Diseases & Conditions
Popularly known as “manic depression,” this condition is characterized by manic episodes alternating with DEPRESSION. Mood swings are often dramatic and unpredictable. Almost one-third of six- to 12-year-old children diagnosed with major depression will develop bipolar disorders within a few years.
Because the manic periods (with impulsive behavior and bursts of energy) can be similar to symptoms of ATTENTION DEFICIT HYPERACTIVITY DISORDER, a good diagnosis is important for any child experiencing repeated episodes of mania or depression. The feelings of depression, inadequacy, fatigue, and sadness are also similar to emotions experienced by children with other disorders.
While everyone experiences normal mood changes during everyday life, bipolar disorder is a medical condition in which people have mood swings totally unrelated to things going on in their lives. These swings affect thoughts, feelings, physical health, behavior, and functioning.
Bipolar disorder, which affects about 1 percent of the adult population of the United States, is in the same family of illnesses (called “affective disorders”) as clinical depression. Unlike depression, which affects more girls than boys, bipolar disorder seems to affect boys and girls equally.
For a clinical deﬁnition of bipolar disorder, symptoms must include one or more manic episodes accompanied by one or more major depressive episodes, which usually occur in cycles.
Bipolar disorder usually begins in adolescence or early adulthood, although it can sometimes start in early childhood. There is no single, proven cause of bipolar disorder, but research strongly suggests that it is often an inherited problem related to a lack of stability in the transmission of nerve impulses in the brain. This biochemical problem makes people with bipolar disorder more vulnerable to emotional and physical stresses. This means that if a person experiences stress, substance use, lack of sleep, or too much stimulation, the normal brain mechanisms for restoring calm functioning do not always work properly.
Bipolar disorder tends to run in families, and a number of genes have been linked to the condition, suggesting the presence of several different biochemical problems. If one parent has bipolar disorder and the other does not, there is a one in seven chance that the couple’s child will develop the condition. The chance may be greater if one spouse has several relatives with bipolar disorder or depression.
A child with bipolar disorder may experience any or all of four different kinds of episodes—mania, mild mania (hypomania), depression, or a combination (“mixed episode”).
Mania (manic episode): This episode often begins with a pleasant sense of high energy, creativity, and social conﬁdence, which becomes more intense until it develops into a full-blown manic episode. Children with mania typically lack insight and deny that anything is wrong, angrily blaming anyone who suggests otherwise. A manic episode is characterized by feeling unusually euphoric or irritable for at least a week, plus at least four (and often almost all) of the following symptoms:
• Needing little sleep yet having great amounts of energy
• Talking fast
• Having racing thoughts
• Being easily distracted
• Having an inﬂated feeling of power, greatness, or importance
• Doing reckless things without concern about possible negative consequences, such as spending too much money or (for teenagers) engaging in inappropriate sexual activity
• Psychotic symptoms may occur in very severe cases, such as hallucinations or delusions
Mild mania (hypomania): This milder form of mania causes similar but less severe symptoms, which often begin with someone feeling better and more productive than usual, but then usually build into a full-blown mania or crash into depression.
Depression (major depressive episode): To be considered a full-blown “major” depressive episode, a child will feel sad and lack interest for at least two weeks, in addition to exhibiting at least four other symptoms:
• Trouble sleeping or sleeping too much
• Loss of appetite or eating too much
• Problems concentrating or making decisions
• Feeling slow or agitated
• Feeling worthless or guilty
• Loss of energy; fatigue
• Thoughts of suicide or death
• Hallucinations or delusions (in severe cases)
Mixed episode: The most disabling episodes are those that include symptoms of both mania and depression at the same time, or that alternate often during the day. A person in this condition will feel excited or agitated but also feel irritable and depressed.
Types of Episodes
Untreated patients with bipolar disorder may have more than 10 total episodes of mania and depression during their lifetime. Often, ﬁve years or more may pass between the ﬁrst and second episode, but the time periods between subsequent episodes get shorter and shorter. However, people do not all experience bipolar disorder in the same way. Some people have equal numbers of manic and depressive episodes; others have mostly one type or the other.
The average person with bipolar disorder has four episodes during the ﬁrst 10 years of the illness. Boys are more likely to begin with a manic episode, while girls tend to experience depression ﬁrst. While a number of years can elapse between the ﬁrst two or three episodes of mania or depression, without treatment most people eventually have episodes more often. Sometimes these follow a seasonal pattern, but a few people cycle frequently or even continuously through the year.
Episodes can last days, months, or sometimes even years. On average, without treatment, manic or mild manic episodes last a few months, while depressions often last well over six months. Some children recover completely between episodes and may go many years without any symptoms, while others continue to have low-grade but troubling depression or mild swings up and down. There are two main types of bipolar disorder:
. • Bipolar I: the “classic” form of the condition, which most often involves widely spaced, longlasting bouts of mania followed by long-lasting bouts of depression
. • Bipolar II: at least one episode of mild mania (hypomania) and one major depressive episode
Although the shifts from one state to another are usually gradual, they can be quite sudden. In this so-called rapid-cycling form of the disorder, a person could experience four or more complete mood cycles within a year’s time. Some rapid cyclers can complete a mood cycle in a matter of days (or more rarely, hours). Rapid cycling occurs in between 5 percent and 15 percent of patients.
While there are a few rare documented cases of mania without depression, the DSM-IV does not currently include a category for “mania.” Using DSM-IV to diagnose the condition, a person with symptoms of mania will almost always be diagnosed as bipolar.
Typically, children with bipolar disorder see three or four doctors over at least eight years before being correctly diagnosed. The earlier the diagnosis and proper treatment, the quicker children can be helped and the more likely they will be able to avoid later problems with suicide attempts, alcohol, and substance abuse. In addition, some research suggests that the earlier the treatment the better the outcome; evidence indicates that the more mood episodes a person has, the harder it is to treat each subsequent episode and the more frequent episodes may become. This is sometimes referred to as “kindling.”
While there is no cure for bipolar disorder, a combination of drug treatment and therapy can lessen the frequency, severity, and consequences of symptoms and improve functioning between episodes. The two most important types of medication used to control the symptoms of bipolar disorder are mood stabilizers and antidepressants; other medications can help ease insomnia, anxiety, restlessness, or psychotic symptoms.
Mood stabilizers are used to improve manic symptoms, but they also may sometimes ease depression as well. They are the mainstay of longterm preventive treatment for both mania and depression. Three mood stabilizers are widely used in the United States: lithium, valproate, and carbamazepine. Each of the three affects the body differently, so that if one does not work another may prove to be better. For all three, blood tests determine the correct dose.
Traditionally, lithium has been the primary drug treatment for patients with bipolar disorder. Discovered to be effective in 1949, it has been widely used since the mid-1960s for prevention and treatment. Valproate and carbamazepine are newer drugs used for bipolar disorder since the late 1970s.
Although mood stabilizers (especially lithium) can ease depression, many patients also need a specific antidepressant to treat the depressive episode. However, antidepressants alone can sometimes trigger a manic attack or rapid cycling. For this reason, an antidepressant is given together with a mood stabilizer.
Although electroconvulsive therapy (ECT) has received negative publicity, it can be the safest and most effective treatment for psychotic depression. ECT may also be needed if a patient is severely ill and cannot wait for medicine to work, if there have been several unsuccessful attempts with different antidepressants, or if the patient is pregnant or has a health condition that makes drug therapy less safe. Like all treatments, ECT has potential side effects, including a short-term memory loss.
Hospitalization may be needed but usually lasts only a week or two, and it can prevent selfdestructive, impulsive, or aggressive behavior. During a depressed phase, hospitalization may be needed if a person becomes suicidal. Hospitalization is also used for people who have medical complications that make it hard to monitor medication or for those who cannot stop using drugs or alcohol. Early recognition and treatment of manic and depressive episodes can lower the chances of hospitalization.
At least half of those who take medication have side effects, especially if high doses and a combination of medicines are needed. Lower doses and fewer medicines help offset symptoms, but some people may have severe enough side effects to require different medicine. Although side effects tend to be worse early in the treatment, some people who have taken lithium for 20 years or more can suddenly develop side effects as they age. Valproate or carbamazepine make excellent alternatives as long the switch is made gradually. Valproate appears to cause the fewest side effects during long-term treatment.
Successful management of bipolar disorder can be challenging, especially if a patient wants to stop medication because he feels better, does not like the side effects, or misses the “highs.” A patient who stops medication probably will not have an acute episode right away, but eventually a relapse will likely occur, and each episode runs the risk of making it harder to manage subsequent ﬂare-ups.
Sometimes a diagnosis of bipolar disorder is not clear after just one episode, and medication can be tapered off after about a year. However, if a patient has had only one episode of mania but has a very strong family history, or if the episode was severe, experts believe the patient should probably take medication for several years—or for life. After two or more manic or depressive episodes, experts strongly recommend taking preventive medication indeﬁnitely.
About one in three people with bipolar disorder will be completely free of symptoms by taking lithium, valproate, or carbamazepine for life, and most people become ill much less often and much less severely with each episode.