Bipolar Depression

What is bipolar depression?
Bipolar depression is the depressed phase of the disorder, which is also known as "manic-depressive" disease. Bipolar disorder is a mental illness that causes people to switch from feeling overly happy and joyful (or irritable) to feeling very sad. Because of the highs and the lows -- or two poles of mood -- the condition is referred to as "bipolar." In between episodes of mood swings, a person may experience normal moods.

The word "manic" describes the periods when the person feels overly excited and confident. These feelings can quickly turn to confusion, irritability, anger, and even rage. The word "depressive" describes the periods when the person feels very sad or depressed. Because the symptoms are similar, sometimes people with bipolar depression are incorrectly diagnosed as having major depression.

Most individuals with bipolar disorder spend more time in depressed phases than in manic phases.

Symptoms
The dramatic and rapidly changing mood swings from highs to lows do not follow a set pattern, and depression does not always follow manic phases. A person may also experience the same mood state several times before suddenly experiencing the opposite mood. Mood swings can happen over a period of weeks, months, and sometimes even years.

The severity of the depressive and manic phases can differ from person to person, and in the same person at different times.

Symptoms of mania ("The highs"):

Excessive happiness, hopefulness, and excitement
Sudden changes from being joyful to being irritable, angry, and hostile
Restlessness
Rapid speech and poor concentration
Increased energy and less need for sleep
High sex drive
Tendency to make grand and unattainable plans
Tendency to show poor judgment, such as deciding to quit a job
Drug and alcohol abuse
Increased impulsivity

Some patients can become psychotic, seeing and hearing things that aren't there and holding false beliefs from which they cannot be swayed. In some instances they see themselves as having superhuman skills and powers, or think they are god-like.

The symptoms of bipolar depression are the same as those of major depression and include:

Sadness
Loss of energy
Feelings of hopelessness or worthlessness
Loss of enjoyment from things that were once pleasurable
Difficulty concentrating
Uncontrollable crying
Difficulty making decisions
Irritability
Increased need for sleep
Insomnia or excessive sleep
A change in appetite causing weight loss or gain
Thoughts of death or suicide
Attempting suicide

Who experiences bipolar disorder?
According to the National Institute of Mental Health, over two million American adults have bipolar disorder. Bipolar disorder usually begins in early adulthood, appearing before age 35. Children and adolescents, however, can develop this disease in more severe forms and often in combination with attention deficit hyperactivity disorder (ADHD). Some studies have indicated that bipolar depression is genetically inherited, occurring more commonly within families.

While bipolar disorder occurs equally in women and men, women with bipolar disorder may switch moods more quickly -- this is called "rapid cycling." Varying levels of sex hormones and activity of the thyroid gland in the neck, together with the tendency to be prescribed antidepressants, may contribute to the more rapid cycling seen in women. Women may also experience more periods of depression than men.

An estimated 60 percent of all people with bipolar disorder have drug or alcohol dependence. It has also been shown to occur frequently in people with seasonal depression and certain anxiety disorders, like post-traumatic stress disorder (PTSD).

What causes bipolar disorder?
A definite cause for any type of depression is difficult to determine but include genetics, changes in the brain, and environmental factors like stress and major life changes. More research is being done to determine the relationship that these factors have in bipolar disorder, how they may help prevent its onset, and what role they may play in its treatment.

How is bipolar disorder diagnosed?
A diagnosis of bipolar disorder is made only by taking careful note of symptoms, and their severity, length, and frequency. The most telling symptoms include severe mood swings (going from extreme highs to extreme lows) that don't follow a set pattern. Reviewing collateral history from close friends and family is often very helpful in distinguishing bipolar disorder from major depression.

If you or someone you know is experiencing symptoms of bipolar disorder, seek the advice of your family healthcare provider or a psychiatrist. A referral may then be made to an appropriate mental health expert.

A thorough medical evaluation should be performed. Your doctor will ask questions about your personal and family history of mental illness. You may also be asked to complete a depression-screening questionnaire -- a series of structured questions that you will be asked to answer verbally or in writing.

What are the treatments?
Bipolar disorder is a long-term illness that requires management throughout a person's life. People who have numerous (four or more) episodes of mood changes (rapid cycling) in a year can be much more difficult to treat. Medication is the primary form of treatment, but the additional use of psychotherapy or "talk" therapy is sometimes recommended to help prevent future episodes.

There are many medications available to treat depression. In 2004, Symbyax, a combination of the antipsychotic olanzapine and the antidepressant fluoxetine, became the first drug specifically approved to treat bipolar depression.

Lithium (brand names Eskalith, Lithobid, Lithonate), a mood-stabilizing drug, is the most commonly prescribed medicine for people with bipolar disorder. It has proven helpful in controlling mood swings in both directions from mania to depression and from depression to mania. Lithium will reduce symptoms of mania within two weeks of starting therapy, but it may take weeks to months before the condition is completely controlled. Thus, other drugs like antipsychotic drugs or antidepressant drugs may also be used to help control symptoms.

Common side effects of lithium include:

Frequent need to urinate
Weight gain
Increased thirst
Slight trembling of the hands
Nausea

Thyroid and kidney problems are a concern, so your doctor will monitor the function of your thyroid and kidneys as well as monitor the levels of lithium in your blood since levels can easily become too high. Anything that lowers the level of sodium in the body, such as switching to a low-sodium diet, heavy sweating, fever, vomiting or diarrhea may cause a buildup of lithium in the body and toxicity. Be aware of these conditions and alert your doctor if you are on lithium and experience them.

The following are signs of a lithium overdose. Call your doctor immediately or go to the nearest emergency room if you experience:

Blurred vision
Irregular pulse
Extremely fast or slow heartbeat
Difficulty breathing
Confusion
Convulsions
Dizziness
Severe trembling
Need to pass large amounts of urine
Uncontrolled eye movements
Double vision
Unusual bruising or bleeding

Valproate (Depakote), an antiseizure medicine, is also effective for controlling mania. It is highly effective for people with rapid-cycling bipolar disorder. The drug has some side effects, can cause inflammation of the liver and can decrease the amount of platelets (blood cells needed for blood to clot) that the body makes so your doctor will monitor levels of Depakote as well as liver function and platelet counts.

Common side effects of valproate include:

Sedation
Stomach cramps
Diarrhea
Indigestion
Nausea
Weight gain
Slight trembling of hands

Other antiseizure medicines often used to treat bipolar disorder include carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin), and topiramte (Topamax).

Most people with bipolar disorder take more than one medication. Along with the mood stabilizer -- either lithium or an anticonvulsant, they may take a medication for agitation, anxiety, insomnia, or depression.

What can I expect after treatment?
For most people, a good treatment program can stabilize severe moods and provide effective symptom relief. Treatment that is continual has proven more effective in preventing relapses and controlling cycling. Those who also have a substance abuse problem may need more specialized treatment.

Can bipolar disorder be prevented?
There is no known method to prevent bipolar disorder. Because its exact cause has not yet been determined, it is especially important to know its symptoms and seek early intervention. Some people who experience bipolar disorder may become suicidal. By knowing how to recognize these symptoms, there is a better chance for effective treatment and finding coping methods that may prevent long periods of illness, extended hospital stays, and suicide.


This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional written health information, please contact the Health Information Center at the Cleveland Clinic (216) 444-3771 or toll-free (800) 223-2273 extension 43771 or visit www.clevelandclinic.org/health/.

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