- Have you ever been prescribed benzos?
(benzodiazepines) These include: diazepam (Valium), lorazepam
(Ativan), temazepam (Restoril), nitrazepam (Mogodon),
chlordiazepoxide (Librium) or alprazolam (Xanax). Have you
tried to stop, or reduce, them? If you have, the
Royal College of Psychiatrists would like to hear about your
experiences. Our short survey
only takes about 10 minutes to fill in and will be completely
This leaflet is for anyone who wants to know
more about bipolar disorder (sometimes called bipolar affective
disorder or manic depression). It is especially helpful for anyone
who has bipolar disorder, their friends and relatives. Many
patients prefer the term ‘bipolar’ rather than ‘bipolar disorder’
as they have an illness not a disorder.
This leaflet describes:
- the disorder
- some of the problems it can create
- ways of coping
- some of the treatments available.
What is bipolar disorder?
Bipolar disorder used to be called ‘manic
depression’. As the older name suggests, someone with bipolar
disorder will have severe mood swings. These usually last several
weeks or months and are far beyond what most of us experience. They
Low or 'depressive'
intense depression and despair
High or 'manic'
extreme happiness and elation
||for example, depressed mood with the restlessness and
overactivity of a manic episode
How common is bipolar disorder?
About 1 in every 100 adults has bipolar
disorder at some point in their life. It usually starts during or
after the teenage years. It is unusual for it to start after the
age of 40. Men and women are affected equally.
What types are there?
- There has been at least one high or manic
episode, which has lasted for longer than one week.
- Some people with Bipolar I will have only
manic episodes, although most will also have periods of
- Untreated, manic episodes generally last 3 to
- Depressive episodes last rather longer - 6 to
12 months without treatment.
- There has been more than one episode of
severe depression, but only mild manic episodes – these are called
- More than four mood swings happen in a 12
month period. This affects around 1 in 10 people with bipolar
disorder, and can happen with both types I and II.
- The mood swings are not as severe as those in
full bipolar disorder, but can be longer. This can develop into
full bipolar disorder.
What causes bipolar disorder?
We don't understand this well, but research
- Bipolar disorder runs in families - it seems
to have more to do with genes than with upbringing.
- There may be a physical problem with the
brain systems which control our moods - this is why bipolar
disorder can often be controlled with medication.
- Episodes can sometimes be brought on by
stressful experiences or physical illness.
What does it feel like?
This depends on which way your mood has swung.
The feeling of depression is something we all
experience from time to time. It can even help us to recognise and
deal with problems in our lives but in clinical depression or
bipolar disorder, the feeling of depression is worse. It goes on
for longer and makes it difficult or impossible to deal with the
normal things of life. If you become depressed, you will notice
some of these changes:
- feelings of unhappiness that don't go
- feeling that you want to burst into tears for
- losing interest in things
- being unable to enjoy things
- feeling restless and agitated
- losing self-confidence
- feeling useless, inadequate and hopeless
- feeling more irritable than usual
- thinking of suicide.
- can’t think positively or hopefully
- finding it hard to make even simple
- difficulty in concentrating.
- losing appetite and weight
- difficulty in getting to sleep
- waking earlier than usual
- feeling utterly tired
- going off sex.
- difficulty in starting or completing things –
even everyday chores
- crying a lot – or feeling like you want to
cry, but not being able to
- avoiding contact with other people.
Mania is an extreme sense of well-being,
energy and optimism. It can be so intense that it affects your
thinking and judgement. You may believe strange things about
yourself, make bad decisions, and behave in embarrassing, harmful
and - occasionally - dangerous ways.
Like depression, it can make it difficult or
impossible to deal with life in an effective way. A period of mania
can affect both relationships and work. When it isn't so extreme,
it is called 'hypomania'.
If you become manic, you may notice that you
- very happy and excited
- irritated with other people who don't share
your optimistic outlook
- feeling more important than usual.
- full of new and exciting ideas
- moving quickly from one idea to another
- hearing voices that other people can't
- full of energy
- unable or unwilling to sleep
- more interested in sex.
- making plans that are grandiose and
- very active, moving around very quickly
- behaving unusually
- talking very quickly - other people may find
it hard to understand what you are talking about
- making odd decisions on the spur of the
moment, sometimes with disastrous consequences
- recklessly spending your money
- over-familiar or recklessly critical with
- less inhibited in general.
If you are in the middle of a manic episode
for the first time, you may not realise that there is anything
wrong – although your friends, family or colleagues will. You may
even feel offended if someone tries to point this out to you. You
increasingly lose touch with day-to-day issues – and with other
If an episode of mania or depression becomes very severe, you
may develop psychotic symptoms.
- In a manic episode - these will tend to be
grandiose beliefs about yourself - that you are on an important
mission or that you have special powers and abilities.
- In a depressive episode - that you are
uniquely guilty, that you are worse than anybody else, or even that
you don't exist.
As well as these unusual beliefs, you might experience
hallucinations - when you hear, smell, feel or see something, but
there isn't anything (or anybody) there to account for
It used to be thought that if you had bipolar disorder, you
would return to normal in between mood swings. We now know that
this is not so for many people with bipolar disorder. You may
continue to experience mild depressive symptoms and problems in
thinking even when you seem to be better.
Bipolar disorder may result in you having to stop driving for a
while. Visit the DVLA
website for further information.
There are some things you can try to control
mood swings so that they stop short of becoming full-blown episodes
of mania or depression. These are mentioned below, but medication
is still often needed to:
- keep your mood stable (prophylaxis)
- treat a manic or depressive episode.
Medications to stabilise mood
There are several mood stabilisers, most of
which are also used to treat epilepsy. However, Lithium (a
naturally occurring salt) was the first effective mood
Lithium has been used as a mood stabiliser for 50 years – but
how it works is still not clear. It can be used to treat both manic
and depressive episodes.
Treatment with Lithium should be started by a psychiatrist. The
difficulty is getting the level of Lithium in the body right – too
low and it won't work, too high and it becomes toxic. So, you will
need regular blood tests in the first few weeks to make sure that
you are getting the right dose. Once the dose is stable, your GP
can prescribe your Lithium and arrange the regular blood tests.
The amount of Lithium in your blood is very sensitive to how
much, or how little, water there is in your body. If you become
dehydrated, the level of Lithium in your blood will rise, and you
will be more likely to get side-effects, or even toxic effects. So,
it’s important to:
- drink plenty of water – more in hot weather or when you are
- be careful with tea and coffee - they increase the amount of
water you pass in your urine.
It can take three months or longer for Lithium to work properly.
It's best to carry on taking the tablets, even if your mood swings
continue during this time.
These can start in the first few weeks after starting Lithium
treatment. They can be irritating and unpleasant, but often
disappear or get better with time.
- feeling thirsty
- passing more urine than usual
- weight gain.
Less common side-effects are:
- blurred vision
- slight muscle weakness
- occasional diarrhoea
- fine trembling of the hands
- a feeling of being mildly ill.
These can usually be improved by lowering the
dose of Lithium.
The following signs suggest that your Lithium
level is too high. Contact your doctor immediately if you
- you feel very thirsty
- you have bad diarrhoea or vomiting
- obvious shaking of your hands and legs
- twitching of your muscles
- you get muddled or confused.
At first you will need blood tests every few
weeks to make sure that you have the right level of Lithium in your
blood. You will need these tests for as long as you take Lithium,
but less often after the first few months.
Long-term use of Lithium can affect the
kidneys or the thyroid gland. It is wise to have blood tests every
few months to make sure that they are working properly. If there is
a problem, you may need to stop Lithium and consider an
Taking care of yourself
- Eat a well-balanced diet.
- Drink unsweetened fluids regularly. This
helps to keep your body salts and fluids in balance.
- Eat regularly - this will also help to
maintain your fluid balance.
- Watch out for caffeine – in tea, coffee or
cola. This makes you urinate more, and so can upset your Lithium
Other mood stabilisers
There are other medications, apart from Lithium, that can
be used to help.
It is possible that Sodium Valproate, an
anti-convulsant, works just as well Lithium, but we don’t yet have
enough evidence to be sure. It should not be prescribed to women of
Olanzapine, an antipsychotic medication.
Carbamazepine and Lamotrigine are also
effective for some people.
What is the best treatment for me?
You need to discuss this with your doctor, but
some general principles are:
- Lithium, Sodium Valproate and Olanzapine will
usually be recommended for long-term treatment.
- Carbamazepine may be suggested if you have
faster and more frequent mood swings.
- Lamotrigine may be suggested for bipolar II disorder.
- Sometimes a combination of drugs is
Much depends on how well you get on with a
particular medication. What suits one person may not suit another,
but it makes sense to first try the medications for which there is
What will happen without medication?
Lithium reduces your chance of relapse by
30–40%, but the more manic episodes you’ve had, the more likely you
are to have another one.
Number of previous manic episodes
Chance of having another episode in
the next year
Not taking Lithium
10% (10 in 100)
6-7% (6-7 in 100)
20% (20 in 100)
12% (12 in 100)
40% (40 in 100)
26% (26 in 100)
As you get older, the risk of getting further
episodes stays much the same. Even if you have been well for a long
time, you still run the risk of having another episode.
When to start a mood stabiliser
After just one episode, it’s difficult to
predict how likely you are to have another. You may not want to
start medication at this stage – unless your episode was very
severe and disruptive.
If you have a second episode, there is a
strong chance of further episodes – so most psychiatrists would
usually recommend a mood stabiliser at this point.
For how long should a mood stabiliser be continued?
For at least two years after one episode of
bipolar disorder, and for up to five years if there have been:
- frequent previous relapses
- psychotic episodes
- alcohol or substance misuse
- continuing stress at home or at work.
If you continue to have troublesome mood
swings, you may need to continue medication for longer.
More information about other mood stabilisers
can be found in our online leaflet Medications for Mania.
In between episodes of mania or depression,
psychological treatments can be helpful. Treatment usually
involves around 16 one-hour sessions over a period of 6 to 9
Psychological treatment should include:
- psychoeducation – finding out more about
- mood monitoring – helps you to pick up when
your mood is swinging
- mood strategies – to help you stop your mood
swinging into a full-blown manic or depressive episode
- help to develop general coping skills
- cognitive behavioural therapy (CBT) for
(More information about CBT can be found in
our online leaflet Cognitive Behavioural
You should discuss any pregnancy plans with
your psychiatrist. Together, you can arrange how to manage your
mood during the pregnancy and for the first few months after the
If you are pregnant, it's best to discuss with
your psychiatrist whether or not to stop Lithium. Although Lithium
is safer in pregnancy than the other mood stabilisers, the risk to
the baby needs to be weighed against the risk of you becoming
depressed or manic. The risk is greatest during the first three
months of pregnancy. Lithium is safe after the 26th week of
pregnancy, although you should not breastfeed your baby if you are
During pregnancy, everyone involved - the
obstetrician, midwives, health visitors, GP, psychiatrist, and
community psychiatric nurse – need to stay in touch with each
Treating a manic or depressive episode
- If your depression is moderately severe, your doctor may
well recommend an SSRI
- If you are already on Lithium or Sodium Valproate, then
sometimes adding Quetiapine can help.
- If you have had a recent manic episode or have a rapid-cycling
disorder, an antidepressant may push you into a manic swing. It may
be safer to increase the dose of the mood stabiliser, without an
- Antidepressants can take between 2 and 6 weeks to improve your
mood, but sleep and appetite often improve first. Antidepressants
should be continued for at least 8 weeks after the depression has
improved, and then consider stopping them by tailing off the dose
- If you have repeated depressive episodes, but have never
switched to mania on antidepressants, you can continue on both a
mood stabiliser and an antidepressant to prevent further
- If you have had manic episodes, you should not continue
Mania and mixed depressive episodes
Any antidepressant should be stopped. Lithium,
Sodium Valproate, Olanzapine, Quetiapine or Risperidone are most
often used to treat a manic episode.
Once the treatment has started, symptoms
usually improve within a few days, but it may take several weeks
for a full recovery. You should check with your doctor if you
want to drive while taking this sort of medication.
Stopping the mood swings - helping yourself
Learn how to recognise the signs that your
mood is swinging out of control so you can get help early. You may
be able to avoid both full-blown episodes and hospital admissions.
Keeping a mood diary can help to identify the things in your life
that help you – and those that don't.
Find out as much as you can about your illness
- and what help there is. There are sources of further information
at the end of this leaflet. See support groups and caring
Try to avoid particularly stressful situations
- these can trigger off a manic or depressive episode. It's
impossible to avoid all stress, so it may be helpful to learn ways
of handling it better. You can do relaxation training with CDs or
DVDs, join a relaxation group, or seek advice from a clinical
- Depression or mania can cause great strain on
friends and family - you may have to rebuild some relationships
after an episode.
- It's helpful if you have at least one person
that you can rely on and confide in. When you are well, try
explaining the illness to people who are important to you. They
need to understand what happens to you - and what they can do for
Try to balance your life and work, leisure,
and relationships with your family and friends. If you get too busy
you may bring on a manic episode.
Make sure that you have enough time to relax
and unwind. If you are unemployed, think about taking a course, or
doing some volunteer work that has nothing to do with mental
Reasonably intense exercise for 20 minutes or
so, three times a week, seems to improve mood.
Make sure you regularly do things that you
enjoy and that give your life meaning.
Continue with medication
You may want to stop your medication before
your doctor thinks it is safe – unfortunately this often leads to
another mood swing. Talk it over with your doctor and your family
when you are well.
Have your say in how you are
If you have been admitted to hospital for bipolar disorder, you
may want to write an ‘advance directive’ with your doctor and
family to say how you want to be treated if you become ill
What can I expect from my GP? (England & Wales only)
If you are taking Lithium or any other
medication for your bipolar disorder, your GP is now expected to
give you an annual physical health check. This will include:
- a blood pressure
- smoking and alcohol use
- plasma glucose levels
- lipid levels - for all patients over the age of 40.
A Lithium level check will need to be
done every 3-6 months and a blood test for thyroid and kidney
function at least every 15 months.
Advice for family and friends
Mania or depression can be distressing – and
exhausting - for family and friends.
Dealing with a mood episode
It can be difficult to know what to say to
someone who is very depressed. They see everything in a negative
light and may not be able to say what they want you to do. They can
be withdrawn and irritable, but at the same time need your help and
support. They may be worried, but unwilling or unable to accept
advice. Try to be as patient and understanding as
At the start of a manic mood swing, the person
will appear to be happy, energetic and outward-going - the ‘life
and soul’ of any party or heated discussion. However, the
excitement of such situations will tend to push their mood even
higher. So try to steer them away from such situations. You can try
to persuade them to get help, or get them information about the
illness and self-help.
Practical help is very important – and much
appreciated. Make sure that your relative or friend is able to look
after themselves properly.
Helping your loved ones stay well
In between mood episodes, find out more about
bipolar disorder. It may be helpful to go with your friend or loved
one to any appointments with the GP or psychiatrist.
Staying well yourself
Give yourself space and time to recharge your
batteries. Make sure that you have some time on your own, or with
trusted friends who will give you the support you need. If your
relative or friend has to go into hospital, share the visiting with
someone else. You can support your friend or relative better if you
are not too tired.
Dealing with an emergency
- In severe mania, a person can become hostile,
suspicious and verbally or physically explosive.
- In severe depression, a person may start to
think of suicide.
If you find that they are:
- seriously neglecting themselves by not eating
- behaving in a way that places them, or
others, at risk
- talking of harming or killing themselves
get medical help
Keep the name of a trusted professional (and
their telephone number) for any such emergency. A short admission
to hospital may sometimes be needed.
Looking after children
If you become manic or depressed, you may
temporarily not be able to look after your children properly. Your
partner, or another family member, will need to organise the
children's care while you are unwell. It can be helpful to make
plans for this in advance when you are well.
You may find that your child may feel anxious
and confused when you are not well. If they cannot express their
distress in words, toddlers can become difficult or clingy, and
older children will show it in other ways.
Children will find it helpful if the adults
around them are sensitive, understanding, and can respond to their
difficulties in a calm, consistent and supportive way. Adults can
help them to understand why their parent is behaving differently.
Questions will need to be answered calmly, factually and in
language they can understand. They will feel better if they can
keep to their usual daily routine.
Explaining bipolar disorder to children
Older children may worry that they have caused
the illness – that it is their fault. They need to be reassured
that they are not to blame, but also to be shown what they can do
to help. When an older child takes responsibility for caring for a
sick parent, they will need particular understanding and practical
More information about helping children cope
with a sick parent is provided in our factsheet 'Parental mental illness - the problems for
Support groups and caring organisations
Provides support, advice and information for
people with bipolar disorder, their friends and carers.
Tel: 0141 560 2050. Provides information,
support and advice for people affected by bipolar disorder and all
who care for them. Promotes self-help throughout Scotland, and
informs and educates about the illness and the organisation.
Tel: 0845 123 23 20; email: email@example.com.
Information, support and understanding for people who suffer with
depression, and for relatives who want to help. Self-help groups,
information, and raising awareness for depression.
Tel: 029 2069 2891; email:firstname.lastname@example.org.
Welsh organisation which supports people affected by
Tel: 08457 90 90 90 (ROI 1850 60 90 90);
Confidential, non-judgmental support 24 hours a day by telephone
and email for anyone who is worried, upset, or suicidal.
- An unquiet mind by Kay Redfield Jamison.
- Loving someone with bipolar disorder:
understanding and helping your partner by Julia A Fast and
The Mind: a user’s guide: Consultant Editor Raj
Goodwin, G.M. (2003) Evidence-based guidelines for treating
Bipolar Disorder: recommendations from The British Association for
Psychopharmacology. Journal of Psychopharmacology, 17;
Geddes, J. (2003) Bipolar disorder. Evidence Based
Mental Health, 6 (4): 101-2.
Morriss, R. (2004). The early warning symptom intervention
for patients with bipolar affective disorder. Advances in
Psychiatric Treatment, 10: 18 - 26.
Guideline 38: Bipolar Disorder: the management of bipolar
disorder in adults, children and adolescents, in primary and
secondary care (2006) National Collaborating Centre for Mental
This leaflet was produced by the Royal College of Psychiatrists'
Public Education Editorial Board.
Series Editor: Dr Philip Timms
Review: Dr Martin Briscoe, Deborah
User and carer input: Members of
the Royal College of Psychiatrists’ Service User
Recovery Forum, Bipolar UK and Bipolar Scotland
Illustration by Lo Cole: www.locole.co.uk/
This leaflet reflects the best available evidence available at
the time of writing.
© Royal College of Psychiatrists. June 2012: Due for
review: June 2014 (We are currently waiting for the new NICE
guidance). This leaflet may be downloaded, printed out, photocopied
and distributed free of charge as long as the Royal College of
Psychiatrists is properly credited and no profit is gained from its
use. Permission to reproduce it in any other way must be obtained
The College does not allow reposting of its leaflets on other
sites, but allows them to be linked to directly.
A range of materials for carers of people with mental health
problems has also been produced by the Partners in Care campaign.
These can be downloaded from www.partnersincare.co.uk
a catalogue of public education materials or copies of our leaflets
Department, The Royal College of Psychiatrists, 21
Prescot Street, London E1 8BB. Telephone: 020
7235 2351 x 2552
Charity registration number (England and Wales) 228636
and in Scotland SC038369.
Please note that we are unable to offer advice on individual cases. Please see our
advice on getting help.
Please answer the following questions and press 'submit' to send your answers OR
E-mail your responses to email@example.com
On each line, click on the mark which most closely reflects how you feel about the
statement in the left hand column.
Your answers will help us to make this leaflet more useful - please try to rate
Did you look at this leaflet because you are a (maximum of 2 categories please):
Age group (please tick correct box)