The Highs and Lows of Bipolar Disorder

What is Bipolar Disorder?

Bipolar disorder is a complex mood disorder that affects millions of people worldwide. Though it is not as widely discussed as other mental health issues, it’s very common and can greatly interfere with the lives of those with the condition. The mental health condition is characterized by episodes of mania and/or hypomania ("highs") and depression ("lows").

Bipolar disorder is classified as type I or type II depending on the specific criteria.

• Bipolar I Disorder (BPID)
  Diagnosed if you experience at least one clear episode of mania. This can be with or without any episodes of hypomania and/or depression.
• Bipolar II Disorder (BPIID)
  Diagnosed if you have a history of hypomania as well as a history of depressive episodes, and you must NOT have a history of a clear-cut manic episode.

“Highs” of Bipolar Disorder

The highs of bipolar disorder are the most characteristic feature of the mental health condition. The presence of either mania or hypomania are what separates bipolar disorder from other mental health conditions, such as major depressive disorder. Mania and hypomania present slightly differently for everyone, but in general can be described as followed:

Mania

• An abnormally elevated or irritable mood
• Increased energy and activity
• Possible psychotic symptoms (disorganized speech, strange, confused thinking and behaviour, etc.)
• Plus, an additional 3–4 of the following symptoms:
  • Increased amount and speed of talking
  • Engagement in potentially dangerous activities without regard to consequences
  • Less need/desire for sleep
  • Easy distractibility/jumping from one topic to the next
  • More attention and activity related to achieving goals (realistic or not realistic)
  • Thoughts of grandiosity; unrealistic sense of superiority and increased self-worth
  • Talking quickly and rapidly jumping between thoughts and ideas, also known as the “flight of ideas”
• Must last at least one week and be present most of the day for every day of its duration and be debilitating/interfere with regular functioning

Hypomania

• Similar to mania, but less intense and not debilitating
• No psychotic symptoms
• Must be present for at least 4 days, and be present for most of the day for each day of the duration

It can be difficult to discriminate between mania and hypomania, so it is best to discuss your symptoms with your doctor for a proper evaluation.

“Lows” of Bipolar Disorder

Depression

• Low mood and a lack of interest and/or pleasure in things you typically enjoy
• Must last for at least two weeks and represent a very significant change in typical functioning.
• Must also include at least four of the following:
  • Increase or decrease in sleep
  • Increase or decrease in appetite
  • Fatigue
  • Moving very slowly or very quickly/unable to sit still
  • Feelings of worthlessness
  • Difficulty thinking and making decisions
  • Thoughts of hurting yourself or of suicide*

    *If you have any thoughts of hurting yourself or of suicide, seek medical attention immediately as it is considered a medical emergency.

How is Bipolar Disorder Diagnosed?

If you think you may have bipolar disorder, the first step is to speak with your doctor. They will discuss your symptoms alongside your medical history and potentially your family's medical history. This is because mental health conditions can be genetic and “run in families”. Your doctor will likely ask you to undergo a full physical exam. This is done in order to ensure your symptoms are not being caused by any other medical condition or substance.

It can be difficult to differentiate between major depressive disorder (MDD) and BPIID, due to the presence of depressive episodes. When screening for MDD, your doctor should always ask if you have ever experienced anything that could be considered either mania or hypomania. This is an important step in the diagnostic process, as MDD and BPIID are distinct mental health conditions and the treatment for each condition differs considerably.

If you have experienced at least one episode of mania, which wasn't caused by another medical condition or substance, you may be diagnosed with bipolar I disorder. However, if your doctor thinks that you have more likely experienced hypomania and depression, you may be diagnosed with bipolar II disorder.

The exact diagnosis of bipolar disorder can get more complicated. Bipolar disorder with "mixed features" is when mania/hypomania occurs with 3 or more symptoms of depression, OR, when a depressive episode occurs with 3 or more symptoms of mania/hypomania.

Then, the mental health condition gets further specified based on the type and frequency of episodes you experience. These specifications are any of as follows:

• With mixed features (manic or hypomania simultaneously mixed with depressive symptoms, or vice versa).
• With atypical features (BPID or BPIID with symptoms that vary from the norm).
• With psychotic features (BPID with episodes of psychosis during mania).
• With anxious distress (BPID or BPIID with additional symptoms of anxiety).
• With rapid cycling (when you experience 4 or more cycles of mania or hypomania and depression throughout one 12-month period).
• With peripartum onset (BPID or BPIID that occurs during pregnancy or within 4 weeks of birth of the infant).
• With seasonal pattern (BPID or BPIID that follows a relatively consistent pattern with the change of seasons).
• With melancholic features (BPID or BPIID in which the depressive symptoms are particularly severe).
• With catatonia (BPID or BPIID with catatonic symptoms such as a lack of communication and movement or even agitation, confusion, and/or restlessness).

Once you meet the criteria for a form of bipolar disorder, your healthcare provider will begin discussing the treatment options.

Treatment for Bipolar Disorder

Bipolar disorder is a mental health condition that usually requires lifelong treatment. The ideal treatment outcome is to reduce the frequency and severity of manic and/or hypomanic and depressive episodes. The main difficulty with bipolar disorder treatment is that when someone enters a manic episode, they sometimes stop taking their medication or stop attending treatment sessions. In general, treatment for bipolar disorder requires a mix of both medication and non-medication management.

Non-medication Management for Bipolar Disorder

Education is key for controlling the condition. This is both education about what the condition is and how to recognize and manage manic, hypomanic, and/or depressive episodes. It is important for patients to be able to recognize when they are entering an episode, so it can be properly managed. There are structured programs designed for giving this information, or you can learn from books, websites, and individual providers. It has also been shown to be beneficial for family and loved ones to be involved in this education as they are also involved and effected by the condition.

Therapies are proven to be beneficial for those with bipolar disorder.

• Cognitive behavioural therapy (CBT)

  The therapy teaches you that thoughts, feelings, and behaviours are connected. Changing parts of this cycle can help to alter the way you think about situation and consequently change the way you behave. This therapy has been effective in decreasing bipolar disorder symptoms and severity.

• Family therapy

  The therapy involves family members and loved ones working together to help improve communication and establish healthier relationships. It is beneficial for the patient and for family members to understand their role in effectively managing the condition.

Medication Management for Bipolar Disorder

The medications for managing bipolar disorder are called “mood stabilizers”. They stabilize the mood to an ideal range, rather than allowing the mood to get overly high or overly low. The medication used for each individual will differ based on their specific symptoms and types of episodes: manic and/or hypomanic and/or depressive. The medication regimen may also change during an acute episode of mania, hypomania, or depression.

Lithium

Approved for treatment of bipolar disorder and acute management of manic episodes.

Pros

• Most effective management drug for bipolar disorder

Cons

• Has to be closely monitored in the blood to ensure the medication is at appropriate levels
• Can reach toxic levels easily
• Cannot be used during pregnancy or breastfeeding
• Can unmask Brugada syndrome, a condition characterized by abnormal heartrate. Must be watchful of any changes to heartrate or light-headedness/fainting when starting lithium therapy.
• Side effects: hand tremor, tiredness, increased thirst, increased urine output

Aripiprazole

Approved for acute manic episodes in those with BPID. Not approved for maintenance of bipolar disorder.

Pros

• Works well to treat acute manic episodes
• Can be combined with medications used for maintenance therapy for bipolar disorder.

Cons

• Not beneficial for depressive episodes, not best for people who experience depressive episodes.
• Increased risk of death in elderly people experiencing dementia-related psychosis.
• May increase thoughts of hurting yourself or of suicide.

*If you have any thoughts of hurting yourself or of suicide, seek medical attention immediately as it is considered a medical emergency.

• Side effects: restlessness, drowsiness, tremor

Lamotrigine

Approved for maintenance of BPID.

Pros

• Tolerated well by most people
• Good option for whom do not tolerate lithium.
• Especially effective at preventing depressive episodes

Cons

• Associated with a small chance of developing a serious life-threatening condition called Stevens-Johnson syndrome. This typically occurs within 2–8 weeks of treatment initiation and comes on as a rash. If you develop a rash when you begin taking lamotrigine, seek medical attention immediately.
• Dosage may need to be adjusted if taking oral contraceptive pills while taking lamotrigine
• Side effects: dizziness, drowsiness, nausea, anxiety

Quetiapine

Approved for acute depressive episodes of bipolar disorder and for acute manic episodes of BPID.

Pros

• Effective for both depressive and manic episodes

Cons

• Must be used cautiously if you have cardiovascular disease, as quetiapine can cause low blood pressure
• Increased risk of death in elderly people experiencing dementia-related psychosis.
• May cause changes to metabolism resulting in: increased blood sugar, increased fat levels in blood, and weight gain
• Higher likelihood of side effects compared to other medications: weight gain, drowsiness, dry mouth, dizziness, constipation

It's important to speak with your HCP about which medication may be best for you. They will be able to discuss, in detail, the treatment best suited to your specific range of symptoms.

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