What is bipolar disorder?
Bipolar disorder (also known as “manic depression”) is a psychiatric illness that affects a person’s mood, thinking, and behavior with episodes of extremes of mood (both up and down) and energy. Episodes may last a few days to several weeks and may be more elevated, more down, or both.
How do patients experience bipolar disorder?
Like any other illness, bipolar disorder differs from person to person. Bipolar 1 disorder is considered more severe because the manic episodes cause disturbances that impair their daily functioning, and the individual may even lose touch with reality (psychosis) or require hospitalization. The diagnosis of bipolar 1 disorder does not require episodes of depression, although most will experience such, especially as they age. The patient’s behavior may cause personal, occupational, or legal problems. They may express extreme ideas about religion, politics, and their own importance. In both disorders, their mood is elevated, grouchy, angry or forcefully negative, and typically not in proportion to the circumstances.
Patients with bipolar 2 disorder experience depression alternating with hypomanic episodes consisting of increased energy, decreased need for sleep, impulsivity, and elevated or irritable mood or mixed episodes (symptoms of depression at the same time as manic symptoms). In the case of hypomania, the individual behaves such that family and friends may observe the person as being unusually talkative, restless, energetic, or active.
To be given the diagnosis of Bipolar Disorder, the individual must have experienced at least one episode of either mania or hypomania. Hypomania requires four days of symptoms, while mania requires seven days of symptoms or hospitalization. Symptoms include:
- Elevated, expansive mood (e.g. “I am SOOO Happy,” or “Life is GREEEAT.”)
- Impulsivity. Making decisions without concern for negative consequences. Examples include going on a road trip without planning, spending so much money in a short period of time that they are in financial trouble, and increased sexual activity without concern for physical safety.
- Racing thoughts. Ideas come faster than they can register or change rapidly.
- Pressured speech. Speaking unusually fast, talking without stopping even when interrupted, calling or trying to socialize at odd hours or with strangers, jumping from subject to subject.
- They need little sleep, getting by on just a few hours per night, if that much.
- They are grandiose — overly confident, overly estimating their abilities or qualities, at times believing they are exceptional or special (e.g. “I should run for president,” “I could be an astronaut,” “I understand God in a way that others can’t”).
- Irritability to the point of having arguments or shouting at others, getting into physical altercations or fights.
Patient Example 1: Lily presents to her OB-GYN for an incision check. Lily completed a depression survey and Lily’s score was elevated. After talking with her, the OB-GYN provided samples of an antidepressant, which Lily started as directed. A week later, the OB-GYN received a call from Lily’s concerned spouse. Lily had not slept for several days and ordered over a thousand dollars of baby clothes and toys. Her family and friends became concerned when she began calling them in the middle of the night.
Patient Example 2: Rose saw her midwife two weeks after her delivery. She scored 12 on the EPDS, so the midwife had her complete an MDQ, which she scored positively on. The midwife called PEACE for Moms, which arranged a telehealth visit with Rose that afternoon. The psychiatrist diagnosed bipolar disorder and instructed the midwife how to begin a mood stabilizer and help find the patient a local psychiatrist.
How does bipolar disorder differ from other mental health diagnoses?
Patients with bipolar disorder experience episodes that change their mood, thinking, and behavior so that they are very different from their baseline. Family, friends or coworkers will often notice and comment on the behavior as unusual.
Other disorders share symptoms with bipolar, but do not present as distinct episodes of change in behavior and thinking. For example:
- An anxious person may have difficulty sleeping and may talk more when they are nervous, but they are disturbed by the symptoms.
- People with ADHD may be impulsive or have difficulty focusing their thoughts.
- Individuals with post-traumatic stress disorder may be edgy and react forcefully when they feel threatened.
- Some may experience mood lability, irritability and impulsivity as part of their personality. They may acknowledge that these interfere with their ability to build relationships or achieve goals. This is common in borderline personality disorder, and less so in histrionic and antidocail personality disorder.
- The abuse or misuse of stimulants may induce a manic state, and are often followed by a depression like “crash.”
In a perfect world, all patients who present with depression, insomnia, or irritability should be screened for bipolar disorder as well as major depression. At the very least, we recommend that two groups of patients be screened for bipolar disorder if they first screen positively for depression.
- Patients who have a family history of bipolar disorder. Individuals with a single parent with bipolar disorder have a 5-10% risk of developing bipolar disorder themselves.
- Patients whose behavior has changed dramatically and abruptly should be screened for bipolar disorder. If the patient was very energetic and excited in the days before developing depression, screening for bipolar disorder may be helpful. This includes people who have changes in behavior after starting an antidepressant.
We recommend using the Mood Disorder Questionnaire (MDQ). The surveys are simply tools to help clinicians. We recommend that patients who are thought to be bipolar are seen by a psychiatrist for clarification of the diagnosis.
Psychotherapy can be helpful in supporting patients with bipolar disorder, but most patients will need medication to stabilize their moods. In many cases these medications help both depression and mania.
Many mood stabilizing medications require adjustment or monitoring in pregnancy. It is important to work with a mental health professional to address bipolar disorder. Patients with bipolar disorder frequently relapse in pregnancy, and almost always relapse if their medications are stopped abruptly. In extreme cases, patients may respond to electroconvulsive therapy (ECT), which is considered safe in pregnancy. All patients on lithium or anticonvulsants should be on high dose folic acid supplementation prior to pregnancy, or as early in pregnancy as possible.
|Anti-seizure medications||Depakote (valproic acid)|
|High risk for birth defects and developmental disorders.|
|Anti-seizure medications||Lamictal (lamotrigine)||Lower risk of birth defects but requires monitoring of levels.|
|Increased risk for weight gain and gestational diabetes.|
|Lithium||Lithibid||Requires monitoring and adjustment throughout pregnancy. Affects thyroid function.|
Special issues with bipolar disorder in pregnancy
Pregnant women with bipolar disorder are at a high risk of both depression and mania. When ill, they may engage in dangerous activities or become suicidal, putting themselves or their babies at risk. Sleep disruptions and stress often trigger manic episodes. Patients with bipolar disorder are at an increased risk of postpartum psychosis. They may develop delusions focused on the baby; they may think the baby is possessed by demons or needs to be sacrificed to be saved, and inadvertently harm the baby under the influence of these beliefs.
Perinatal patients with bipolar disorder should be followed by obstetric and mental health professionals. The mental health and obstetric care providers should encourage active involvement of her support system. Support persons should be instructed to watch for behavior or mood changes. Patients should consider bottle or formula feeding at night to allow shared childcare and maintain healthy sleep.
Patients with bipolar disorder considering pregnancy should discuss their plans for pregnancy with their psychiatrist, so their treatment may be altered to suit pregnancy better. Patients should be encouraged to start prenatal vitamins before attempting pregnancy, and may need higher doses of folic acid to reduce risks of birth defects.
As always, PEACE for Moms consultants can provide assistance with managing bipolar patients.