Bipolar disorder

It used to be called ‘manic depressive illness’. As this phrase suggests, you have severe mood swings. These usually last several weeks or months and are far beyond the emotional ups and downs that most of us experience. They can be:¹

These mood states are described in more detail below.

About 1 in every 50 adults will have bipolar disorder at some point in their life. It usually starts between the ages of 15 to 25 - and rarelyafter the age of 50¹.

The following types exist²:

Bipolar I

• You have had at least one high or manic episode, which has lasted for longer than one week - usually far longer.
• You may only have manic episodes, although most people with Bipolar I also have periods of deep depression.
• Untreated, a manic episode will generally last 3 to 6 months.
• Depressive episodes last rather longer - 6 to 12 months without treatment.

Bipolar II

• You have more than one episode of severe depression, but only mild manic episodes – this is called ‘hypomania’.

Rapid cycling

• You have four mood or more episodes in a 12-month period. This affects around 1 in 10 people with bipolar disorder and can happen with both types I and II.

Cyclothymia

• The mood swings are less severe than those in full bipolar disorder but can be longer. This can, in time, develop into full bipolar disorder.

Depression

We all experience feelings of depression from time to time⁴. It can even help us to recognise and deal with problems in our lives. However, in major depression or bipolar depression, these feelings are much more intense^{5 6}. They go on for longer and makes it difficult or impossible to deal with the normal things of life⁵. If you become depressed, you will notice some, or all of these things:

Emotional changes

• feelings of unhappiness that don't go away.
• feeling that you want to burst into tears for no reason.
• 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.

Difficulties with your thinking

• You can’t think positively or hopefully.
• You find it hard to make even simple decisions.
• You can’t concentrate properly.

Physical symptoms

• You don’t want to eat and lose weight.
• It’s hard to get to sleep.
• You wake really early – and can’t get back to sleep again.
• You feel utterly tired.
• You get constipated.
• You lose interest in sex.

Behaviour

• It’s hard to start or finish things – even everyday chores.
• You cry a lot – or feel like you want to cry but can’t.
• You avoid other people.

Mania

You feel intensely well, energetic and optimistic – so much so that it affects your thinking and judgement. You can start to 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 day-to-day life. Mania can badly affect both your relationships and your work.

When it isn't so extreme, it is called 'hypomania'. It can still affect your judgement, and how you get on with other people¹.

When you are manic, you may notice that you are:

Emotional

• Very happy and excited.
• Very irritable (often because people can’t see the point of your wildly optimistic ideas, or join in with what you want them to do).
• Feeling more important than usual.

Thinking

• Full of new and exciting ideas.
• Moving quickly from one idea to another, and losing track of what you are trying to think about or explain.
• Hear voices that other people can't hear.

Physical

• Full of energy and more active than usual
• Unable or unwilling to sleep
• May be more interested in sex.

Behaviour

• Making plans that are grandiose and unrealistic.
• Very active, moving around very quickly.
• Behaving unlike your normal self.
• Talking very quickly – so quickly that 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 other people.
• 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 usually will. You may even feel annoyed if someone tries to point this out to you. You start to lose touch with day-to-day issues – and with other people's feelings.

Psychotic symptoms

If an episode of mania or depression becomes very severe, you may develop delusional ideas¹.

• 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 – you can feel 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.

Between episodes

Some people with bipolar disorder feel that they recover completely in between their mood swings - but many do not. You can continue to feel depressed and to have problems in thinking, even when you appear (to other people) to be better.

An episode of bipolar disorder may mean that you have to stop driving for a while – you must tell the DVLA if you have bipolar disorder. The Government website has information about this.

Who will I see?

You may see your GP at first, particularly if you have a depressive episode. But, if they make a diagnosis of bipolar disorder, they will have to refer you to a specialist – a psychiatrist. NICE guidance suggest that mood-stabilisers need to be started by a specialist⁷, even if your care is later taken over by a GP.

When you see a psychiatrist, you will also meet other members of the community mental health team (CMHT). They will be able to help with emotional support, information, psychological interventions, and help with sorting out practical matters.

Once any medication you are taking seems to established and effective, your GP can take over most of your care, although they will usually want you to stay in touch with a psychiatrist and the CMHT.

Medications for bipolar disorder

There are some things that can help 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.

There are several mood stabilisers, some of which are also used to treat epilepsy or to help with schizophrenia⁸. Your psychiatrist may need to use more than one medication to control mood swings effectively⁹.

Lithium

Lithium has been used as a mood stabiliser for decades – but how it works is still not clear. It is still the first choice for long-term treatment of bipolar disorder and 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 can harm you. So, you will need regular blood tests in the first few weeks to make sure that you are getting the right dose^{1 10}. Once the dose is stable, your GP can prescribe your lithium and arrange regular blood tests for the longer term.

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 effects¹. So, it’s important to:

• drink plenty of water – more in hot weather or when you are active
• 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.

Side-effects

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.

They include:

• feeling thirsty.
• passing more urine (and more often) 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 notice:

• 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.

Blood and urine tests

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. You will need to have blood and urine tests every few months to make sure that these organs are still working properly. If there is a problem, you may need to stop lithium and discuss an alternative with your doctor.

Taking care of yourself⁵

• Eat a well-balanced diet.
• Drink unsweetened fluids regularly. This helps to keep your body salts and fluids in balance. Steer clear of colas and soft drinks with a lot of sugar in them.
• 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 level.

Other mood stabilisers

There are other medications, apart from lithium, that can help. How these are used will depend on whether it is for a manic or depressive swing, or to stop these from happening – and whether the person is already taking an antidepressant.

• Anti-epileptic medications/anticonvulsants:
  • Sodium valproate, an anti-convulsant, may work just as well as lithium, but we don’t yet have enough evidence to be sure. If it is taken during pregnancy it can harm an unborn baby, so it should not be prescribed to anyone who could become pregnant. Read our resource on Valproate to find out more.
  • Carbamazepine and lamotrigine are also effective for some people.
• Antipsychotic medications: Haloperidol, olanzapine, quetiapine and risperidone.

When to start a mood stabiliser

After just one episode, it’s difficult to predict how likely you are to have another. Some people don’t want to start a mood stabiliser at this stage, but episodes of mania can be severe and very disruptive.

If you have a second episode, there is a strong chance of further episodes. So, at this point, a mood stabiliser would be more strongly recommended.

For how long should someone take a mood stabiliser?

For at least:

• Two years after one episode of bipolar disorder.

• Five years if there have been:

  • frequent previous relapses
  • psychotic episodes
  • alcohol or substance misuse
  • continuing stress at home or at work.

If you do decide to stop your medication, you should discuss this with your doctor. It’s usually best to carry on seeing your psychiatrist for 2 years after stopping medication for bipolar disorder, so that they can check you for any signs of relapse.

If you continue to have troublesome mood episodes, you may need to continue medication for longer.

You need to discuss this with your doctor, but there are some general principles.

• Lithium is usually the first choice; sodium valproate a second choice, although it can also be prescribed with lithium. Olanzapine can be tried if lithium and sodium valproate have not helped.
• Quetiapine can also be used, particularly where someone remains depressed between manic episodes⁸.
• Lamotrigine may be suggested for bipolar II disorder or bipolar depression, but not for mania.
• Sometimes a combination of these drugs is needed.

Much depends on how well you get on with a particular medication. What suits one person may not suit another.

Lithium reduces your chance of relapse by 30–40%⁸, but the more manic episodes you’ve had, the more likely you are to have another one.

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 baby arrives. Lithium and sodium valproate should not be prescribed if you are pregnant or planning to become pregnant.

If you become are pregnant while taking lithium, it's best to discuss with your psychiatrist whether you need to stop lithium. Although lithium is safer in pregnancy than the other mood stabilisers, there is a significant risk to the baby of heart problems. This risk will need 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 taking lithium as it can be toxic for your baby¹².

It will be worth the discussing the possibility of starting some of the psychological treatments mentioned above.

During pregnancy, everyone involved - the obstetrician, midwives, health visitors, GP, psychiatrist, and community psychiatric nurse – need to keep in close touch with each other.

During a depressive episode, or in between episodes of mania and depression, psychological treatments can be helpful^{1 5 11}. These can include:

• psycho-education – learning more about bipolar disorder
• mood monitoring –you learn to recognise when your mood is starting to swing.
• help to develop general coping skills
• cognitive behavioural therapy (CBT) for depressive episodes, as well as in between such episodes (treatment usually involves around 16 to 20 one-hour sessions over a period of 3 to 4 months)
• interpersonal therapy (IPT)
• couples therapy
• family meetings.

Find out more about Cognitive Behavioural Therapy.

Depressive episodes

• If your depression is at least moderately severe, your doctor may suggest:
  • fluoxetine (an SSRI antidepressant) with olanzapine (an antipsychotic medication that acts as a mood stabiliser)
  • quetiapine
  • other options if the above choices have not helped.
• If you are already taking lithium or sodium valproate, 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 antidepressant.
• Antidepressants can take between two and six weeks to improve your mood, but sleep and appetite often improve first. Antidepressants should be continued for four weeks after the depression has improved. Then, you and your doctor can discuss how to continue medication or whether to try a talking treatment. If your antidepressant is to be stopped, it will need to be cut down slowly before you stop completely.
• 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 episodes.
• If you have had manic episodes, you should not take antidepressants long-term.

Mania and mixed depressive episodes

Any antidepressant should be stopped. Haloperidol, olanzapine, quetiapine or risperidone can be used to treat a manic episode. If these do not work well, Lithium can be added.

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.

Other help

If you run into trouble from, say, spending too much when you are high, your mental health team should help you to negotiate with your bank or people you owe money to. If this has happened, it may be worth thinking about giving power of attorney over your affairs to a carer or relative whom you trust.

Self-monitoring

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.

Knowledge

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 below for support groups and caring organisations.

Stress

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 psychologist.

Relationships

Depression or mania can put a lot of strain on friends and family - you may find that you 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 you.

Activities

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 illness.

Exercise

Reasonably intense exercise for 20 minutes or so, three times a week, seems to improve mood.

Fun

Make sure you regularly do things that you enjoy and that give your life meaning.

Continue with your medication

You may want to stop your medication before your doctor thinks it is safe – but this can lead to another mood swing. Talk it over with your doctor and your family when you are well.

If you have been admitted to hospital for bipolar disorder, you may want, with your doctor and family, to write:

• an 'advance statement', to set out how you want to be treated if you become ill again (it can include any information that you feel is important for your health or care)
• an 'advance decision' if there are particular treatments you do not want to have.

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.1 This will check your:

• Blood pressure.
• Weight and Body Mass Index (BMI).
• Smoking and alcohol use.
• Blood sugar levels.
• Lipid levels - for all patients over the age of 40.
• If you are taking Lithium, you will need:
•  a Lithium level check every 3-6 months.
• A blood test for thyroid and kidney function every 6 months. If there are any problems, you may need to have these blood tests more often.  

Mania or depression can be distressing – and exhausting - for family and friends.

Dealing with a mood episode

• Depression

  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 possible.

• Mania

  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 maybe get them some 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 - and that practical, everyday tasks, like paying bills, are not forgotten.
  

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.

Your local psychiatric service should be able to provide your family with support, family meetings and information about bipolar disorder.

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 someone is:

• seriously neglecting themselves by not eating or drinking
• behaving in a way that places them, or others, at risk
• talking of harming or killing themselves

Get medical help immediately. There may be a crisis number to ring for the mental health trust or an emergency team. A&E departments with have a psychiatrist available 24 hours a day.

Keep the name of a trusted professional (and their telephone number) who you can call in any such emergency. A short admission to hospital may sometimes be needed.

If you become manic or depressed, you may not be able to look after your children properly for a while. Your partner, or another family member, will need to do this while you are unwell. It may help to make plans for this in advance, when you are well.

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. 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 and questions in a calm, consistent and supportive way. An adult 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 sometimes worry that they have caused their parent’s illness. They need to be reassured that they are not to blame, but also given time and support for themselves. When an older child finds themselves caring for a sick parent, they will need particular understanding and practical support.

More information about helping children cope with a sick parent is provided in our factsheet When a parent has a mental illness.

Bipolar UK

Bipolar UK provide support, advice and information for people with bipolar disorder, their friends and carers.

Peer support line: 07591375544 (ansaphone and call back)

Phone: 0141 560 2050

Side by Side - MIND online community

Side by Side is a supportive online community where you can feel at home talking about your mental health and connect with others who understand what you are going through.

MIND Helplines

MIND provide several helplines to discuss mental health.

Samaritans

Samaritans provide confidential, non-judgmental support 24 hours a day by telephone and email for anyone who is worried, upset, or suicidal.

Phone: 116 123

Email: jo@samaritans.org.

Further reading

Fast A. J., Preston J. D. Loving someone with bipolar disorder: understanding and helping your partner. New Harbinger Publications; 2012.

Geddes, J. (2003) Bipolar disorder. Evidence Based Mental Health, 6 (4): 101-2.

Goodwin, G.M. (2009) Evidence-based guidelines for treating Bipolar disorder: revised third edition - recommendations from The British Association for Psychopharmacology. Journal of Psychopharmacology, 30(6); 495-553.

Kay Redfield Jamison. An unquiet mind. Alfred A. Knopf; 1995.

NICE information for the public

NICE quality standards for bipolar disorder

Morriss, R. (2004). The early warning symptom intervention for patients with bipolar affective disorder. Advances in Psychiatric Treatment, 10: 18 - 26.

Persaud R., Royal College of Psychiatrists. The Mind: A User's Guide. Bantam; 2007.

1. National Institute for Health and Care Excellence (NICE). Bipolar disorder: assessment and management. NICE Clinical Guideline (CG185). 2020.
2. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. Arlington, VA: American Psychiatric Association; 2013.
3. Sandstrom A, Sahiti Q, Pavlova B, Uher R. Offspring of parents with schizophrenia, bipolar disorder, and depression, Psychiatric Genetics: October 2019. 29.5, 160-169
4. Haller H, Anheyer D, Cramer H, Dobos G. Complementary therapies for clinical depression: An overview of systematic reviews. British Medical Journal. 2019;9:1-15.
5. National Institute for Health and Care Excellence (NICE). Depression in adults: recognition and management. NICE Clinical Guideline (CG90). 2009.
6. Perlis RH, Brown E, Baker RW, Nierenberg AA. Clinical features of Bipolar Depression Versus Major Depressive Disorder in Large Multicentre Trials. The American Journal of Psychiatry. 2006;163:225-231.
7. National Institute for Health and Care Excellence (NICE). Bipolar disorder: assessment and management. Clinical guideline [CG185] 2020.
8. Butler M, Urosevic S, Desai LPP, Sponheim SR, Popp J, Nelson VA, et al. Treatment for Bipolar Disorder in Adults: A Systematic Review. Agency for Healthcare Research and Quality. Comparative Effectiveness Review: 208, 2018.
9. Thase, ME. Quetiapine monotherapy for bipolar depression. Neuropsychiatr Dis Treat. 2008; 4(1): 21–31.
10. Geddes JR, Burgess S, Hawton K, et al. Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials. Am J Psychiatry. 2004;161:217–22.
11. Oud M, Mayo-Wilson E, Braidwood R, Schulte P, Jones SH, Morriss R, et al. Psychological Interventions for Adults with Bipolar Disorder: Systematic Review and Meta-Analysis. The British Journal of Psychiatry. 2016;3:213-222.
12. National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. NICE Clinical Guideline (CG192).2020.