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Seasonal Affective Disorder
also known as manic-depressive illness, is a brain disorder
that causes unusual shifts in a person’s
mood, energy, and ability to function. Different from the
normal ups and downs that everyone goes through, the symptoms
of bipolar disorder are severe. They can result in damaged
relationships, poor job or school performance, and even suicide.
But there is good news: bipolar disorder can be treated,
and people with this illness can lead full and productive
About 5.7 million American
adults or about 2.6 percent of the population age 18 and
older in any given year,1 have bipolar disorder. Bipolar
disorder typically develops in late adolescence or early
adulthood. However, some people have their first symptoms
during childhood, and some develop them late in life. It
is often not recognized as an illness, and people may suffer
for years before it is properly diagnosed and treated.
Like diabetes or heart disease, bipolar disorder is a long-term
illness that must be carefully managed throughout a person’s
What Are the Symptoms of Bipolar Disorder?
Bipolar disorder causes dramatic
mood swings—from overly “high” and/or
irritable to sad and hopeless, and then back again, often
with periods of normal mood in between. Severe changes in
energy and behavior go along with these changes in mood.
The periods of highs and lows are called episodes of
mania and depression.
Signs and symptoms of mania (or a manic episode)
- Increased energy, activity, and restlessness
- Excessively “high,” overly
good, euphoric mood
- Extreme irritability
- Racing thoughts and talking very fast, jumping from one
idea to another
- Little sleep needed
beliefs in one’s abilities and powers
- Poor judgment
- Spending sprees
- A lasting period of behavior that is different from usual
- Increased sexual drive
- Abuse of drugs, particularly cocaine, alcohol, and sleeping
- Provocative, intrusive, or aggressive behavior
- Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with
three or more of the other symptoms most of the day, nearly
every day, for 1 week or longer. If the mood is irritable,
four additional symptoms must be present.
Signs and symptoms
of depression (or a depressive
- Lasting sad, anxious, or empty mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities once enjoyed,
- Decreased energy, a feeling
of fatigue or of being “slowed
- Difficulty concentrating, remembering, making decisions
- Restlessness or irritability
- Sleeping too much, or can’t
- Change in appetite and/or unintended weight loss or gain
- Chronic pain or other persistent bodily symptoms that
are not caused by physical illness or injury
- Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if five or more of these
symptoms last most of the day, nearly every day, for a period
of 2 weeks or longer.
A mild to moderate level of mania is called hypomania.
Hypomania may feel good to the person who experiences it
and may even be associated with good functioning and enhanced
productivity. Thus even when family and friends learn to
recognize the mood swings as possible bipolar disorder, the
person may deny that anything is wrong. Without proper treatment,
however, hypomania can become severe mania in some people
or can switch into depression.
Sometimes, severe episodes of mania or depression include
symptoms of psychosis (or psychotic symptoms).
Common psychotic symptoms are hallucinations (hearing, seeing,
or otherwise sensing the presence of things not actually
there) and delusions (false, strongly held beliefs not influenced
by logical reasoning or explained by a person’s usual
cultural concepts). Psychotic symptoms in bipolar disorder
tend to reflect the extreme mood state at the time. For example,
delusions of grandiosity, such as believing one is the President
or has special powers or wealth, may occur during mania;
delusions of guilt or worthlessness, such as believing that
one is ruined and penniless or has committed some terrible
crime, may appear during depression. People with bipolar
disorder who have these symptoms are sometimes incorrectly
diagnosed as having schizophrenia, another severe mental
It may be helpful to think of the various mood states in
bipolar disorder as a spectrum or continuous range. At one
end is severe depression, above which is moderate depression
and then mild low mood, which many people call “the
blues” when it is short-lived but is termed “dysthymia” when
it is chronic. Then there is normal or balanced mood, above
which comes hypomania (mild to moderate mania), and then
In some people, however, symptoms of mania and depression
may occur together in what is called a mixed bipolar
state. Symptoms of a mixed state often include agitation,
trouble sleeping, significant change in appetite, psychosis,
and suicidal thinking. A person may have a very sad, hopeless
mood while at the same time feeling extremely energized.
Bipolar disorder may appear to be a problem other than mental
illness—for instance, alcohol or drug abuse, poor school
or work performance, or strained interpersonal relationships.
Such problems in fact may be signs of an underlying mood
Some people with bipolar disorder become suicidal. Anyone
who is thinking about committing suicide needs immediate
attention, preferably from a mental health professional or
a physician. Anyone who talks about suicide should be taken
seriously. Risk for suicide appears to be higher
earlier in the course of the illness. Therefore, recognizing
bipolar disorder early and learning how best to manage it
may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings include:
- talking about feeling suicidal or wanting to die
- feeling hopeless, that nothing will ever change or get
- feeling helpless, that nothing one does makes any difference
- feeling like a burden to family and friends
- abusing alcohol or drugs
- putting affairs in order
(e.g., organizing finances or giving away possessions
to prepare for one’s death)
- writing a suicide note
- putting oneself in harm’s
way, or in situations where there is a danger of being
If you are feeling suicidal or know someone who
- call a doctor, emergency room, or 911 right away to get
- make sure you, or the suicidal person, are not left alone
- make sure that access is prevented to large amounts of
medication, weapons, or other items that could be used
While some suicide attempts are carefully planned over time,
others are impulsive acts that have not been well thought
out; thus, the final point in the box above may be a valuable long-term strategy
for people with bipolar disorder. Either way, it is important
to understand that suicidal feelings and actions are symptoms
of an illness that can be treated. With proper treatment,
suicidal feelings can be overcome.
What Is the Course of Bipolar Disorder?
Episodes of mania and depression typically recur across
the life span. Between episodes, most people with bipolar
disorder are free of symptoms, but as many as one-third
of people have some residual symptoms. A small percentage
of people experience chronic unremitting symptoms despite
The classic form of the illness, which involves recurrent
episodes of mania and depression, is called bipolar
I disorder. Some people, however, never develop
severe mania but instead experience milder episodes of hypomania
that alternate with depression; this form of the illness
is called bipolar II disorder. When four
or more episodes of illness occur within a 12-month period,
a person is said to have rapid-cycling bipolar
disorder. Some people experience multiple episodes within
a single week, or even within a single day. Rapid cycling
tends to develop later in the course of illness and is more
common among women than among men.
People with bipolar disorder can lead healthy and productive
lives when the illness is effectively treated (see “How
Is Bipolar Disorder Treated?”). Without treatment,
however, the natural course of bipolar disorder tends to
worsen. Over time a person may suffer more frequent (more
rapid-cycling) and more severe manic and depressive episodes
than those experienced when the illness first appeared.4
But in most cases, proper treatment can help reduce the frequency
and severity of episodes and can help people with bipolar
disorder maintain good quality of life.
Can Children and Adolescents Have Bipolar Disorder?
children and adolescents can develop bipolar disorder. It
is more likely to affect the children of parents who have
Unlike many adults with bipolar disorder, whose episodes
tend to be more clearly defined, children and young adolescents
with the illness often experience very fast mood swings between
depression and mania many times within a day.
mania are more likely to be irritable and prone to destructive
tantrums than to be overly happy and elated. Mixed symptoms
also are common in youths with bipolar disorder. Older adolescents
who develop the illness may have more classic, adult-type
episodes and symptoms.
Bipolar disorder in children and adolescents can be hard
to tell apart from other problems that may occur in these
For example, while irritability
and aggressiveness can indicate bipolar disorder, they also
can be symptoms of attention deficit hyperactivity disorder,
conduct disorder, oppositional defiant disorder, or other
types of mental disorders more common among adults such as
major depression or schizophrenia. Drug abuse also may lead
to such symptoms.
For any illness, however, effective treatment depends on
appropriate diagnosis. Children or adolescents with emotional
and behavioral symptoms should be carefully evaluated by
a mental health professional.
Any child or adolescent
who has suicidal feelings, talks about suicide, or attempts
suicide should be taken seriously and should receive immediate
help from a mental health specialist.
What Causes Bipolar Disorder?
Scientists are learning
about the possible causes of bipolar disorder through
several kinds of studies. Most scientists now agree that
there is no single cause for bipolar disorder—rather,
many factors act together to produce the illness.
Because bipolar disorder tends to run in families, researchers
have been searching for specific genes—the microscopic “building
blocks” of DNA inside all cells that influence how
the body and mind work and grow—passed down through
generations that may increase a person’s chance of
developing the illness. But genes are not the whole story.
Studies of identical twins, who share all the same genes,
indicate that both genes and other factors play a role in
bipolar disorder. If bipolar disorder were caused entirely
by genes, then the identical twin of someone with the illness
would always develop the illness, and research has
shown that this is not the case. But if one twin has bipolar
disorder, the other twin is more likely to develop the illness
than is another sibling.
In addition, findings from gene research suggest that bipolar
disorder, like other mental illnesses, does not occur because
of a single gene.7 It appears likely that many different
genes act together, and in combination with other factors
of the person or the person’s environment, to cause
bipolar disorder. Finding these genes, each of which contributes
only a small amount toward the vulnerability to bipolar disorder,
has been extremely difficult. But scientists expect that
the advanced research tools now being used will lead to these
discoveries and to new and better treatments for bipolar
Brain-imaging studies are helping scientists learn what
goes wrong in the brain to produce bipolar disorder and
other mental illnesses.8,9 New brain-imaging techniques
allow researchers to take pictures of the living brain
at work, to examine its structure and activity, without
the need for surgery or other invasive procedures. These
techniques include magnetic resonance imaging (MRI),
positron emission tomography (PET), and functional magnetic
resonance imaging (fMRI). There is evidence from imaging
studies that the brains of people with bipolar disorder
may differ from the brains of healthy individuals. As
the differences are more clearly identified and defined
through research, scientists will gain a better understanding
of the underlying causes of the illness, and eventually may
be able to predict which types of treatment will work most
How Is Bipolar Disorder Treated?
Most people with bipolar
disorder—even those with the
most severe forms—can achieve substantial stabilization
of their mood swings and related symptoms with proper treatment.
Because bipolar disorder is a recurrent illness, long-term
preventive treatment is strongly recommended and almost always
indicated. A strategy that combines medication and psychosocial
treatment is optimal for managing the disorder over time.
In most cases, bipolar disorder is much better controlled
if treatment is continuous than if it is on and off.
But even when there are no breaks in treatment, mood
changes can occur and should be reported immediately
to your doctor. The doctor may be able to prevent a
full-blown episode by making adjustments to the treatment
plan. Working closely with the doctor and communicating
openly about treatment concerns and options can make
a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms,
treatments, sleep patterns, and life events may help
people with bipolar disorder and their families to
better understand the illness. This chart also can
help the doctor track and treat the illness most effectively.
Medications for bipolar
disorder are prescribed by psychiatrists—medical
doctors (M.D.) with expertise in the diagnosis and treatment
of mental disorders. While primary care physicians who do
not specialize in psychiatry also may prescribe these medications,
it is recommended that people with bipolar disorder see a
psychiatrist for treatment.
Medications known as “mood stabilizers” usually
are prescribed to help control bipolar disorder.10 Several
different types of mood stabilizers are available. In general,
people with bipolar disorder continue treatment with mood
stabilizers for extended periods of time (years). Other medications
are added when necessary, typically for shorter periods,
to treat episodes of mania or depression that break through
despite the mood stabilizer.
- Lithium, the first mood-stabilizing medication approved
by the U.S. Food and Drug Administration (FDA) for treatment
of mania, is often very effective in controlling mania
and preventing the recurrence of both manic and depressive
- Anticonvulsant medications,
such as valproate (Depakote®)
or carbamazepine (Tegretol®), also can have mood-stabilizing
effects and may be especially useful for difficult-to-treat
bipolar episodes. Valproate was FDA-approved in 1995 for
treatment of mania.
- Newer anticonvulsant medications,
including lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate
(Topamax®), are being studied to determine how well
they work in stabilizing mood cycles.
- Anticonvulsant medications may be combined with lithium,
or with each other, for maximum effect.
- Children and adolescents with bipolar disorder generally
are treated with lithium, but valproate and carbamazepine
also are used. Researchers are evaluating the safety and
efficacy of these and other psychotropic medications in
children and adolescents. There is some evidence that
valproate may lead to adverse hormone changes in teenage
girls and polycystic ovary syndrome in women who began
taking the medication before age 20.13 Therefore,
young female patients taking valproate should be monitored
carefully by a physician.
- Women with bipolar disorder who wish to conceive, or
who become pregnant, face special challenges due to the
possible harmful effects of existing mood stabilizing medications
on the developing fetus and the nursing infant.14 Therefore,
the benefits and risks of all available treatment options
should be discussed with a clinician skilled in this area.
New treatments with reduced risks during pregnancy and
lactation are under study.
Treatment of Bipolar Depression
Research has shown that people with bipolar disorder are
at risk of switching into mania or hypomania, or of developing
rapid cycling, during treatment with antidepressant medication.15
Therefore, “mood-stabilizing” medications
generally are required, alone or in combination with antidepressants,
to protect people with bipolar disorder from this switch.
Lithium and valproate are the most commonly used mood-stabilizing
drugs today. However, research studies continue to evaluate
the potential mood-stabilizing effects of newer medications.
antipsychotic medications, including clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone
(Risperdal®), quetiapine (Seroquel®), and ziprasidone
(Geodon®), are being studied as possible treatments
for bipolar disorder. Evidence suggests clozapine may be
helpful as a mood stabilizer for people who do not respond
to lithium or anticonvulsants.16 Other research has supported
the efficacy of olanzapine for acute mania, an indication
that has recently received FDA approval.17 Olanzapine may
also help relieve psychotic depression.18
insomnia is a problem, a high-potency benzodiazepine
medication such as clonazepam (Klonopin®) or lorazepam
(Ativan®) may be helpful to promote better sleep. However,
since these medications may be habit-forming, they are
best prescribed on a short-term basis. Other types of sedative
medications, such as zolpidem (Ambien®), are sometimes
- Changes to the treatment plan may be needed at various
times during the course of bipolar disorder to manage the
illness most effectively. A psychiatrist should guide any
changes in type or dose of medication.
- Be sure to tell the psychiatrist about all other prescription
drugs, over-the-counter medications, or natural supplements
you may be taking. This is important because certain medications
and supplements taken together may cause adverse reactions.
- To reduce the chance of relapse or of developing a new
episode, it is important to stick to the treatment plan.
Talk to your doctor if you have any concerns about the
People with bipolar disorder often have abnormal thyroid
gland function.4 Because too much or too little thyroid
hormone alone can lead to mood and energy changes, it is
important that thyroid levels are carefully monitored by
People with rapid cycling tend to have co-occurring thyroid
problems and may need to take thyroid pills in addition to
their medications for bipolar disorder. Also, lithium treatment
may cause low thyroid levels in some people, resulting in
the need for thyroid supplementation.
Medication Side Effects
Before starting a new medication
for bipolar disorder, always talk with your psychiatrist
and/or pharmacist about possible side effects. Depending
on the medication, side effects may include weight gain,
nausea, tremor, reduced sexual drive or performance, anxiety,
hair loss, movement problems, or dry mouth. Be sure to tell
the doctor about all side effects you notice during treatment.
He or she may be able to change the dose or offer a different
medication to relieve them. Your medication should not be
changed or stopped without the psychiatrist’s guidance.
As an addition to medication,
certain forms of psychotherapy (or “talk” therapy)—are
helpful in providing support, education, and guidance to
people with bipolar disorder and their families. Studies
have shown that psychosocial interventions can lead to increased
mood stability, fewer hospitalizations, and improved functioning
in several areas. A licensed psychologist, social worker,
or counselor typically provides these therapies and often
works together with the psychiatrist to monitor a patient’s
progress. The number, frequency, and type of sessions should
be based on the treatment needs of each person.
Psychosocial interventions commonly used for bipolar disorder
are cognitive behavioral therapy, psychoeducation, family
therapy, and a newer technique, interpersonal and social
rhythm therapy. NIMH researchers are studying how these interventions
compare to one another when added to medication treatment
for bipolar disorder.
- Cognitive behavioral therapy helps people with bipolar
disorder learn to change inappropriate or negative thought
patterns and behaviors associated with the illness.
- Psychoeducation involves teaching people with bipolar
disorder about the illness and its treatment, and how to
recognize signs of relapse so that early intervention can
be sought before a full-blown illness episode occurs. Psychoeducation
also may be helpful for family members.
- Family therapy uses strategies
to reduce the level of distress within the family that
may either contribute to or result from the ill person’s
- Interpersonal and social rhythm therapy helps people
with bipolar disorder both to improve interpersonal relationships
and to regularize their daily routines. Regular daily routines
and sleep schedules may help protect against manic episodes.
- As with medication, it is important to follow the treatment
plan for any psychosocial intervention to achieve the greatest
- In situations where medication, psychosocial treatment,
and the combination of these interventions prove ineffective,
or work too slowly to relieve severe symptoms such as psychosis
or suicidality, electroconvulsive therapy (ECT) may be
considered. ECT may also be considered to treat acute episodes
when medical conditions, including pregnancy, make the
use of medications too risky. ECT is a highly effective
treatment for severe depressive, manic, and/or mixed episodes.
The possibility of long-lasting memory problems, although
a concern in the past, has been significantly reduced with
modern ECT techniques. However, the potential benefits
and risks of ECT, and of available alternative interventions,
should be carefully reviewed and discussed with individuals
considering this treatment and, where appropriate, with
family or friends.19
- Herbal or natural supplements,
such as St. John’s
wort (Hypericum perforatum), have not been well
studied, and little is known about their effects on bipolar
disorder. Because the FDA does not regulate their production,
different brands of these supplements can contain different
amounts of active ingredient. Before trying herbal
or natural supplements, it is important to discuss them
with your doctor. There is evidence that St. John’s
wort can reduce the effectiveness of certain medications.20
In addition, like prescription antidepressants, St. John’s
wort may cause a switch into mania in some individuals
with bipolar disorder, especially if no mood stabilizer
is being taken.
- Omega-3 fatty acids found in fish oil are being studied
to determine their usefulness, alone and when added to
conventional medications, for long-term treatment of bipolar
A Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come
and go, it is important to understand that bipolar disorder
is a long-term illness that currently has no cure. Staying
on treatment, even during well times, can help keep the
disease under control and reduce the chance of having recurrent,
Do Other Illnesses Co-occur with Bipolar Disorder?
Alcohol and drug abuse are very common among people with
bipolar disorder. Research findings suggest that many factors
may contribute to these substance abuse problems, including
self-medication of symptoms, mood symptoms either brought
on or perpetuated by substance abuse, and risk factors that
may influence the occurrence of both bipolar disorder and
substance use disorders.23 Treatment for co-occurring substance
abuse, when present, is an important part of the overall
Anxiety disorders, such as post-traumatic stress disorder
and obsessive-compulsive disorder, also may be common in
people with bipolar disorder.24,25 Co-occurring anxiety disorders
may respond to the treatments used for bipolar disorder,
or they may require separate treatment.
How Can Individuals and Families Get Help for Bipolar Disorder
Anyone with bipolar disorder should be under the care of
a psychiatrist skilled in the diagnosis and treatment of
this disease. Other mental health professionals, such as
psychologists, psychiatric social workers, and psychiatric
nurses, can assist in providing the person and family with
additional approaches to treatment.
Help can be found at:
- University—or medical school—affiliated
- Hospital departments of psychiatry
- Private psychiatric offices and clinics
- Health maintenance organizations (HMOs)
- Offices of family physicians, internists, and pediatricians
- Public community mental health centers
People with bipolar disorder may need help to get help.
- Often people with bipolar disorder do not realize how
impaired they are, or they blame their problems on some
cause other than mental illness.
- A person with bipolar disorder may need strong encouragement
from family and friends to seek treatment. Family physicians
can play an important role in providing referral to a mental
- Sometimes a family member or friend may need to take
the person with bipolar disorder for proper mental health
evaluation and treatment.
- A person who is in the midst of a severe episode may
need to be hospitalized for his or her own protection and
for much-needed treatment. There may be times when the
person must be hospitalized against his or her wishes.
- Ongoing encouragement and support are needed after a
person obtains treatment, because it may take a while to
find the best treatment plan for each individual.
- In some cases, individuals with bipolar disorder may
agree, when the disorder is under good control, to a preferred
course of action in the event of a future manic or depressive
- Like other serious illnesses, bipolar disorder is also
hard on spouses, family members, friends, and employers.
- Family members of someone
with bipolar disorder often have to cope with the person’s
serious behavioral problems, such as wild spending sprees
during mania or extreme withdrawal from others during
depression, and the lasting consequences of these behaviors.
- Many people with bipolar disorder benefit from joining
support groups such as those sponsored by the National
Depressive and Manic Depressive Association (NDMDA), the
National Alliance for the Mentally Ill (NAMI), and the
National Mental Health Association (NMHA). Families and
friends can also benefit from support groups offered by