. People may feel overwhelming despair, guilt and worthlessness. They may feel chronic fatigue and gain weight, or have difficulty sleeping. They lose interest in everything. Problems concentrating and remembering things can make life very difficult and undermine the simplest tasks. The experience of bipolar disorder may provoke suicidal feelings.

The current diagnoses in the UK are likely to be:

• Bipolar I or II, depending on the severity and the duration of the episodes of mania and/or depression.
• Cyclothymic disorder - with short periods of mild depression and short periods of hypomania.
• Rapid cycling - four or more episodes a year.
• Mixed states - periods of depression and elation at the same time.

Some people have very few bipolar disorder episodes, with years of stability in between them. They may experience a couple of cycles (episodes) in their whole lifetime. Others have more frequent cycles.

About one to two per cent of the general population is diagnosed with bipolar disorder (a roughly equal number of men and women) usually in their 20s or 30s, although some teenagers are affected.

Note: Some conditions, such as an overactive thyroid gland, can mimic the symptoms of bipolar disorder, and it is important that these are excluded by appropriate tests when the diagnosis is made.

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What causes bipolar disorder?

Very little is known about the causes of bipolar disorder, although it does run in families, suggesting a genetic link. Some people, however, have no family history of it. During pregnancy, the mother’s nutrition and mental and physical health on the developing foetus are also seen as important factors.

The fact that symptoms can be controlled by medication, especially lithium and anticonvulsants, suggests that there may be problems with the function of the nerves in the brain, and this is supported by some research. Disturbances in the endocrine system (controlling hormones) may also be involved.

Most research suggests that a stressful environment, social factors, or physical illness may trigger the condition. Stress (in a variety of forms) seems to be the most significant trigger, and sleep disturbance is an important contributor.

Stressful life events
Some people can link the start of their bipolar disorder to a period of great stress, such as  childbirth, a relationship breakdown, money problems or a career change.

Family background
Some believe bipolar disorder can result from severe emotional damage caused in early life, such as physical, sexual or emotional abuse. Grief, loss, trauma and neglect can all be contributing factors – they all shock the developing mind and produce unbearable stress.

Life problems
It's possible that bipolar disorder could be a reaction to overwhelming problems in everyday life. Mania could be a way of escaping unbearable depression: someone who appears to have a very over-inflated sense of their own importance and their place in society may be compensating for a severe lack of self-confidence and self-esteem.

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What sort of treatment can I get?

If you go to your GP, he or she may refer you to a psychiatrist, who will be able to discuss the various treatments available. If a treatment does not suit you, say so and ask for other options.

Medication
Although drugs cannot cure bipolar disorder, many people find that they help to manage the symptoms, and should be seen as part of a much wider treatment that takes account of individual need.

Lithium is often prescribed for bipolar disorder and comes in two forms: lithium carbonate (Camcolit, Liskonum, Priadel) and lithium citrate (Li-liquid, Priadel). If you are taking lithium, you will have to have regular blood tests to make sure that the level of lithium in your blood is safe and effective. It is also important to maintain steady salt and water levels as far as possible. Common side effects of lithium include weight gain, thirst, and tremor. Long-term use is potentially toxic to the thyroid gland and the kidneys, and their function should be checked regularly during treatment.

Alternative drugs to lithium are some of the anticonvulsants. Anticonvulsants are found to be particularly effective in people who have rapid cycling between mania and depression, and who have no family history of bipolar disorder. In the UK, carbamazepine (Tegretol) and semisodium valproate (Depakote) are licensed for use with bipolar disorder. Lamotrigine is also increasingly used, although it is not yet licensed for manic depression in the UK. Lamotrigine has the advantage of having antidepressant effects as well as being effective as a mood stabiliser for some people. There are adverse effects associated with all of these drugs, which should be made clear before beginning treatment.(See Making sense of lithium and other mood stabilisers, for more information.)

The drugs above are mood stabilisers, and are usually taken long-term. Some antipsychotic drugs – specifically olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify) and risperidone (Risperdal) – are also licensed for the treatment of manic episodes and may be taken at the same time as mood stabilisers; usually for short periods. In addition, psychotic episodes may be treated with older antipsychotics, such as haloperidol or chlorpromazine (Largactil). All of these drugs are associated with potentially serious side effects and should be used at the lowest possible effective dose for the shortest possible time. (See Mind’s booklet, Making sense of antipsychotics.)

Talking treatments
Hopefully the use of talking treatments will increase. They reduce the relapse rate considerably and do not turn the disorder into a chronic condition as drug treatments tend to.

Counselling, psychotherapy or sessions with a psychologist can help people understand why they feel as they do, and change both the way they think and feel. It may help people to overcome relationship difficulties often associated with the condition. It offers an opportunity to talk about the very stressful experience of bipolar disorder and so to cope better with it. Unfortunately, psychotherapy for people diagnosed with bipolar disorder is rare under the NHS outside a hospital setting, but it may be possible to find an organisation offering a low-fee scheme.

Cognitive behaviour therapy aims to help people to identify problems and overcome emotional difficulties. It's a practical talking treatment with the focus on changing the negative thought patterns that are often associated with depression. There are government initiatives to make CBT much more widely available in the community, including self-help computerised CBT programmes. (See 'Useful organisations' for sources of information about talking treatments).

Group therapy can help too - either in or out of hospital or provided by a voluntary organisation.

Hospital admission
If you are particularly distressed, you may benefit from an environment that is not too demanding. At the moment, hospital is often the only place that provides this. It will give staff the opportunity to assess your needs and try to find the best way to help you. And, for those close to you, it may provide some relief.

You can be admitted to hospital voluntarily, in which case you are called an ‘informal patient’. Most admissions are informal but, if you are unwilling to go into hospital, you may be admitted compulsorily under the Mental Health Act 1983 (see Mind rights guide 1: civil admission to hospital). Your community health council, a law centre, a solicitor, or Mind Legal Advice Service can advise you.

Unfortunately, being in a psychiatric hospital or unit can be a distressing experience. There may be little privacy, and people miss their own possessions and surroundings. It can also be frightening to be with other people who are acting in a way that is difficult to understand and is sometimes threatening. Some wards are still mixed sex, although this is supposed to be changing. There may be little opportunity to talk to staff. People who stay in hospital for a long time may become so used to the institutional routine that they find it hard to readjust to the outside world again.

Crisis services
Crisis services have been developed in some areas as alternatives to hospital. Sometimes they can offer accommodation (crisis houses), but otherwise they can offer support 24 hours a day in your own home, with the idea of avoiding admission to hospital. Crisis services rely less on drug treatments and more on talking treatments and informal support. (See Mind’s Crisis services factsheet.)

ECT
Electroconvulsive therapy (ECT) is a highly controversial treatment, which involves passing an electric current through the brain of someone who is under anaesthetic. It's given for severe depression and was regularly used to ‘treat’ mania before antipsychotic drugs became available. ECT can cause short or long-term memory loss. It's much less common nowadays, although it is said that it provides some people with relief they can't otherwise get. It is disproportionally used on older women.

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What other support can I get?

Everyone referred to psychiatric services in England should have their needs assessed and care planned within the Care Programme Approach (CPA). This should provide you with a thorough assessment of your social and health care needs, a care plan, a care co-ordinator who is in charge of your care, and ongoing reviews. You are entitled to say what your needs are, and have the right to have an advocate present. (An advocate is someone that can speak for you, if necessary. See The Mind guide to advocacy) The assessment might also include carers and relatives. The same system applies in Wales.

As part of the CPA, or separately, you can request social services to make an assessment of your needs for community care services. This covers everything from daycare services to your housing needs, with the aim of providing services in your own home or appropriate accommodation. You might need careworkers, and the cost may need to be included in the needs assessment.

It's important to find out as much as you can about local services you can make use of, whether they are run by the NHS, social services departments or voluntary organisations. Try asking your GP, the social services department, community health council, Citizens Advice and voluntary organisations, such as local Mind, or look on the internet or at your local library.

Community Mental Health Teams
Often community care assessments are made by Community Mental Health Teams. Their aim is to enable you to live independently. They can help with practical issues, such as sorting out welfare benefits and housing, and services, such as day centres, back-to-work schemes or drop-in centres. They can also arrange for a community psychiatric nurse (CPN) to visit you at home.

Accommodation
There are hostels where people in need of support can live for a limited length of time and be helped by staff to gain the confidence to live independently again. Sheltered housing schemes offer less intensive support to a group of residents who can live there as long as they want. (See Mind’s Housing and mental health factsheet.)

Day centres
Day centres, day hospitals and drop-in centres can vary widely. Services may include therapy groups, counselling, information or advice. Some offer a chance to learn new skills, such as music, cooking or crafts; some organise day trips, or simply provide the opportunity for a cup of tea, a good lunch and a chat. You may need to be referred by a social worker or psychiatrist.

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What can I do to help myself?

Getting support and understanding
During a manic phase you may be quite unaware that your actions are distressing or damaging to other people. Later, you may feel guilty and ashamed. It can be especially difficult if those around you seem afraid or hostile. It helps if you provide people with information about bipolar disorder.

After going through a manic depressive episode you may find it difficult to trust others, and may want to cut yourself off. These feelings are to be expected after experiencing such difficulties, but it may be far more helpful to talk through your emotions and experiences with friends, family, carers or a counsellor.

There are now many support groups, where people who have gone through similar problems can come together to support each other. (See 'Useful organisations')

Managing your own condition
Self-management involves finding out about bipolar disorder and developing the skills to recognise and control mood swings early, before they become full blown.

It can be very difficult at first to tell whether a 'high' is really the beginning of a manic episode or whether you are just feeling more confident, creative and socially at ease. It can be a strain watching out for symptoms all the time, particularly when you are first learning about the effect bipolar disorder might have on your life. There are various guides to self-managing bipolar disorder (see 'Further reading'). They may feature checklists and exercises to help you recognise and control mood swings, like mood diaries, tips on self-medication, and practical tips for dealing with depression and mania. Self-management is by no means instant, and can take some time to use effectively. However, you may find you need to rely less on professionals, and have more control over mood swings. This can lead to greater self-confidence and lessens relapse.

Day-to-day life
Routine is important, as well as good diet, enough sleep, exercise and enough vitamins, minerals and fatty acids. Gentle stress free activities also help, like yoga or swimming. You could also try complementary therapies, such as reflexology and massage.

Working life
It's important to take things slowly and avoid stressful situations. If you already have a job, you might want to find out if you can return on a part-time basis to start with. (For more information on your rights at work, and on employment opportunities, see The Mind guide to surviving working life). If you are a student, most colleges and universities will offer good support and advice.

Recovery
Bipolar disorder need not be chronic and it can be possible to recover. There is a growing recovery movement among survivors. Developing countries have a far higher non-relapse rate than industrialised countries. Great recovery tools are hope, love, support and work.

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What can friends and relatives do?

Seeing someone you care for going through the symptoms of manic depression can be very distressing. It's painful enough to be with someone who is in a deep depression, but during a manic phase they may not accept that there is anything unusual about their behaviour, and they may become hostile towards you. This can leave you feeling frightened and helpless. However, you can be vital in providing support and helping them to get practical assistance.

How to cope
Try to make sure you have support in coping with your own feelings. Give yourself time away from the person you are caring for, and ask friends and relatives for help. You may find counselling is helpful. Learning as much as possible about bipolar disorder can help you to cope better with your caring role. It's also worth remembering that, under the Carers (Recognition and Services) Act 1995, you may be entitled to ask for an assessment of your own needs from your local social services.

Sometimes, people with manic depression experience suicidal feelings. If the person you are caring for feels like this, you might find it useful to contact a support organisation. (Also see Mind’s booklet How to help someone who is suicidal.)

Addressing difficult behaviour
If someone is hearing or seeing things that you don't, there's no point trying to argue them out of it. Nor is it helpful to pretend you see or hear them too. It's much better to say something like,'I accept that this is how you see things, but I don't share that way of looking at it.' Try to focus on how the person is feeling at the time, to empathise with their emotions and encourage them to talk about them.

Giving practical support
Being organised can be a problem for people with this diagnosis. They may need help with practical matters (like ensuring they get enough to eat and sleep) and with their finances, particularly if they have built up debts during a manic phase. (See Mind's Money and mental health series of booklets.)

Try to work together with your friend or relative, rather than taking over completely. Ask them what support they want and then help them establish what is available. Encourage them to manage their own condition safely. Respect their wishes regarding care as far as possible. If they are in agreement, you can go ahead and approach agencies for help. Help them try to combat the stigma they may face from work colleagues or friends.

Compulsory hospital admission
If all else fails, particularly if the person is a risk to themselves or to other people, it may be necessary to seek admission to hospital. The 'nearest relative', as defined under the Mental Health Act 1983, has the legal right to request a mental health assessment from an Approved Mental Health Professional to look at possible options and to decide whether the person should be detained. (For more information, see Mind rights guide 1 and The Mental Health Act 1983 – an outline guide)

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Useful organisations

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484, web: www.babcp.com
Full directory of psychotherapists available online

British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 316, minicom: 01455 550 307
web: www.bacp.co.uk
See website for details of local practitioners

Carers UK
carers line: 0808 808 7777,
web: www.carersuk.org or www.carerswales.org
Information and advice on all aspects of caring

Depression Alliance
tel. 0845 123 23 20, web: www.depressionalliance.org
Support and understanding to anyone affected by depression

MDF The Bipolar Organisation
tel. 08456 340 540
web: www.mdf.org.uk and www.mdfwales.org.uk
Runs self-help groups and self management courses.

National Debtline
freephone: 0808 808 4000
web: www.nationaldebtline.co.uk
Offers confidential advice concerning debts

Rethink
advice line: 020 7840 3188, tel. 0845 456 0455
web: www.rethink.org
Working together to help everyone affected by severe mental illness to recover a better quality of life

Samaritans
Chris, PO Box 9090, Stirling FK8 2SA
helpline: 08457 90 90 90, textphone: 08457 90 91 92
email: jo@samaritans.org
web: www.samaritans.org
24-hour telephone helpline offering emotional support for people who are experiencing feelings of distress or despair, including those that may lead to suicide

Useful websites

www.nice.org.uk
For guidelines on the treatement of bipolar disorder

www.thyromind.info
Website raising awareness of thyroid disease as a possible cause of mental distress

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Further reading

The bipolar disorder survival guide D.Miklowitz (Guilford 2002)
The BMA new guide to medicines and drugs The British Medical Association (Dorling Kindersley 2007)
How to cope as a carer (Mind 2008)
How to cope with suicidal feelings (Mind 2008)
How to help someone who is suicidal (Mind 2008)
Inside Out (MDF The Bipolar Organisation 1995)
A lifelong journey: staying well with manic depression/bipolar disorder (Michelle Anderson Publishing 2005)
Making sense of antipsychotics (Mind 2007)
Making sense of cognitive behaviour therapy (Mind 2009)
Making sense of counselling (Mind 2004)
Making sense of ECT (Mind 2008)
Making sense of lithium and other mood stabilisers (Mind 2009)
Making sense of psychotherapy and psychoanalysis (Mind 2004)
Mental illness: a handbook for carers eds. R. Ramsay, C. Gerada, S. Mars, G. Szmukler (JKP 2001)
The Mind guide to advocacy (Mind 2005)
Mind rights guide 1: civil admission to hospital (Mind 2009)
Money and mental health: looking after your personal finances (Mind 2006)
Money and mental health: staying in employment (Mind 2007)
Overcoming childhood trauma: a self-help guiding using cognitive-behavioural techniques H. Kennerley (Robinson 2000)
Overcoming mood swings: a self-help guide using cognitive behavioural techniques J.Stott (Robinson 2001)
Understanding psychotic experiences (Mind 2009)
Understanding talking treatments (Mind 2005)
Your drug may be your problem: how and why to stop taking psychiatric medications P. Breggin, D. Cohen (Perseus 2000)

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First published by Mind 1995. Revised edition © Mind 2009
ISBN 978-1-874690-96-2
No reproduction without permission