What are the basics of bipolar disorder treatment?

First, before treatment actually starts, you and your doctor must be sure that you don’t have thyroid changes causing your mood problem. This can be done with a simple test called “TSH”, which measures the level of “thyroid stimulating hormone”. Usually your doctor will also order other tests at this time, if you have not had a recent check of cell counts and blood chemicals, to make sure you don’t have other potential medical causes for your mood problems. Because it is not very common to find a problem using these tests, treatment can start even before the results are back. The doctor is just making sure she/he doesn’t miss something unusual. (Thyroid hormone has also been shown to act as a treatmentfor bipolar disorder in some cases, so it is important to know just where your “TSH” is).

Now, the three most important principles, in my view, of bipolar treatment:

1. Maximize non-medication approaches. This will include at least 3 basics for anyone with a bipolar mood problem.
2. Medications: start with the ones that have evidence for being effective. These are generally called mood stabilizers.
3. Beware of antidepressants (but do not stop yours now!; you must work with your doctor, perhaps using some ideas below)

Read through the rest of this page first, for an overview of treatment. Then skim through again and take some of the links in each section for more details on concepts of particular interest to you.

Principle A: Maximize Non-Medication Approaches

Brace yourself. The good news: here come lots of non-medication options for treatment. The bad news: they all take at least a little work on your part. Some take a lot. But almost all are virtually risk free and cheap. Hard to beat that. I wish they were easier for most people. Some are hard for people without symptoms to do! But if you maximize these, you’ll almost certainly need less medication; and — importantly — the opposite is also true: if you don’t, you’re likely to need more medication.

Here are a few details for some of the not-obvious treatment components above. One approach that is crucial for most patients with bipolar disorder is to maintain a regular daily schedule, especially regular patterns of sleep. An entire therapy for bipolar disorder is organized around this daily schedule idea (“social rhythm therapy”) — especially around having a regular time to go to sleep, and a regular time to wake up and get out of bed. Yes, sorry to say, it would be best to do that same routine even on weekends.

Talk about lifestyle change! This idea of a regular sleep schedule could be very difficult for some people. Unfortunately, the most important steps you can take, without medications, can seem quite restrictive. Many people resist these restrictions, which is understandable. But that often means they will have to rely more heavily on medications, which can mean having to deal with more side effects or risks.

For many people, a very important part of bipolar disorder treatment is getting help coming to terms with having the illness at all. Accepting the illness, and accepting some limitations in order to deal with it — sometimes getting some help with this makes a huge difference. Call it “psychotherapy”, or just call it getting some help: either way, it can make this important step much easier. I hope this is obvious: if you are still spending all your energy trying to resist the fact that you have a mood problem, you won’t be able to accept some of the lifestyle changes that could make your mood problem much easier to manage.

In fact, multiple research studies have shown that using a therapist to help you with this acceptance stage, and then with making some of the necessary changes in your routines, leads to much better long-term outcomes. Three major forms of bipolar-specific psychotherapy emphasize this process of acceptance and change. All of them are variations on techniques which have been around for a long time: cognitive behavioral therapy, interpersonal therapy, and family therapy. Most therapists you can find will be familiar with one or several of these techniques. The bipolar-specific versions simply incorporate some special features pertinent to people with bipolar disorder.

Unfortunately, most psychotherapists (as of 2008) are not specifically trained in the bipolar-specific versions of these therapies. Unless you live near one of the training centers for these methods, you may not be able to find a therapist who who has had specific training on using such an approach. Worse yet, the training manuals for these therapies, which are easily obtained, tend to focus on Bipolar I. The emphasis is on preventing subsequent severe episodes of mania or depression. For people with Bipolar II, these psychotherapies require some adaptation. For now, the easiest way to do this is to work closely with a good therapist, emphasizing the following (you can even point out to your therapist where to find more information on these, using the resources in the right-hand column):

The research behind these approaches has been summarized on a separate page on this website, Psychotherapies for Bipolar Disorder.

Principle B: Medications — use evidence-based Mood Stabilizers

In addition to these non-medication approaches, most people with bipolar disorder also need to use medications — although if more people were really rigorous about the non-medication approaches, and I mean really rigorous, perhaps we’d be able to use less medications. But that’s really tough, especially since motivation goes missing during bipolar depression, and most of those approaches require either motivation or a really good system of habits.

The main medications for bipolar disorder are called “mood stabilizers”. There are at least 5 options, and the list continues to grow. Your doctor will choose, or help you choose, based on her/his sense of what will work best for your set of symptoms; or what has worked for others in your family, which is often a huge clue; or based on your preferences, looking at the potential side effects and risks.

You might think “whoa, I’m being offered medications they use for people with serious mental illnesses — look, there’slithium!” But you didn’t know that lithium is commonly used as a booster for antidepressants in plain old depression. It even works by itself as an antidepressant. So taking lithium is not a marker for “serious” mental illnesses (whatever that means. See my little essay about “Normal — or Mentally Ill?”  in Treatment FAQ). But what about side effect risks from mood stabilizers? Are they worse than antidepressants?

Some mood stabilizer options carry significant risks, unfortunately. Many doctors shy away from talking about bipolar disorder as a possible diagnosis because the think the risks of the treatments are much greater than the risks of antidepressants, for example. But if you read Prozac Backlash, which offers an extreme view of the possible risks of antidepressants, you’d probably think at least some of the mood stabilizers look better, by comparison. If you include the risk of antidepressants making bipolar disorder worse, then the risks of the mood stabilizers could be regarded as roughly in the same realm as the risks of antidepressants. Update 7/2006 : when I wrote that last sentence, this view was pretty radical. But listen to this statement from one of the most widely respected bipolar experts in the world, Dr. Fred Goodwin, who said that doctors and patients tend to think of antidepressants:

“…as light, easy uncomplicated drugs; and mood stabilizers as heavy drugs that should be reserved for use as a last resort. But in fact, recent data suggest that we may have to reverse that order of preference, or at least put them on an equal plane.” (interview, Primary Psychiatry, 2005)

Dr. Goodwin is saying the same thing I’ve been saying for over 5 years — but neither of us has very solid data to go on, unfortunately. We’re worrying, more than we’re saying we know.

Ahem, back to the mood stabilizer options. While your mind may leap to considering the risks, you should step back first and consider the evidence for effectiveness, of any treatment you’re considering. Will it work? If that evidence isn’t very strong, then the risk side of the equation may not matter much — unless the treatment is cheap, harmless, and may have other benefits. There are several such options, it turns out. But you won’t like the sound of them, when described. Too bad. Wait a minute, wait a minute. What is he talking about: cheap, harmless, other benefits? Okay, try this:     “exercise”   (it’s like invoking the name of the devil, in some circles, to say that).  Or this:   “sleep”  (ah, that wasn’t so bad, was it)  Well, “about 8 hours of sleep on a regular schedule”, that’s the hard part. Even good old fish oil has remarkably good evidence for a “mood stabilizer” effect, but you have to take a lot. So it’s not entirely “cheap”. But it does appear to be nearly harmless and have other benefits.

Ahem again (why is this so hard to stay on track here? Well, there is just so much to say about all this. You won’t see them all but this website now has about 300 pages, many on very specific topics with only a single path that will take you there. So I’ve buried a lot of information. Let’s get back to the basics, shall we?)

My main point about choosing a medication: become familiar with at least some of the evidence for the options you’re being offered, or should be offered. Some doctors don’t keep up with that evidence; or are too swayed by pharmaceutical company pitches; or just use what they are comfortable with. The more you learn the more you’ll be in a position to help determine your own treatment. (Not that it will be an easy negotiation with your doctor all the time. Read my hints about Talking with Doctors.)

Principle C:  Beware of Antidepressants

Depression is the big problem in non-manic versions of bipolar disorder (these versions include Bipolar II, and “softer” versions, as described in the Diagnosis section of this website). Thus many people with bipolar mood problems are offered antidepressants at some point. Seems logical, yet research does not strongly support this approach. Worse yet, antidepressants can make some people with bipolar disorder worse. Therefore most mood experts recommend using antidepressants only when one or several of the mainstay medications, the “mood stabilizers” discussed below, have not been able to prevent or relieve a bipolar depression. In other words, there is general agreement that antidepressants are not the first thing to turn to in the treatment of bipolar depression.

However, beyond that general agreement, controversy abounds. Some experts think that antidepressants do not have a role at all in treating bipolar depression, except perhaps as a maneuver of last resort. Such experts point either to the lack of evidence for sustained benefit, or the several lines of evidence that they can do harm. More details about the role of antidepressants in bipolar disorder treatment, including links to relevant articles that form the basis of my view, and a summary of an alternative point of view, can be found on the Antidepressant Controversies page.

Because antidepressants are so widely used, I will take this opportunity here to make sure that you are familiar with the concerns about antidepressants. First let us look at the generally agreed upon risks of antidepressants– although even these are somewhat controversial, because some doctors think they are not common; and some think that if they occur, then one simply treats them and continues the antidepressant.

1. Antidepressants can cause “rapid cycling”. Technically this means more than 4 mood episodes per year, of any type (depressed or manic or mixed), but cycles can be as often as every day or few days and a few people can go even faster, so-called “ultradian (more than one per day) cycling”. Rapid cycling is often harder to treat.
2. Antidepressants can cause hypomanic or manic symptoms (sometimes called switching”, meaning from depressed to manic). Overall, this is thought to occur between 20 and 40% of the time when a depressed patient with bipolar disorder is given an antidepressant. Though one review found much smaller percentages, the first study dedicated tolooking for this rate came out with a switch rate of 20-30% in the first 10 weeks.^Leverich
3. Antidepressants can cause “mixed states“. Remember, bipolar disorder is not like the north and south pole; hypo/manic symptoms can occur while depressed symptoms are also present. In a way, this is the same problem as #2 above, except that instead of switching from one state to another, you have both at the same time. Usually this looks like agitation or anxiety, or irritability; and difficulty sleeping; and depression, all at the same time.

Secondly, here are the more controversial risks.

1. Antidepressants may cause “mood destabilizing” — increasing cycle frequency over a longer period of time; in other words, having more mood episodes than before, or more rapid switches from one mood state to another. This is regarded as worsening the mood condition overall, making it less stable. This is one of the main concerns expressed by one of the lead experts on this issue, Dr. Ghaemi, whose work is cited extensively in the Antidepressant Controversiesessay.
2. Finally, could antidepressants cause kindling”, in which the illness worsens more quickly with time than it might have if antidepressants weren’t there? I don’t hear too many other experts fretting about this as I do, so I won’t worry you with it here. If you’d like to hear some more of my concerns, there is a section on “kindling”  in the Antidepressant Controversies essay.

Whatever you do with antidepressants, you really need to work closely with your doctor on this. DO NOT STOP your antidepressant. It must be tapered at minimum, if you’re going off, or you could — for sure; I’m not making this up — actually end up quickly worse. You have to plan this out with your doctor. If you have trouble getting your concerns or ideas heard, here are some ideas on talking with doctors.

Meanwhile, however, the good news is that we have at least ten different ways of treating depression in bipolar disorder, without using antidepressants. These are summarized on the page entitled Antidepressants That Aren’t “Antidepressants”. Most of these are ingredients in basic treatment, outlined in the next two sections B and C below.

Which mood stabilizer should I start with?

There are several options, shown by generic name in the diagram below. How do you decide which to use? Here’s a very simplified view to start; then we’ll look at some other ways to choose; and finally, we will look in detail at the most commonly used medications.

(For women of child-bearing age: I am sorry to say, all of these medication approaches carry significant risks in pregnancy. It is generally recommended that women take very effective precautions against becoming pregnant while taking these medications. It is possible to have a child, but it must be a planned pregnancy. Before stopping your birth control methods, you should have a very solid treatment relationship developed with a competent psychiatrist. With her or him you will work out a detailed plan, including: how you will taper off your current medications; how your symptoms will be controlled during the pregnancy, if they return; how those medications will be adjusted as you near the end of your pregnancy; and what medications you’ll either be taking, or resume, after delivery. Guys can help out here: use condoms, they’re effective and she doesn’t get side effects — as long as you don’t grumble about using them.)

After I show patients the whole “menu” of mood stabilizers, they almost always end up choosing one based on some combination of these factors:

However, some of these medications have been around longer, so we know much more about their benefits and risks (those whose role is in some doubt have a question mark in the figure above). We’ll start by looking at what mood experts have suggested.

Expert agreement: “first line” medications
Lithium and valproate/divalproex/Depakote used to be the first line” options according to expert consensus”. This means that mood experts agree these are the best choices as a place to start if you’ve never taken a mood stabilizer before. Basic information on using lithium and valproate follows below. But since those consensus guidelines were written up, most of the new recommendations focus on the non-medication options above. There is little new, in terms of medications; except a lot more controversy about the role of antidepressants. You’re welcome to see for yourself: here’s an introduction to international guidelines.

It Depends On Where You’re Starting From
For people whose predominant symptom is depression, as is almost always the case in Bipolar II, then their “mood stabilizer” ought to have plenty of antidepressant “oomph” (a peculiar American term meaning clout, or ability to knock the air out of your lungs, reflecting our peculiar passion for violent versions of football). Here are some mood stabilizers that have well-accepted antidepressant “oomph”, yet are not antidepressants themselves.

• lithium
• lamotrigine (formerly Lamictal, now generic)
• olanzapine/Zyprexa (capitalized is the U.S. trade name)
• quetiapine/Seroquel
• omega-3 fatty acids (fish oil), perhaps?
• some authors would include risperidone and aripiprazole/Abilify (more on those, and why I don’t include them, here).

Careful now — you will soon discover that olanzapine and quetiapine are new-generation “antipsychotics”. Wow, the idea of lithium was freaky enough, and now we’re talking antipsychotics? Aren’t those the big guns”? If that worries you, see my little essay about the term antipsychotic; it might reassure you a little bit.

But as you can see, I emphasize lithium and lamotrigine over the rest. This helps avoid the “atypical antipsychotic” group, which includes olanzapine/Zyprexa and quetiapine/Seroquel, as well as risperidone and aripiprazole/Abilify, and now the new guy, lurasidone/Latuda.  My patients usually don’t like to stay on those medications long-term, for two reasons. First, even the new “second generation” or “atypical” antipsychotics still feel like antipsychotics to a lot of people: they slow down thinking, especially. Sometimes that’s a very good thing, and when that effect is necessary, these are great options. But I generally prefer to use medications that when they are working well are still basically “invisible” to the person taking the medication: you feel “normal”, not “drugged” in the least.

Secondly, all of these medications sometimes cause weight gain and can raise the risk of diabetes. Olanzapine is worst in this respect^Leslie and risperidone and quetiapine are thought to be intermediate. Aripiprazole causes less weight gain, but it can still cause this problem just like the rest; and ziprasidone perhaps least, maybe only rarely doing so (unfortunately ziprasidone is the trickiest to use; after years of fooling with it I still have trouble prescribing it, so don’t expect your primary care doctor to be suggesting it, despite the better risk profile regarding weight). Lurasidone/Latuda, we don’t really know yet about the weight gain; it’s looking pretty good so far (11/2014).

Not first line but worth a serious look in some cases
Omega-3 fatty acids from fish oil have several studies supporting their use (too bad there’s no company going to make millions by studying this more closely, as that would move the research on O-3’s along faster). The reason for looking closely at fish oil is not the great results in research trials, although there are some; but rather the complete lack of any risk known at this point. In fact, there’s even a potential for lowering cholesterol levels. So, it’s cheap; it has no long term risk; it has almost no side effects; it’s available without a prescription — hey, if it actually worked, that would be sort of a bonus!

(That’s a joke, mind you. Usually we start by looking at benefits of medications, since if they have no evidence for benefit, the evidence about risks doesn’t matter much, right? I’d like to hear a resounding “RIGHT” there, folks…) Here are theresearch studies showing it may indeed work, at least to some degree, and links to more detail about fish oil. Even if it does work, though, it appears to take over a month, probably closer to two. So if you have symptoms that are really getting in your way now, don’t rely on fish oil alone. (For sure do not go off some other medication and onto fish oil instead; that must be discussed with your doctor.)

Finally, there are add-on medications as well (not mood stabilizers themselves, as such). These include benzodiazepines(alprazolam/Xanax, lorazepam/Ativan, diazepam/Valium), which work well at first but usually lose some of their effectiveness over time, with the possible exception of clonazepam/Klonopin.

Thyroid hormone has a specific role, especially when a person’s thyroid hormone is already low, or on the low side of normal — and perhaps especially if there are a lot of people in the family who have both thyroid and mood problems. Recent research suggests that thyroid hormone, which is very inexpensive, may be both an antidepressant and a mood stabilizer, at least in women (2010); this has been under study for years, but with recent emerging evidence has climbed much higher on my list of options. For details, first read basics about thyroid and bipolar disorder; then see my page onhigh-dose thyroid hormone.

Another add-on: verapamil has been around for a long time but has received renewed interest as an option during pregancy^Wisner, and for women at risk of weight gain and metabolic changes from other mood stabilizers; it may only work when added to lithium, though.^Mallinger

In any case, you can see there are a lot of medications you might consider. Here’s a master list with several other waysof looking at the options. You might end up trying quite a few looking for the best one for you. And you’ll need to be keeping track of your symptoms to know how you’re doing on each one. So you may as well start right now with the tracking.  Options include paper/pencil and electronic.  Parents and significant others can keep such a chart, if the patient her/himself is not doing so, even if there are a lot of missing data-days. I strongly recommend that, at least at first.

What should I do with my antidepressant?

If you are currently on an antidepressant:

• If you’re doing well, maybe continue it. This is controversial.
• If you’ve just been diagnosed as bipolar, most doctors will add a mood stabilizer to your antidepressant.
  • If things clearly get better, and you’re doing well, again it’s controversial what to do.
  • If things get better but still you’re cycling up and down, just not as much, then in my opinion it’s clear: you should talk to your doctor about tapering off the antidepressant (very slowly! Take at least several months to get to zero).
• If you’re currently on a mood stabilizer and not doing well, then in my view you need to ask your doctor what risks she sees in tapering off the antidepressant.

Please note the emphasis on talking with your doctor. Some of my colleagues have expressed their concern to me that their patients will read this website and stop their antidepressants. If that was really happening very often, I’d have to consider shutting down the site. The intent here is not to undermine other doctors, just to educate those who wish to learn more than their doctors have time to teach.

There is strong consensus that antidepressants can — in some people — make bipolar disorder worse.The depression gets better, but the “manic” side symptoms (remember, this can include sleep problems, anxiety/agitation, irritability, and difficulty concentrating) get worse. The whole mess can start to “cycle” more frequently, even though the depression is better. In many people, eventually a full depression episode occurs again, despite being on an antidepressant, even one that “worked” before! For some people, you can even say that the antidepressant is causing depression, by making the cycling continue, including cycling into depression.

In that case, even if a mood stabilizer does not have antidepressant effects by itself (there is debate about valproate and carbamazepine in this respect, compared to lithium) it can “work” as an antidepressant very well, by stopping the cycling. I have seen this happen many, many times: so many, in fact, that I routinely rely on the mood stabilizers to help depressed people, and taper off their antidepressants, even while they are depressed. Many times it’s the only way out of the problem (though usually I’ll start the mood stabilizer along with their antidepressant, then taper off the antidepressant when it’s clear the person is getting better).

Gary Sachs, the Harvard bipolar expert, jokes that he tell bipolar patients who experience a very strong antidepressant response: “great, let’s celebrate, let’s lower the dose of your antidepressant!” Note how different an approach this is than in unipolar depression, where continuing an effective antidepressant for 6 months is the standard advice .

I advise patients that they have not had an adequate trial of mood stabilizers if they were simultaneously on an antidepressant at the time. If we try almost everything and the patient still does not improve, eventually she/he will need to try the same mood stabilizers again without an antidepressant on board.

Should I show you that link to controversies regarding antidepressant use one more time? (the language is more complex but I hope you’ll find the concepts fairly clear). Yeesh, this Phelps guy really seems to have a thing about antidepressants, doesn’t he?

How long should someone stay on mood stabilizer medications?

Most people ask: “will I have to take this for the rest of my life?” I generally answer this by suggesting that first we should see whether the medication seems to work; later, if it does, we’ll discuss how long to continue it. People often seem to grasp intuitively that if they have had symptoms for many years, they will probably require medications to “normalize their brain chemistry” for many years.

Bipolar I is a long-term illness that usually requires lifelong preventive strategies, at least after several manic or depressed phases have occurred. Bipolar II is less well defined but intuition is generally correct: the longer people have had symptoms, the longer it makes sense to continue the medication before a trial of tapering it off. In any case, “taper” is the most important concept. There are several studies in Bipolar I which seem to indicate that rapidly discontinuing lithium leads to rapid relapse, where tapering off does not present that risk. For lithium at least, stopping should take months, decreasing by 150mg increments all the way to zero; and this probably applies, by extension (for the moment, at least, until we have some data to go on), to other mood stabilizers.

However, you obviously have ultimate control over how your medication is managed — you’re the one that has to put the pills in your mouth every day. If you decided to, you could just stop doing that. So you really ought to know about any risks that might come with doing that, and there are some. At minimum, if your symptoms have been severe in the past, you should have some sort of a “safety net” if you’re going to stop the medications: a partner, or parent, or several close friends and a work acquaintance. Somehow there should be a group who’s going to easily notice if you’re “slipping”, including someone who can take charge of getting you help, if you are not able to do so yourself.

Be aware that you cannot expect the medications will “work” again if you stop taking them, then start again. Bipolar disorder in many cases seems to progress, as though each cycle was increasing the likelihood and the severity of yet more cycles. Left uncontrolled for a period of time, it can worsen so that previously effective treatments are no longer adequate.

The thoughtful reader may have wondered: “is there any evidence that starting mood stabilizers then stopping them is worse than never having started them at all?” There is no evidence of this that I know of. We should worry about it, though. I have seen about three patients where it looked to me as though this might have occurred (out of more than two thousand), but there are so many variables involved it is impossible to be at all certain. The fact that I have yet to encounter other experts writing about this possibility is somewhat reassuring.

I have seen mood stabilizers seem to make people more depressed than they were before they started, so that is worth watching for (we stopped the medication and things got better; then tried other approaches). This has occurred particularly with divalproex/Depakote, oxcarbazepine/Trileptal, and carbamazepine/Tegretol, though it’s very uncommon, perhaps 1 in 50 or so by my estimate. I’ve not seen other mood experts describe this problem. Nor have I seen it with lithium or lamotrigine or thyroid, all of which have some “built-in” antidepressant potential.

Can I really do this with my primary care doctor?

You should do this with a psychiatrist who knows about bipolar II if you can.   But if it is impossible for you to find a psychiatrist, obviously you and your primary care provider may be stuck trying whatever you can. Hopefully this website will help you decide if “bipolarity” should be considered, and help with trying some basic treatments if you decide bipolarity has the power to explain your experience.

Primary care providers are being bombarded with material from the internet. They don’t have time to read it all. If you think your doctor needs to know some of the kinds of things you are learning here, you can gently suggest she read this page you’re on now. You might be able to convince her if you say something like:

“I know you’re trying to help me, and I wish I had a simpler problem to deal with. I found a site on the internet that made a lot of sense to me, and might help us help me. Here’s a letter from the doctor who wrote it.”

Then hand her a Dear Doctor letter — or use any approach you think might work to get her here!

But please remember: most primary care providers have not been well-trained in this area. Asking them to do something outside their training will make many providers very anxious. They may resist this, and in some cases they may resist in odd ways. If they are frustrated at not being able to help you, which is probably true, their frustration can sometimes seem like it’s aimed at you. It should be aimed at the symptoms, of course. Give him room to “say no” gracefully — which may save both of you some discomfort. After that, if you need it, here are those thoughts about how to talk to doctors.

The “bottom line” of diagnosis

If your depressions are complicated; if you have mood swings, but not “mania”, you can still be “bipolar enough” to need a treatment that’s more like the treatments we use in more easily recognized Bipolar Disorder. You’ll read here about forms of depression  which do not have “mania” to make them stand out as different, yet are not plain depression either. For these people, Depression is  by far the main symptom, including especially sleeping too much, extreme fatigue, and lack of motivation. What makes bipolar depression different is the presence of something else as well.

But that “something else” often does not look anything like mania. “Hypomania”, which you’ll learn about here, can show up as extreme insomnia, irritability, agitation/anxiety, and difficulty concentrating.  And finally, some people can havesome bipolarity without any hypomania at all. Really. You’ll see references to mood experts who have shown all these things as you go.

Wait a minute: isn’t there concern about overdiagnosis of bipolar disorder? Yes, we’ll talk about that too, after you’ve learned some basics.

What happened to “manic-depressive”? What’s “Bipolar II”? 

Somewhere along the way you probably learned about manic-depressive illness: episodes of mania, and episodes of severe depression. Here are the symptoms of “mania”.  Not that you have these, as such; the lack of them is the main point here. Hang on.

• Mood much better than normal
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence
• Delusions (often grandiose, but including paranoid)

What happened to “manic-depressive”? As our understanding of bipolar disorder has grown, the naming system has changed as well. Recently the concept of a “mixed state” of bipolar disorder, in which manic symptoms and depressive symptoms are found at the same time, was added. Obviously this changes the understanding of manic-depressive illness from one in which the two mood states alternate, to one in which they can co-occur! Things are getting more complicated.

Psychiatry has a diagnostic “rule book” that lists the symptoms people must have in order to meet the definition of a particular “disorder”, called the Diagnostic and Statistical Manual. The most recent edition came out in 2013, the “DSM-5”. If much of what you read below seems to describe you well, but someone tells you “you don’t have bipolar disorder”, it could be that they are using a strict interpretation of the DSM rules. This is a highly controversial area in psychiatry. Even the validity of the DSM itself is now controversial. (For examples of this, see my page on DSM vs Spectrum diagnosis).

Technically Bipolar II describes a pattern in which patients experience “hypomania” (to be discussed in detail below), alternating with episodes of severe depression. However, one of the most experienced professionals in this field, who has bipolar disorder herself, has criticized the DSM as too limited:

“The clinical reality of manic-depressive illness is far more lethal and infinitely more complex than the current psychiatric nomenclature, bipolar disorder, would suggest. Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. The illness encompasses the extremes of human experience. Thinking can range from florid psychosis, or “madness,” to patterns of unusually clear, fast and creative associations, to retardation so profound that no meaningful mental activity can occur. Behavior can be frenzied, expansive, bizarre, and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swing erratically between euphoria and despair or irritability and desperation. The rapid oscillations and combinations of such extremes result in an intricately textured clinical picture.” (Kay Jamison, Ph.D.)

I arrived at the same conclusion from listening to patients describe their symptoms. When I used this broader conception to guide treatment, people who had struggled for years often got much better.

Yet when I tried to explain this to some of my colleagues, they thought I was a “bipolar wacko”. That’s how this website got started, and why you’ll see so many reference links. I needed to show that these were not my ideas alone, but rather those of mood experts around the world (it also seemed like a handy way to explain all this to my patients without saying the same thing over and over!) For example, everything you will read below can be found in a review by two mood experts, except that their version is written in full medical jargon.

Even the International Society for Bipolar Disorders has advocated a change in diagnostic procedure, moving beyond the DSM, using what we’ve learned in the last decade.  See Ghaemi and colleagues; if you look closely you’ll see that my name is on the list of co-authors. I was honored to be invited to participate and write for this 2008 update on bipolar diagnosis guidelines. I was the lead author on the “Bipolar Spectrum” paper. Its content is reflected below.

What’s “Bipolar II”? 

Depression for sure. Depression far more than anything else. And then there’s this other little part.  The technical name is misleading, and causes all sorts of trouble, so careful, don’t get thrown off by it.  We’re talking about a very small amount (sometimes larger) of manic-side symptoms:

• Mood better than normal
• Rapid speech
• Dramatically reduced sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence

People with Bipolar II don’t have mania. They don’t have “psychosis” (loss of contact with reality). They don’t have extreme behaviors that people think are “crazy”.  They do have phases that their family and friends recognize as “not your usual self”:  something unusual along the lines of the bullets above.  Notice that “delusions” are gone from the earlier list.

Another variation less severe than Bipolar II is the combination of hypomanic phases with separate phases of milddepression.  This is called “cyclothymia”. Getting confused? I certainly was, until I began to think of these variations as points on a continuous spectrum. I hope the following discussion will impress you as simpler.

What is the “mood spectrum?” 

Until very recently, depression and “manic-depressive illness” were understood as completely independent: a patient either had one or the other. Now the two are seen by most mood specialists as two extremes on a continuum, with variations found at all points in between, even though only some points have names (e.g. Ghaemi; Pies; Moller;Birmaher; Skeppar; Mackinnon; Angst and Cassano; my ISBD review in 2008; and 2014 updates.)

On the left, the “unipolar” extreme represents straightforward depression with no complications. There are many forms of depression, of course (see  “What kinds of depression are there?“). The depressions discussed further below are of a more genetic, or “chemical” nature; versus those of a more situational type, like losing a loved one. Situational depressions may respond well to time or therapy and not require “bipolar” thinking.

On the right, the “manic-depressive” extreme is defined by the presence of manic episodes, just the kind that most people have seen or heard of:  full delusional mania. But in between these extremes is a large area which some mood experts think might be the most common form of bipolar disorder: the green zone below.^Angst 

Got all that?  It gets trickier yet.  Consider the points A and B on this spectrum:

Point A on the continuum describes people who have a complex depression but who still respond well to antidepressant medication or psychotherapy. Around point B, however, there is some sort of threshold where these approaches are no longer completely or continuously effective: either they don’t work at all, offer only partial relief, or help for a while then “stop working” (which may account for some or much of “Prozac poop-out”, now regarded as a non-manic marker of bipolar disorder, described below).

Until 1994 and the publication of the DSM-IV, there was no official name for all the variations between B and the “manic-depressive” extreme. It was as though these variations did not exist. In the minds of a few, they still don’t, including some psychiatrists who have not adopted this new “spectrum” way of thinking about diagnosis. The DSM does not describe this “spectrum” concept. In it, the entire span between blue and green is still “Major Depression”, the same as the violet end to your left. Only the orange and red zones are clearly “bipolar”.

Light green and yellow is BP NOS, Bipolar Not Otherwise Specified (or in the DSM5: BP-NEC, Not Elsewhere Classified). That diagnosis means you have something that looks like bipolar disorder but does not meet the criteria for BP II or BP I. Isn’t it simpler just to think of it as a continuum? That is much closer to reality. We see all sorts of variations in between these named points on the graph above.

What do “bipolar variations” look like?

Warning: this is controversional territory. Ironically, your diagnosis could be determined more by the professional whom you see than the symptoms you have. Really. Read that again. This happens all the time. If your therapist or nurse practitioner or doctor uses a DSM framework, and you don’t meet criterial for bipolar disorder, then you just don’t have bipolar disorder at all. Period.

On the other hand, if your therapist/NP/etc thinks in terms of a “spectrum” of bipolarity, then you could get a bipolar label that someone else might think was “overdiagnosis”. Starts to sound kind of ridiculous, doesn’t it?  But a lot of energy becomes focused here. “Bipolar” carries more stigma than “depression”. Many believe that antidepressants are less risky than mood stabilizers (that’s not so clear either, in my view). So the “yes-or-no” view is still very powerful. You could easily be told “you don’t have bipolar disorder” when someone else has said you do.  The solution is to learn more. Read on.

Roller coaster depression
Many people have forms of depression in which their symptoms vary a lot with time: “crash” into depression, then up into doing fine for a while, then “crash” again — sometimes for a reason, but often for no clear reason at all. They feel like they are on some sort of mood “roller coaster”. They wonder if they have “manic-depression”. But, most people know someone or have heard of someone who had a “manic” episode: decreased need for sleep, high energy, risky behaviors, or even grandiose delusions (“I can make millions with my ideas”; “I have a mission in space”; “I’m a special representative for God”). So they think “well, I can’t have that — I’ve never had a manic episode”.

However, a spectrum view of mood disorders  invites you to reconsider. Hypomania doesn’t look or feel at all like full delusional mania in some patients. Sometimes there is just a clear sense of something cyclic going on. (For a striking version of this, read a patient’s account).

Some mood disorder experts consider depression that occurs repeatedly to have a high likelihood of having a manic phase at some point^Fawcett, especially if the first depression occurred before age twenty. ^{Geller, Rao} These two features–repeated recurrence, and early onset–are also included among the non-manic markers below: not enough to make a diagnosis, but suggestive, especially if they occur with several other such signs  (even if “hypomania” is not detectable at all).

Depression with profound anxiety
Many people live with anxiety so severe, their depression is not the main problem. They seem to handle the periods of low energy, as miserable as they are. Often they sleep for 10, 12, even 14 hours a day during those times. But the part they can’t handle is the anxiety: it isn’t “good energy”. Many say they feel as though they just have too much energy pent up inside their bodies. They can’t sit still. They pace. And worst of all, their minds “race” with thoughts that go over and over the same thing to no purpose. Or they fly from one idea to the next so fast their thoughts become “unglued”, and they can’t think their way from A to C let alone A to Z.

When this is severe, people who enjoy books can find themselves completely unable to read: they just go over and over the same paragraph and it doesn’t “sink in”. They will get some negative idea in their head and go around and around with it until it completely dominates their experience of the world. Usually these “high negative energy” phases come along with severely disturbed sleep (see Depression with Severe Insomnia, below). Thoughts about suicide are extremely common and the risk may be high.^Fawcett

Depressive episodes with irritable episodes
Many people with depression go through phases in which even they can recognize that their anger is completely out of proportion to the circumstance that started it. They “blow up” over something trivial. Those close to them are very well aware of the problem, of course. Many women can experience this as part of “PMS“. As their mood problems become more severe, they find themselves having this kind of irritability during more and more of their cycle. Similarly, when they get better with treatment, often the premenstrual symptoms are the “last to go”. Others can have this kind of cyclic irritability without any relationship to hormonal cycles. Many men with bipolar variations say they have problems with anger or rage.

Depression that doesn’t respond to antidepressants (or gets worse, or “poops out”)
Many people have repeated episodes of depression. Sometimes the first several episodes respond fairly well to antidepressant medication, but after a while the medications seem to “stop working”. For others, no antidepressant ever seems to work. And others find that some antidepressants seem to make them feel terrible: not just mild side effects, but severe reactions, especially severe agitation. These people feel like they’re “going crazy”. Usually at this time they also have very poor sleep. Many people have the odd experience of feeling the depression actually improve with antidepressants, yet overall —perhaps even months later —they somehow feel worse overall. In most cases this “worse” is due to agitation, irritability, and insomnia.

In some cases, an antidepressant works extremely well at first, then “poops out”.^Byrne The benefits usually last several weeks, often months, and occasionally even years before this occurs. When this occurs repeatedly with different antidepressants, that may mark a “bipolar” disorder even when little else suggests the diagnosis.^Sharma

Depression with periods of severe insomnia
Finally, there are people with depression whose most noticeable symptom is severe insomnia. These people can go fordays with 2-3 hours of sleep per night. Usually they fall asleep without much delay, but wake up 2-4 hours later and the rest of the night, if they get any more sleep at all, is broken into 15-60 minute segments of very restless, almost “waking” sleep. Dreams can be vivid, almost real. They finally get up feeling completely unrested. Note that this is not “decreased need for sleep” (the Bipolar I pattern). These people want desperately to sleep better and are very frustrated.

Non-manic markers of bipolarity? Even with no hypomania at all?

You have probably figured it out by now: making a diagnosis of bipolar disorder can be pretty tricky sometimes!  You’re about to read a list of eleven more factors that have been associated with
bipolar disorder. None of these factors “clinches” the diagnosis. They are suggestive of bipolarity, but not sufficient to establish it. They are best regarded as markers which suggest considering bipolar disorder as a possible explanation for symptoms. They are not a scoring system, where you might think “the more I have of these, the more likely it is that I have bipolar disorder.” That way of thinking about these factors has not been tested.

Here’s the list of items which are found with bipolar disorder more often than you would expect by chance alone. These factors are well accepted. (e.g. International Society for Bipolar Disorders reviews: Mitchell et al; Phelps et al).  The particular list below is adapted from a landmark article by Drs. Ghaemi and Goodwin and Ko.  (Drs. Goodwin and Ghaemi are among the most respected authorities on bipolar diagnosis in the world. This important article is online).

1. The patient has had repeated episodes of major depression (four or more; seasonal shifts in mood are also common).
2. The first episode of major depression occurred before age 25 (some experts say before age 20, a few before age 18; most likely, the younger you were at the first episode, the more it is that bipolar disorder, not “unipolar”, was the basis for that episode).
3. A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder.
4. When not depressed, mood and energy are a bit higher than average, all the time (“hyperthymic personality”).
5. When depressed, symptoms are “atypical”: extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and reactions of others; and (the weakest such sign) appetite is more likely to be increased than decreased.  Some experts think that carbohydrate craving and night eating are variants of this appetite effect.
6. Episodes of major depression are brief, e.g. less than 3 months.
7. The patient has had psychosis (loss of contact with reality) during an episode of depression.
8. The patient has had severe depression after giving birth to a child (“postpartum depression“).
9. The patient has had hypomania or mania while taking an antidepressant (remember, severe
   irritability, difficulty sleeping, and agitation may — but do not always — qualify for “hypomania”).
10. The patient has had loss of response to an antidepressant (sometimes called “Prozac Poop-out”):  it worked well for a while then the depression symptoms came back, usually within a few months.
11. Three or more antidepressants have been tried, and none worked.

Bipolarity with no hypomania at all? (!)

There is a very radical idea buried in the above 11 items, which we should look at before going on. But be aware that this idea is likely be dismissed with a “hmmmph” by many  practicing psychiatrists. The idea is this: Dr. Ghaemi and colleagues propose that there might be a version of “bipolar disorder” that does not have any mania at all, not even hypomania. They call it “bipolar spectrum disorder”.

This is strange, you are saying to yourself. “Don’t you have to have some hypomania in order to be bipolar?  How could it be ‘bi’ – polar if there is no other pole!?”

But Dr. Ghaemi and colleagues assert that there are versions of depression that end up acting more like bipolar disorder, even though there is no hypomania at all that we can detect (or, as in item #9, only when an antidepressant has been used). These conditions often do not respond well, in the long run, to antidepressant medications (which “poop out” or actually start making things worse). They respond better to the medications we routinely rely on in bipolar disorder, the “mood stabilizers” you’ll be introduced to in the Treatment section of this website (including several non-medication approaches). And these patients have other folks in their family with bipolar disorder or something that looks rather more like that (e.g. dramatic “mood swings”, even if the person never really gets ill enough to need treatment).

In Dr. Ghaemi’s description, then, there are people whose depression looks so “unipolar” that even a “fine-toothed comb” approach to looking for hypomania will not identify their depression as part of the “bipolar spectrum”. According to Ghaemi and colleagues, these people should be regarded as “bipolar”, in a sense, because of the way they will end up responding to treatment. In other words, there is something in these people which doesn’t look like our old idea of bipolar disorder, or even our newer idea of bipolar disorder (bipolar II, etc.), but will still better describe their future and the medications that are most likely to help them.

Remember that this is the very purpose of “diagnosis”, to describe the likely outcomes with and without treatment, and to identify effective treatments. So, on that basis, it seems reasonable to include these patients on the “bipolar spectrum”, like this:

The idea that someone can “have” bipolar disorder and yet not have any hypomania at all is not widely understood. You probably would get blank looks from most psychiatrists if you mention it, and frank disbelief from nearly all primary care doctors, who don’t have time to read the literature on the diagnosis of bipolar disorder. So, if you mention this idea to anyone, be prepared for some serious resistance.

Here’s some ammunition for you (nice soft paper bullets…) . As of 2005 the Harvard-associated Mood Disorder program started using this approach to diagnosis. They call it the Bipolarity Index.

More:  Other researchers are also beginning to use the same framework of thought. For example, one research group just reported that patients with migraine headaches are much more likely to have these bipolar spectrum traits.^Oedgaard(Migraines are much more common in patients with unipolar and Bipolar II than in Bipolar I, interestingly.^Fasmer) One recent summary article for primary care doctors, about bipolar disorder, discusses these “soft signs” in considerable detail.^Swann

More: The concept of a bipolar “spectrum” is supported by work from a research group calling themselves the Spectrum Project.^e.g.Cassano 

More?  Consider the sources.  Dr. Ghaemi was the chairman of the Committee on Diagnosis for the International Society for Bipolar Disorder. His co-author is Dr. Frederick Goodwin, who wrote the “bible” of bipolar disorder for our lifetime (Manic-Depressive Illness, with Dr. Kay Jamison). These are highly respected researchers amongst mood experts.   Dr. Ghaemi emphasizes the need to rely on evidence in all his papers on diagnosis and treatment and is very frequently cited by other authors on this topic.  You’ll see quite a few references to him on this website. But he is certainly not the only such voice, as I hoped you’ve noticed from all the references linked so far.

Anxious depression could be “bipolar”?
Yes, in Mixed States

An international group of experts^ISBD described anxiety in bipolar disorder thus:

• General hyperarousal
• Inner tension
• Irritability /impatience
• Agitation
• “Frantically anxious”

These symptoms are not generally regarded as symptoms of bipolar disorder. Unfortunately, the very name “bi-polar” is misleading. As noted above by Dr. Jamison, mania can be negative as often as it is positive. The “racing thoughts” can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inabilityto sleep, a desperate wish to be able to sleep to get out of the agitated state.

One way to understand these states is called “mixed states”. Bipolar disorder is an unfortunate name, as it implies a North/South Pole experience.  A better picture looks like this graph:

Both manic symptoms and depressive symptoms at the same time? Sure enough. Not intuitive, if you think North/South pole. But these symptoms can vary independently or occur together (For more on that, see mixed states as waves of depression, anxiety, and normal time.)

This is not controversial. Mixed states were officially recognized in the 1994 version of the DSM, and expanded to look more like the graph above in the 2013 version.

What’s the difference between “anxious depression” and a bipolar mixed state? Not enough to easily be able to tell them apart, unfortunately. The same group of experts quoted above also said: “some but not all agitated depressed states are bipolar.”^ISBD

Worst of all, mixed states can be caused by antidepressants.^ISBD Yet antidepressants are what depressed patients commonly receive, of course.right?  But some of those depressed folks have bipolar depression. The antidepressants can take them from pure depression to agitated depression. The good news is that slowly coming off the antidepressant is one way to address anxiety.^Phelps Don’t do that on your own, of course. Here are some guidelines on stopping antidepressants in bipolar disorder.

Bottom line here: bipolar disorder is complicated, much more complex than “bipolar” (North/South) implies. Anxious depression can be bipolar. Tense, irritable agitation can be bipolar disorder. For more, see the Anxiety and Bipolar page.

What does hypomania feel like?  How short or long?

It’s true that hypomania is a milder version of mania —  just how mild, you’ll see in a moment.  Mind you, Bipolar II is not a milder version of Bipolar I, though it is very often described that way, to my utter dismay. The suicide rate in Bipolar II is the same or higher than the rate for Bipolar I, for example.^Dunner So the BP II version is definitely not a “mild” illness. The depression phases are as bad as in BP I, and often more common (that is, they occur more frequently and represent a more dominant part of the person’s life).

Nevertheless, hypomania can indeed by subtle, certainly by comparison with full mania, as shown in this graph (fromSmith and Ghaemi). Here are the symptoms which people with clear-cut hypomania actually experience — and how often. For example, at the bottom of the graph you see that nearly 100% of people with hypomania will have an increase in their activity. By comparison, optimism is prominent only about 70% of the time in hypomania.

As you can see, these “symptoms” are not clearly abnormal. Everyone experiences these feelings from time to time. When they are extreme; and when they show up over and over again in cycles of mood/energy change; when they are accompanied by other signs of bipolarity, such as phases of depression; that’s when we should think of this as “abnormal”, or at least as warranting caution if someone wants to treat those depressed phases with an antidepressant.

However, hypomania is not always positive. Just as manic phases can be very negative (so-called “dysphoric mania”), hypomania also can be very unpleasant. Here is an example of how hypomania can change from a positive experience to a very negative one (from a blogger who wrote eloquently about bipolarity).

First, the positive phase:

Increased energy. A extraordinary feeling of happiness with myself and the world. A very loving feeling towards the people I care about. An uncommon ability to get things done. A huge burst of energy from the moment I awaken until I go to bed. An expanded ability to multi-task. An organizational acuity that is second to none. A willingness to engage with people. A desire to spend more time with people I care about–and even those I don’t.

Then, the negative phase of hypomania (still pretty subtle):

I start feeling burned out. While I still have a lot of energy, I don’t have that “I love the world” feeling. If I’ve been playing my Autoharp at my mother’s assisted living facility, and jumping up and down to help all the participants turn the pages and stay with me, I suddenly feel that the staff should be more helpful in doing this.

… things don’t just slide off my back. While I try not to “snap” back at people, I am not always successful. I am certainly less willing to ignore things that days or weeks earlier wouldn’t have bothered me at all.

I become far less happy, joyful, and kind. I dislike being criticized in any which way.

How short or long can an episode be? 

For hypomania, officially the answer is “four days” (DSM). But in real life, it’s very clear that episodes can be shorter, and that’s  greed upon by nearly all mood experts I’ve ever heard. They might disagree whether we should shorten the required duration in the DSM, as that would “admit” a lot more people into the bipolar camp which is already a controversial issue. But no one really seems to think that a hypomanic episode lasting only 3 days instead of four is anything other than hypomania; it just doesn’t “meet criteria”, that’s all.

Indeed, a recent study^Bauer showed that episodes lasting as little as one day are common. So don’t get hung up on length of episodes as an issue if you’re trying to figure out if you “have bipolar disorder” or not. Remember, that’s the wrong question anyway… Instead, ask “how bipolar are you?” as affirmed in a recent editorial ^Smith in the British Journal of Psychiatry (one of the biggies…).

What does bipolar depression actually feel like?

Theoretically, bipolar depression is exactly the same as “unipolar” or straight Major Depression. Theoretically, you can’t distinguish between the two, so you can’t tell if someone has bipolar disorder just by looking at their depressions.

But I think there is a different quality to the depressions that people with bipolar disorder experience, because beforethey start feeling sad and having difficulty experiencing pleasure from their usual activities, they very often have problems with energy.  To emphasize this I’d just like you to look at this list of symptoms which people with bipolar disorder said they have when they’re just starting to get depressed.

If you think “that’s me!”, careful: this does not mean you have bipolar depressions. But it might help to see what people with bipolar disorder have said about their experience. I don’t hear about these symptoms so much when people have a more purely “unipolar” — not bipolar — depression.

(from Lobban and colleagues, 2011)

Granted, people in this study also endorsed “loss of interest in activities” and “feeling sad, wanting to cry” but those are typical symptoms in official “Major Depression”. And low energy can also be seen in Major Depression. But look at how prominent low energy is in this study. I think this might be telling us something about the nature of bipolar depression. Certainly matches what I hear from patients.

Finally, the original intent of this list was to help people identify symptoms that mark the beginning of another episode of depression. You might find it useful in that respect also.

Overdiagnosis?

I hope it may now make sense to you to think of mood symptoms as falling on a continuum between plain depression and “depression plus”, the far end of which is Bipolar I, with many variations falling in between.

If you are wondering  whether what you’ve just read is “mainstream” or “fringe” (that’s a good thing to wonder), you’ll find the same “spectrum” concept coming from the head of the Harvard Bipolar Clinic, in this 2005 interview: Sachs.

By contrast, sticking to the DSM rules, you’ll hear that bipolar disorder is overdiagnosed  (the most widely cited paperalso shows a notable underdiagnosis rate as well, by the way. Here is a close examination of their findings. ) They’re right: bipolar disorder is overdiagnosed, if one sticks to the DSM rules. But psychiatry is moving beyond that rigid approach; here are more examples of that movement.

At least one thing is clear: when there’s a question, you’ll be better off if you understand more about “bipolarity”, as you have done here. You are an important part of the diagnostic process.

Is there a test for bipolar disorder?

Not exactly, but…

This used to be simple. When “manic” only meant one thing (classic mania) one could ask “have you ever had a manic episode?” and many people knew what was being asked:

• Mood much better than normal
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence
• Loss of contact with reality (delusions)

As you now know, this list looks for obvious mania.  It misses all the complexity we have just discussed. What you might be wanting is a “no way!” bipolar test.  Something to provide a clear
statement, like: “no, you don’t have it, or anything like it”. Or you might be looking for the opposite: “you definitely have bipolar II”. Sorry, that is not possible, but please read on.

On other websites you’ll find a test called the Mood Disorders Questionnaire (MDQ) which is supposed to give you a “yes or no” answer. But another test came along after the MDQ which is better suited to looking for subtle versions of bipolar II.^Ghaemi

Think about it: if by this point on this website you’re saying to yourself “that’s me!”, which some people do, then you really don’t need some test to tell you that you should go ahead and learn more about treatment.   On the other hand, if someone else thinks you might have it, but you don’t think you do, is a test result going to make a difference to you? If so, go ahead and take one of these tests.

Family or friends could “take the test”, answering as if they were you, on the basis of what they’ve seen you do or heard you say. And then they could gently wonder out loud if perhaps the test might mean something, who knows, no one can tell for sure, but darn it sure seems like your life is a struggle sometimes, wow, what if there was a tool out there that would make life a bit smoother sometimes, not even necessarily a medication treatment, oh well, just thinking about this, of course you’d want to decide for yourself, not for me to say of course, etc. etc.

The people who are in a position to benefit from taking one of these diagnostic tests are those who are wondering if a “bipolar” variation might be worth considering to explain their symptoms. Here’s the test I’d recommend for you, called the  Bipolar Spectrum Diagnostic Scale. It won’t give you a yes-or-no answer. I hope by this point you understand why that’s a good thing.  If after all that you still want to use a “fine-toothed comb” to look for hypomanic/manic symptoms, as I sometimes do when people are still wondering about the diagnosis after learning all this, here is a 32-item checklist of such symptoms.

source psyeducation and mentalhealthsupportcommunity.com

Introduction

This page used to be entitled Breaking News: Two Psychiatrists Agree on 31 Points!  Hard enough to get agreement on anything important, let alone 31 different items. But on this issue, my colleague Tam Kelly (Fort Collins, CO) and I are in complete agreement.

Dr. Kelly evolved these 31 recommendations during 20+ years of seeing patients. Like me he has become a mood and anxiety disorders specialist, not entirely on purpose, but because we both found that some people with mood and anxiety problems were not getting better with standard approaches. (Obviously many people have gotten better with standard approaches, which is great; but for those who don’t, well, that’s where these 31 recommendations come in).

I was going to write my own page, and did publish some evidence for this approach, but Dr. Kelly’s list is more fun [with just a few explanations from me in brackets]. As you’ll see, he has a dry sense of humor and likes to speak plainly.

If you’re having trouble tapering

But if you’re having trouble tapering off an antidepressant,  a remarkable forum collects user wisdom and is moderated by a very smart soul.  See Surviving Antidepressants,  e.g. thiscollection of their most useful pages, an amazing array of how-to’s for tapering nearly every antidepressant, based on the experience of people who’ve “been there”.

Here’s Dr. Kelly –

When to stop antidepressants in people with bipolar disorder

1. If they have been on them a short time I stop them.

2. If less than 2-3 weeks and they are suffering from the antidepressant, taper quickly.

3. Less than a week, stop: two weeks then cut in ½ , a week later stop.

4. Likewise if they just increased their dose I will do the above, decreasing to their previous dose and get rid of the rest later.

5. If the pt is doing well, no mixed state symptoms or cycling, leave it.

6. If manic or severely hypomanic, get rid of them now. Usually can stop abruptly.

7. If cycling get rid of them.

8. If mixed get rid of them.

9. I usually wait until the patient is doing better to much better. Trust is an issue. If the first thing we do is make them suffer more they will be unlikely to stay around long or even go to another psychiatrist. Even though we know the antidepressant is causing harm oft time the patient thinks either that the antidepressant is helping or that every time they try to go off they feel much worse. Waiting until they are better is usually a good thing.

10. Also waiting longer usually means that the patient is going to be more educated about bipolar in general.

11. If they are not getting better after several add on meds then slowly decrease.

12. There are more exceptions to the above rules than there are rules.

Guidelines on how to get off antidepressants

1. Educate/prepare the patient well ahead of time and repeatedly.

2. Chart GAF scores [a psychiatric standard, Global Assessment of Function, a single number summarizing how you’re doing] over time. Sometimes getting off anti-depressants isn’t the right thing to do and can be used to identify “Sweet Spot” for dosing. For example, I recently had a patient who was doing poorly on 300 Effexor XR started when she was still “unipolar”. Took two years to wean off. Retrospectively I was able to see that she was doing best around 75mg. Charting the GAF at appointments and the Lowest in between is best.

3. If the patient stops them AMA [against medical advice] abruptly and they are doing well then leave them off. Watch for manic symptoms. (Sometimes patients get better despite our best efforts.)

4. If the patient stops them AMA abruptly and they are doing worse don’t jump back up to the whole dose. The longer they were at the lower without feeling bad before felling worse, the lower dose you can return to. You can sometimes use half-lives to calculate this. Calculate the dose based on when they started feeling bad. Watch patients very closely during this time, even daily by phone or at the office.

5. Warn patients that they will have mood swings if they do this. Warn patients that they will have mood swings if theydon’t do this, probably worse. Warn them of this over and over again. The point is to try and stop them from major panic when they do have a down.

6. Slowly is best. The slower the better. I usually wait . . . at least 6 – 8 weeks between dosage decreases. Prozac/fluoxetine can be an exception to this.

7. Longer if anxiety is a major feature.

8. Faster if they feel better as they decrease dose.

9. Longer if they have difficulty with dosage decreases.

10.Longer if they are doing relatively well.

11.Never decrease before a major event or holiday.

12. Avoid decreasing during times of major stress.

13. The pt can take longer if they want to take longer for any reason.

14. Reduce in the smallest possible increments. As you approach zero then take the dose changes smaller or longer. Get out that pill cutter. If you can’t get dosage changes in small enough changes do every other day between the smaller dose and the larger dose [WARNING: the Surviving Antidepressants group is strongly against this practice. They have come up with an amazing number of ways of making small doses so that you don’t have to do this. See a summary of their wisdom.

15. You can go faster if they feel better as they decrease dose, but not too fast. Look for signs and symptoms of mania as well as depression. I have seen both hypomania and even mania in a [patient with Bipolar II] who stopped their antidepressant without taper. This has been reported in the literature as well. Going down slowly also avoids manic reactions.

Special Rules

1. Effexor XR. If the pt can tolerate doing this then this is by far the best way to do this. Open up the capsule and take one more bead out each day. Rules 11 – 13 of how to get off antidepressants apply. Pour the beads out on a creased piece of paper and count out the correct amount of beads. Then using the crease of the paper to get the beads back in the capsule. [In my town I have the advantage of a compounding pharmacist who can make small doses from the patient’s large doses. If you don’t have that you definitely need to see the Surviving Antidepressants strategies].

2. If pts can’t count beads or don’t want to do this then take out about ¼ capsule for 6 – 8 weeks and repeat.

3. For any anti-depressant you can add in 20 mg of Prozac, get them off the anti-depressant, then taper the Prozac.

4. Prozac is a special case because of its long half-life. I generally will drop of one day at a time when reducing dose, e.g. decrease to 6/7 days a week for 6- 8 weeks then decrease to 5/7 days a week. Prozac is also a good candidate for every other day decreases, e.g. from a dose of 40mg a day go to 20 alternating with 40 mgs a day [to make a 30 mg-equivalent dose].

Introduction

Anxiety can be a symptom of bipolar disorder. This was recognized by the fellow who originally described bipolar disorder as such, Dr. Emil Kraepelin, back in 1921. He described “anxious mania”, and also “excited depression”, which included a “great restlessness”. He specifically named anxiety as one of the components of this illness. All that requires saying, because “anxiety” is not generally regarded as a bipolar symptom. Yet it clearly is, as summarized in an excellent review by Freeman, Freeman and McElroy.^Freeman

The International Society for Bipolar Disorders (ISBD) further strengthened the view that anxiety can be part of bipolar disorder in a Task Force report detailed below. That ought to be enough to put any remaining controversy about this to rest.

Official word: International Task Force

The International Society for Bipolar Disorders assembled committees of bipolar specialists to prepare reports on several aspects of bipolar diagnosis.

One particular report deserves attention here: first, because the authors are very well-regarded bipolar experts. Second, because it was published in a top psychiatric journal. And most importantly, because their statements are firm and clear.^ISBD

Their paper was on “mixed states” in bipolar disorder, which is the primary setting in which anxiety makes sense as a bipolar symptom. For basics on “mixed states”, see that section of the Diagnosis page. Reviewing briefly:

• General hyper-arousal
• Inner tension
• Irritability/impatience
• Agitation
• “Frantically anxious”

can be part of bipolar disorder. In fact, the ISBD report states that anxiety is “a core symptom of mixed states”.  Here the ISBD is not alone.^{Kauer-Sant’anna}

That ought to be enough to put to rest any controversy about this. Unfortunately, however, several of the “anxiety disorders” in the diagnostic manual (the DSM) can look like  “mixed states”. So confusion is the norm. One ought to be confused. As you’ll see below, it’s almost impossible to separate some of these diagnoses.

Two ways to have anxiety with bipolar disorder

There are basically two ways you can have anxiety with bipolar disorder. First, it can be a symptom of the bipolar disorder itself. Secondly, you can have a separate anxiety condition in addition to bipolar disorder. In medical lingo, that is called a “co-morbid” condition (in case you run across that term). It means both conditions are present, and thus implies that anxiety is a separate condition, not coming from the bipolar disorder itself.

These two ways of looking at anxiety have important implications. If the symptoms are coming from bipolar disorder itself, then they should get better when the bipolar disorder gets better. But if they are coming from a separate condition, they could persist even when the bipolar disorder improves.

If your anxiety is really a separate condition, it’s going to require a separate treatment. And that really complicates things, because very often the recommended treatment for the anxiety condition could be an antidepressant medication — and antidepressant medications can make bipolar disorder worse! (see the section on treatment for details on that problem; or the controversy over use of antidepressants in bipolar disorder).

Anxiety as a symptom of Bipolar Disorder

What is the anxiety of bipolar disorder like? Patients describe it as “agitation”, and sometimes that is quite obvious: their foot bounces on the floor while we talk; they pick at their nails; sometimes they can’t even bear to sit still and will get up and pace around the office during our interview. But sometimes the agitation is only “inside”: patients experience “too much energy inside my skin”, like they’re going to “explode”, and usually their thoughts are going very fast (sometimes called “racing thoughts”). However, when this is severe, people may not experience that fast thinking, but instead just an extremely disorganized thinking — not being able to keep their mind on one thing for more than a few seconds, not being able to accomplish anything. Of course that can make “anxiety” worse as people recognize that they are really ill with something that is not obvious to anyone else, yet they are not really functioning either. How do you explain that to someone?

When this kind of anxiety is present with other manic symptoms like irritability, it can create an awful experience people feel desperate to get out of. (Very often they discover that alcohol can help settle this down for an hour or two. Unfortunately when it wears off, the symptoms come back, very often worse than before. If a person responds to that by drinking more, that can cause a worsening of the condition over several days or weeks — but because they get brief relief from drinking, they keep doing it and often have to drink more over time to keep their symptoms controlled. This is a dangerous spiral which is statistically associated with successful suicide attempts, so represents a clear reason to get help as soon as possible.) Fortunately there are very good medication approaches to this which can help within an hour.Olanzapine/Zyprexa has a special role here, in my view.

When this kind of anxiety is present with depression, this may be the worst combination of all. Anxiety is a very strong risk factor for suicide when people are depressed. The future looks hopeless and pointless because of the depression; and the present feels unbearable. Again, it’s important to know that this combination is very treatable. If you find yourself feeling and thinking like this, and you don’t have a doctor or therapist to help you manage it in the short and long term, you should take specific steps to keep yourself safe, including going to an emergency room if necessary.

Anxiety as a separate condition

Now we’ll have to be more specific about “what kind of anxiety are we talking about?”. There are several specific forms of anxiety which appear to be clearly separate from bipolar disorder (e.g. there are people with these conditions who clearly do not have any bipolar symptoms). Here’s a list, and then we’ll look at specific symptoms that identify each one. After that we’ll look at the treatment implications of having one of these. Jump to each by the link below.

• Generalized Anxiety Disorder (GAD)
• Social Phobia
• Panic Disorder (with or without Agoraphobia)
• Post-Traumatic Stress Disorder (PTSD)
• Obsessive-Compulsive Disorder (OCD)
• Specific Phobias

Most of these have been shown to occur more often than you would expect in people with bipolar disorder (more often than the percentage found when thousands of people identified at random from the phone book were interviewed). We’ll look at each one or you can use the link above to jump to the one you’re interested in.

Generalized Anxiety Disorder (GAD)

There is a lot of overlap in the diagnostic criteria for GAD and bipolar II. We need to look at this in some detail because they may be actually the same thing, at least in some people (as opposed to the rest of the list below, which are somewhat more “separate”). If you’ve read about GAD and think you have it; or if you’re curious about anxiety and bipolar disorder generally (pardon the pun); please read this essay on GAD and BPII.

Social Phobia

This condition is well described, including its treatment with a psychotherapy approach (in addition to or instead of antidepressants), on the useful HelpGuide.org site. Go there to learn much more about social phobia.

For our purposes here, you should also know that social phobia is common in people with bipolar disorder. Starting with “how many people with bipolar disorder have social phobia?”, findings range from 15% to almost 50% in one study. Looking at it the other way, “how many people with social phobia have bipolar disorder?”, one recent study found 21%. These numbers come from the review on anxiety and bipolar disorder by Freeman and colleagues.^Freeman

However, some of my patients with bipolar disorder have clearly had “cycling” in their social phobia symptoms, that goes right along with their bipolar cycling. They get much more socially anxious at some times than others. Or rather, on some occasions, which can be rare but seem always to coincide with their hypomanic phases, their social phobia virtually disappears. They can talk freely, even in a group, even with strangers. They can walk up and introduce themselves to people they have never met. They can speak up in front of others, which they normally would strictly avoid. Then, when their mood and energy cycle back down again, their social anxiety returns. They avoid social circumstances, and all the anxiety they usually get if in the center of attention, even dealing with the check-out guy in a grocery store line, comes back.

This “cycling” of social phobia symptoms along with bipolar symptoms suggests that these conditions are not just co-occurring, but are connected somehow. However, unlike the anxiety of GAD which seems to go away when bipolar cycling is controlled, some degree of social phobia symptoms seems to hang around when bipolar disorder is controlled. This is extremely frustrating for a person who knows that once in a while they don’t have to be like this.

However, the usually offered treatment for social phobia — e.g. antidepressants like paroxetine/Paxil — can make bipolar disorder worse.  But fortunately, there is an excellent treatment for social phobia that does not rely on medications at all. This therapy is described well on the HelpGuide site, here.  Usually this treatment is best done with the help of a therapist who knows “cognitive behavioral therapy”. If you can’t get such a therapist, some people have had some success on their own using a basic online anxiety treatment program (free). It works great, but very few people can do this on their own and get through it:  “e-couch” from Australia.

Panic Disorder (with or without Agoraphobia)

In my experience when people have their bipolar cycling controlled, they stop having panic attacks in almost all cases (there are surely some exceptions). So rather than focus on the panic symptoms, I almost always go after the bipolar symptoms first.

Note that if for some reason panic symptoms persisted after bipolar symptoms were treated, there is a non-medication approach that works better in most people than pills.

Post-Traumatic Stress Disorder (PTSD)

This condition too is described well by a HelpGuide page. About 40% of people with bipolar disorder also have PTSD.^Freeman The converse appears to be relevant as well: growing up in an environment of trauma appears to raise the risk of getting bipolar disorder, if one is genetically susceptible.^Post

I see these two conditions together all the time. Sometimes it’s very difficult to tell them apart from one another. This has implications for treatment, as discussed below.

Obsessive-Compulsive Disorder (OCD)

For more information on OCD, there is a comprehensive website by the OCD Foundation. Their page on “What is OCD?” is a good starting place.

OCD has a complex relationship with bipolar disorder. I’ve seen some patients start out looking like they have classic OCD and end up looking like they have definite bipolar disorder without OCD. These two conditions might be part of the same thing somehow, at least in some people. At least we know they are found together very often, much more so that one would expect. In one study, 20% of people with bipolar disorder had OCD, twice the number seen in unipolar depression (which is also higher than people with no diagnosis).^Chen

A group of researchers has looked at how OCD and bipolar relate. They found that whereas unipolar depression was “incidental”, i.e. not clearly related to the OCD (although common), by contrast bipolar disorder seemed to be more directly related to the OCD. For example, people with religious and sexual obsessions as part of their OCD were more likely than those with other obsessions to have bipolar disorder. The authors specifically recommend that bipolar disorder take precedence over the OCD in terms of which is treated first.^Perugi

Specific Phobias

These include snake, spider and height phobias, which are common. They are also extremely treatable using the “behavioral” approaches (i.e. not medications) described for some of the anxiety disorders above (success rates exceed 80%). There is no specific association with bipolar disorder, to my knowledge.

Summary: treatment implications

Antidepressants can make bipolar disorder worse. Eventhough antidepressants are a standard treatment for anxiety problems (e.g. OCD,PTSD; and to a lesser extent Social Phobia, Panic Disorder and GAD), mostexperts agree: treat the bipolar disorder first, then if anxiety symptoms remain, treat them.

I would go a bit further. If symptoms remain, “treat them” with a psychotherapy if at all possible rather than an antidepressant. There are excellent therapies with results equal to or better than medications for panic and social phobia. There are therapies which get good results, though often only with medications, for PTSD and OCD. If after the therapy has been tried, an antidepressant still must be considered, it should be added to mood stabilizers already underway (per theexpert recommendation cited above).

In my opinion, when a diagnosis of GAD is made, the patient should be informed about the extent of overlap with bipolar disorder and an effort made to determine if the patient might have bipolar disorder. (At minimum, use the screening questionnaire called the MoodCheck ). If after that the patient prefers to start with an antidepressant (versus psychotherapy, if available; or a mood stabilizer trial), don’t forget to look for hypomania or cycling of mood and energy in the first few months.

If you have anxiety symptoms, or if you have an anxiety condition in addition to your bipolar symptoms, make sure your doctor and/or therapist know about these because even with bipolar disorder they are treatable. The trick is to make sure the treatment for the one doesn’t make the other worse. That can be done.