Bipolar Support Groups.com blog

Bipolar disorder symptoms include dramatic shifts in mood and the ability to function. Successful bipolar disorder treatment requires a careful course of medication, psychotherapy, and discipline to stay on track–and avoid an emotional crash.

Most teens spend their time discussing their latest crush with friends, studying for college admission tests, and taking driver’s education. Not Robin Molliner. When the 26-year-old California native was 16, she was busy trying to talk car dealers into selling her a new ride — even though she didn’t have a dime to her name — and staging a two-week walkout from her high school chemistry class because she wasn’t “happy with the level of the teaching.”

But what seemed like normally high levels of energy and ambition were just the beginning of the full-blown mania that quickly followed.

“I wanted to have sex with anything, I didn’t care who or what,” she recalls. “I felt like my mom was trying to hurt me, and I had feelings of being a prophet.”

At the time, “I would go from moments of being totally happy, bubbly, and having fun to moments when pain from every point in life would come exploding out and I would lose control,” she says.

The Lowdown

As a result of these symptoms and the depression that followed, Molliner was diagnosed with bipolar disorder. Affecting more than 2 million American adults, this illness brings dramatic shifts in mood, energy, and ability to function.

Just about everyone has ups and downs from time to time, but for people like Molliner, these changes can be severe. Moods range from ecstatic or irritable to sad and hopeless — often with extended periods of normalcy in between. Manic episodes may mean increased energy, euphoria, and an unrealistic belief in one’s abilities. People with bipolar disorder may go on lavish spending sprees. They may also have hallucinations (such as hearing voices) and delusional thoughts, as Molliner did about her mother.

Onset typically occurs in late adolescence, as it did with Molliner, or early adulthood. But some people develop symptoms later in life and still others start showing them during childhood. The illness affects children and teens differently from the way it affects adults, according to results from the Course and Outcome of Bipolar Illness in Youth (COBY) research program. The very young develop symptoms that last longer and swing more swiftly from hyperactivity and recklessness to lethargy and depression, the study showed.

While the exact cause of bipolar disorder is not known, most researchers say that it is the result of a chemical imbalance in certain parts of the brain. And some evidence suggests that individuals may have a genetic predisposition to the illness. More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression. True to form, Molliner has two uncles and a grandfather with the disorder.

Medicating Mania

Bipolar disorder can’t be cured but is typically treated with medication, psychotherapy, and lifestyle changes. Doctors often treat the mania symptoms with one set of drugs, and use other drugs to treat the depression. Maintenance treatment with a mood stabilizer such as lithium or an anticonvulsant drug can substantially reduce the number and severity of episodes for most people, but this can be a tough pill to swallow.

Why? Because many people with bipolar disorder struggle with the idea of staying on their medication for life. Some even enjoy the initial phases of the manic stage, while others feel fine and don’t want to deal with the side effects of the medications, which can include weight gain and sexual problems.

Having been on lithium for 10 years, Molliner says, “I didn’t have that choice [about treatment], because I was 16 at the time of diagnosis. [But] the peak of the mania and the deepest end of the depression were so scary and big that I never wanted to experience them again. In the manic stage, I was totally out of control in my own mind and body, and that is the scariest experience ever,” she recalls. “And the depression felt like death.

“The biggest issue with the lithium for me was that it triggered [the skin condition] psoriasis, and I developed a slight hand tremor. But there were no sexual side effects,” she says. Weight gain was an issue, though. “For the first six years [of treatment] I could not lose weight for the life of me, but finally my body adjusted.”

Balancing Act

One of the concerns voiced by those with bipolar disorder is that medication will wipe out their ability to feel joy and express creativity. Like many artistic types, Maurice Bernard, the Emmy Award-winning actor who for 13 years has played General Hospital’s tempestuous mobster, Sonny Corinthos, at first feared that going on lithium would affect his productivity — and his livelihood.

“If you’re an actor, people think if you take medication for bipolar disorder you won’t be able to creatively do the work,” Bernard tells WebMD. His track record refutes this notion. He received the Emmy for Outstanding Lead Actor in a Daytime Drama Series in 2003 and was also nominated in 1996, 1997, 2004, and again in 2005.

After a series of personal events ranging from being misdiagnosed with a brain virus and being told he had six months to live, Bernard was diagnosed with bipolar disorder at age 22. And even though he knows full well that going off the lithium could result in hospitalization, Bernard says that he flirts with the idea every day.
“I don’t want to take them lately,” he says of the pills he has been on for more than a dozen years. “I don’t have any side effects from the medication — I just don’t feel like taking pills anymore. But the main thing is, I know what the consequences are. It’s pretty simple: When I haven’t taken my pills, I have a breakdown. So I am not stupid.”

The ‘Learning Curve’

Bernard, who also serves as a spokesman for the National Mental Health Association (NMHA), admits that there has been a learning curve. “I did go off for one year and had a breakdown, and then I went off for two and a half years and I had a breakdown,” he says. The last time he stopped taking his medication, he threatened to kill his wife, Paula, and ended up in a psychiatric facility.

Regardless of the downsides, the mania can be compelling. “I felt like God was talking through me at one point, and I bought lavish gifts for my girlfriend [now wife],” Bernard recounts. “It’s the feeling of being high and feeling like you are the messiah.” In an upcoming story on General Hospital, his character Sonny — who also has bipolar disorder — will traverse the manic stage of the illness.

“You feel like you are on top of the world and nothing can stop you. And then, of course, the real problem is having to deal with the crash,” says Bernard.

“I understand that patients who feel elated [also] feel wonderful … it’s like being on cocaine and can be extremely attractive and very seductive,” says Joseph Calabrese, MD, a professor of psychiatry at Case Western Reserve and director of the Mood Disorders Center at the University Hospitals of Cleveland, Ohio. “There is one problem,” he adds. “One hundred percent of people have a depression after a high.

“There are short periods of productivity on the way up, but once the highs get more severe, they are less productive,” Calabrese says. And “once you are ill, you have to be able to stay on your medication for life, since in most instances when medications are stopped, people will relapse.”

“It’s a human phenomenon,” agrees Gary Sachs, MD, an associate professor of psychiatry at Harvard Medical School and director of the Bipolar Mood Disorder Program at Massachusetts General Hospital, both in Boston. “There is a willingness to take a treatment when you’re acutely ill, but then when symptoms are no longer [obvious], it’s hard to get your arms around the idea of taking a drug forever when you are not perceiving any benefit.”

Just as with Bernard, “as patients experience more and more relapses, the wisdom to take medication becomes clearer,” says Sachs. Some people, he adds, may get the message after three lapses — and for others it can take 13.

James E. Rosenberg, MD, director of neuropsychiatry at the Sports Concussion Institute at Centinela Freeman Hospital in Marina del Rey, Calif., says that people with bipolar disorder think, “‘I am going to finally write the great symphony or make some brilliant discovery.’ But in the long term, people with untreated mania may find they no longer have family, are HIV positive from engaging in risky, thrill-seeking activities, are in jail, or are bankrupt. There are horrible consequences that affect the rest of your life.”

For Molliner, the repercussions were mainly social. “I lost my identity as a 16-year-old adolescent girl. I didn’t take final exams [the year] I got diagnosed because I was being treated, and everybody I went to high school with knew why, and the shame that went with that was the biggest repercussion,” she says. “I felt like I didn’t fit in and never would.”

More Than Pills

In addition to medication, there is also family support, counseling, and keeping regular routines to help people with bipolar disorder live with the condition. Molliner has been successfully living with bipolar disorder for 10 years, but that’s not to say she does not feel the onset of symptoms and moods from time to time. “I know I need [help] when I sense symptoms coming on in my sleep. I let the people in my life know that I sense it coming on. In doing that, I feel empowered,” she says. Exercise helps, too.

Molliner’s family has been a huge source of support over the years. “They didn’t throw it in my face,” she says. “Initially they were like, ‘Have you taken your lithium?’ ‘Are you having a manic episode?’ or ‘Are you having depression?’ — which was not helpful,” she recalls. “What was useful for them to say was: ‘You are feeling happy, that’s OK,'” she says. “They learned to be supportive of me having emotional experiences without it being an episode.”

Bernard agrees that support from his family has been crucial in his recovery. “Since taking my medications and starting on General Hospital, I have accomplished a great deal in acting and in my life. My life is as perfect as can be,” he says. “I still go through moods and whatnot; but in general, if you get treatment for bipolar disorder, stay on your medications. You can live an incredible life. That’s the bottom line.”

The same holds true for Molliner. The Berkeley graduate is now earning her master’s degree in psychology at Phillips Graduate Institute in Los Angeles. “I am developing programs for people recently diagnosed with bipolar disorder that incorporate art therapy, relapse prevention, and building medication compliance.” She says she wants to become the therapist that she never had.

“We work on self-esteem and identity through group therapy and relapse prevention through education about symptoms that come on before an episode, as well as coping mechanisms,” Molliner says. “You can’t get rid of bipolar, but you can choose how to live with it.”

No one’s mood is stable 100% of the time. It’s normal to feel down when you hit a rough patch and elated when life goes your way.

But if you have bipolar disorder, the highs and lows are a lot more extreme, and they can sometimes seem random. The good news is that with treatment and some hard work, you can control the impact this disease has on your life.

Symptoms of Bipolar Disorder

Doctors aren’t sure what causes this condition, which is also called manic depression. It could have to do with brain structure — the pathways or circuits that control mood, behavior, and thinking. Or it could be brain chemistry. It’s likely genetic, since it often runs in families. Anyone can get bipolar disorder at any age, but most people show symptoms before the age of 25.

Bipolar disorder is generally known for two opposite phases: depression and mania. During a depressed period, you may feel sad, hopeless, and worthless. You might even think about suicide.

Manic periods (hypomania or mania), which tend to happen less often than depressed ones, involve unusual bursts of energy.

What’s the difference between being happy and manic? “You’ll feel much more energetic than you do at your baseline, have racing thoughts, talk louder and faster than normal, and notice a decreased need for sleep,” says Joseph Calabrese, MD. He’s the director of the mood disorders program at Case Western Reserve University.

Also, your judgment will be off. “People do things quickly without thinking about the consequences,” Calabrese says. For example, you might spend too much money, have impulsive sex, or get into trouble with the law. During full-blown mania, you could have feelings that you’re better or more important than other people. You may even hear and see things that aren’t there.

How to Get Help

About 10 million Americans have bipolar disorder, but many don’t know it. “Between 20 and 40 percent of people with bipolar disorder are not properly diagnosed or not diagnosed at all,” Calabrese says.

Why? Most people don’t seek help unless they’re feeling down. “Bipolar disorder can get missed if a person starts with a depressive episode,” says Ken Duckworth, MD. He’s the medical director of NAMI, the National Alliance on Mental Illness, and an assistant clinical professor at Harvard University Medical School.

It’s a catch-22. If you show up at the doctor’s and appear depressed, you’re likely to get an antidepressant. If you have bipolar disorder, that drug may not work and can sometimes bring on mania. The right treatment is a drug that evens out your mood, like lithium. It can help prevent both depressive and manic episodes.

If you’re in a so-called manic phase, you can feel so happy and productive that you don’t want to come down. But “depression always follows mania,” Calabrese says. “You can’t have your cake and eat it, too.”

Clues to a Diagnosis

If you think you might have bipolar disorder, bring a family member with you when you go to the doctor. “Family members will recognize periods of mood elevation,” Calabrese says.

A thorough review of your family history will also help, even if you don’t have relatives who were diagnosed with bipolar disorder. But if a parent has it, there’s a higher chance you’ll get it, too.
People with bipolar disorder often have other conditions, like anxiety disorders, ADHD, and migraines.

Others abuse alcohol or drugs, which can also cause mood swings or symptoms that mimic mania or depression.

Your doctor will have to sort out a lot of complex symptoms to make a diagnosis. So, be honest with him about what’s going on with you.

You’ll also have to be willing to devote time to the process. A doctor can’t diagnose bipolar disorder in 30 minutes, Calabrese says.

The Effort Is Worth It

If you have trouble finding a good doctor, reach out to a local academic medical center, Duckworth says.

Also, medication is only part of the fix, he says. You need to keep stress in check, get regular exercise, and get enough sleep. “Don’t do shift work, be careful with alcohol and drugs, mind your stress levels, and seek loving relationships,” he says.

It takes work to manage this illness, but the effort is worth it. “People who have it can and do achieve wellness and lead extraordinary, healthy, happy, productive lives,” says Allen Doederlein, president of the Depression and Bipolar Support Alliance (DBSA).

Whether you have bipolar disorder or you know someone with the condition, you’ll want to be aware of the signs of mania — the extreme highs that can lead to big risks with money, sex, and even safety.

If you see these signs in a loved one who has bipolar disorder, let them know your concerns and encourage them to tell their doctor.

If you’re the one with the condition, and a family member or friend tells you that they’re concerned, listen to them and get help as soon as possible. It can be hard to see mania in yourself, and you may even like how it feels. But you need to get it under control for your own health.

Common signs include:

Fast-Talking

The first outward sign might be super-fast speech, so quick that anyone listening can’t get a word in edgewise.

“Someone who is normally more thoughtful and interactive suddenly becomes hyper-talkative, talking over you and not really giving you a chance to get into the conversation,” says Dean MacKinnon, MD, an associate professor of psychiatry and behavioral sciences at The Johns Hopkins School of Medicine.

Inflated Ego

When someone is manic, they may say things that greatly exaggerate their abilities and sense of self-esteem.

For instance, they may think that “they are better at stuff — a better writer, a better artist — than people who are already accomplished in those things,” MacKinnon says. Or they may claim expertise that they don’t have.

Sleep Falls Apart

Mania can make someone cut way down on sleep or not sleep at all. They feel like they don’t need it.

“People burst out of bed in the middle of the night full of energy ready to take on the day, or they stay up late into the night busy with projects or other sorts of stimulation,” MacKinnon says.

At first, they may seem to get away with it. “They function perfectly fine the next day on little sleep,” MacKinnon says.

But the longer someone is sleep-deprived, the worse their bipolar symptoms become.

It Has a High Cost

During mania, people can take a lot of risks that they normally wouldn’t. And that can take big toll for a long time.

Just ask Tonya Williams, who found out she has bipolar disorder in 2008. When she was manic, she’d stay up night after night writing poetry, singing, or shopping online.

One time, “I opened 12 new credit accounts and went on a spending spree,” says Williams, now a lawyer in Raleigh, NC. “Everything I purchased, I bought in excess: towels and sheets, leather jackets, sneakers, trading cards, perfume. I racked up $77,000 in credit card debt and spent a sizeable retirement account.”

Eventually, her house was foreclosed on, her car was repossessed, and she had to file for bankruptcy.
Five years after going bankrupt, Williams now takes medication to control the mania and her other bipolar disorder symptoms. “I bought another house, got a new car, and my credit score is now over 700,” she says.

The Highs Aren’t Always Off the Charts

Mania has a less severe form, called “hypomania,” that can feel manageable.

“The only real difference with hypomania is the severity: how much it affects the person,” MacKinnon says. “The symptoms are generally the same.”

Hypomania can feel good. “My mania actually helps me get things done,” says Abigail Camarota, a jewelry designer and mother of three in Louisville, KY.

But hypomania can turn into full-blown mania or severe depression.

“When I am manic — and it’s taken me years to recognize the signs — I can’t sit down and rest. I want to work more, I want to finish more pieces,” Camarota says. “But I realize I need to take a step back because it will drive me crazy or make me physically sick if I don’t.”

It Can Feel Thrilling at First

Some people with bipolar disorder skip their medication because they like how the highs feel.

“Research shows it takes people about 10 years from the time of their first manic episode for them to really accept treatment,” MacKinnon says. “It’s not just because they like the way they feel when they’re manic. They’ve also lost the ability to gauge that their mood is abnormal.”

Be Aware of Triggers

Things like extreme stress, sleep deprivation, drugs, and alcohol can prompt a manic episode.

This is why it’s so important for people with bipolar disorder to avoid alcohol and other drugs, make sure they get enough sleep, and learn ways to manage stress (such as exercise, positive relationships, and meditation).

Also, although mania can happen at any time of year, for some people it’s more common in the summer. Experts don’t know why. You should still look out for mania year-round, but when summer rolls around, keep the seasonal trend in mind.

Your support can make a difference to a friend or family member who has bipolar disorder. Small gestures count.

One of the simplest things you can start with is to try to accept them — and their condition — just like you would if they had a physical health challenge.

Cynthia Last, a therapist in Boca Raton, FL, didn’t know for a long time that she had bipolar disorder. Her husband, Barry Rubin, didn’t believe at first, either. But soon the couple decided to take Last’s diagnosis as a first step to needed changes. Together, they adjusted.

Walk Your Talk

You can model good physical and emotional health by taking good care of your own sleep, exercise, diet, medical care, and relationships. That makes it easier for your loved one to do the same.

Love the Clock

People with bipolar disorder often do better when they’re on a schedule. Don’t fuss about 10 minutes here and there. But encourage your loved one to stick to a bedtime and wakeup time each day, even on weekends. For instance, Last and Rubin leave events early so that Last can stick to her bedtime.

Work, meals, and group get-togethers are other things to plan ahead.

Keep Vacations Simple

A week by a lake or ocean, where your loved one can keep up a sleep and meal-time routine, is easier than a tour where you visit a different place every day or an action-packed weekend in Las Vegas or New York City.

Stay in your time zone, since jet-lag disrupts sleep. Last likes cruises. The ship “takes me to different places, without my having to change hotel rooms,” she says, and she can stick to her usual hours.

Check In

Alicia Smith, a retired entrepreneur who has bipolar disorder, lives in Bozeman, MT. Her friends have motivated her at times to do things she wouldn’t have done on her own.

“Just having someone get me out of the house is helpful, sometimes,” Smith says. Other times, when she’s racing around, she says she needs a friend to ask, “Is there one thing you’d like to accomplish today?” and do it with her.

Your loved one may appreciate it sometimes more than others.

“Ask how you can help,” Smith says. “Back off if you get a bad response.”

Make an Appointment to Learn More

Ask for a “family education” session with your loved one’s therapist. “It’s no different than what you’d do with someone diagnosed with cancer or heart disease,” says David Miklowitz, PhD, director of the Integrative Study Center in Mood Disorders in Los Angeles.

It’s best if your loved one comes, too. Ask which friends and family members should be there. You might also want a separate appointment with just you and the therapist, if needed.

One key thing to do that this meeting is to make a list of the early signs of a manic spell or depression, so that you know what to look for and what to do about it.

Make an Action Plan

If you’re very close to someone with bipolar disorder — such as a family member, partner, or very close friend — agree with them on what you will do if you see that their symptoms are flaring up, such as if they seem like they’re manic or depressed.

The first step on the plan might be to ask if they’ve changed or stopped their medication. It’s common for people to quit or cut the dose, though they shouldn’t do that without talking to their doctor first. “They’ll usually ‘fess up if you ask,” Last says.

Tell their therapist or psychiatrist if you think your loved one doesn’t take medications as prescribed. Some people won’t give their doctors permission to talk to other people about their case. But you can still reach out to let a doctor know your concerns. You should get a response that your message was received and can watch to see what happens next.
Help Them Handle Side Effects

Whether the problem is acne, weight gain, or something else, encourage them to talk to their doctor.

Remove Threats

Have you noticed signs of mania, such as fast talking, risky behavior, getting very little or no sleep, and having a lot of energy? Then you may need to take away their car keys, money, credit cards, and alcohol or illicit drugs. If there are guns or other weapons in the home, make sure they are not accessible to your friend or loved one, and consider removing them from the home to keep them in a safer place.

Do this quietly. “Don’t confront, ever,” says Jim Klein, a retired college English teacher in New Jersey who has bipolar disease.

You may also need to do the same if he or she becomes severely depressed, especially if they or someone in their family has attempted suicide in the past.

Ask for a Mental Health Wellness Check

If you have even a slight worry that your loved one may attempt suicide or hurt others, call 911. You can ask the police for a “mental health wellness check.”

Collect proof of their manic behavior for the police. You may need this if they seem normal when they arrive, says Jim’s wife, Zorida Mohammed, a social worker at a community mental health center. “Find a way to keep them safe while you’re waiting for the treatment,” she says.

If your loved one is a dear friend, an adult child, or older parent living separately, arrange a check-in routine and ask for a set of keys if they have ever attempted suicide, Miklowitz says.

Stay Loving

Dusty Sklar, a writer in Fort Lee, NJ, attended therapy sessions with her adult son, Joey, who had bipolar disorder. “I knew he wasn’t responsible for what was happening to him and tried very hard to be supportive,” she says. “I didn’t back off at all,” she says.

Some people called her an “enabler,” Sklar says. “I broke off those friendships.”

Still, you’ll want to have healthy boundaries. You have your own life to live, and you can’t let your loved one absorb all your attention.

So you may want to talk to a counselor and join a support group. And make sure you keep doing the things that you love. When you take care of yourself, you’ll be better prepared to help your loved one when needed.

Bipolar disorder may raise the risk of suicide. Mania and depression, the hallmarks of bipolar disorder, can be dangerous. During a manic phase, a person with bipolar disorder may be reckless. In about half of cases, people with mania can become psychotic — hearing or sometimes seeing things that aren’t real. During a depressive state, things may seem so hopeless that life doesn’t seem worth living. . Manic or depressive episodes that involve mixed features (aspects of mania during depression, or depression during mania) are particularly dangerous. A person might feel depressed but keyed-up and agitated or energized at the same time.

Suicide is a very real risk for people with bipolar disorder, particularly when they’re in a depressive episode — 10% to 15% of people with bipolar disorder kill themselves. Many more attempt suicide. It’s an alarming statistic, but you have to remember that treatment greatly lowers the risk.

Any person with bipolar disorder needs to know what to do in an emergency.

Your condition — by its very nature — may prevent you from seeing things clearly. So when you’re feeling well, make a plan with your friends and family for what to do in case you become unsafe. You should agree to:
Call your health care provider, therapist, or a suicide hotline right away if you feel suicidal.
Ask for help from friends or family members.
Stay safe until you can get help.
Remember that mood episodes are temporary. Suicidal thoughts are a symptom of your bipolar disorder. You will feel better with time.

What Are Mixed Episodes in Bipolar Disorder?

Mixed features refers to the presence of high and low symptoms occurring at the same time, or as part of a single episode, in people experiencing an episode of mania or depression. In most forms of bipolar disorder, moods alternate between elevated and depressed over time. A person with mixed features experiences symptoms of both mood “poles” — mania and depression — simultaneously or in rapid sequence.

Who Gets Mixed Bipolar Episodes?

Virtually anyone can develop bipolar disorder. About 2.5% of the U.S. population has some form of bipolar disorder – nearly 6 million people.

Mixed episodes are common in people with bipolar disorder — half or more of people with bipolar disorder have at least some mania symptoms during a full episode of depression. Those who develop bipolar disorder at a younger age, particularly in adolescence, may be more likely to have mixed episodes. People who develop episodes with mixed features may also develop “pure” depressed or “pure” manic or hypomanic phases of bipolar illness. People who have episodes of major depression but not full episodes of mania or hypomania also can sometimes have low-grade mania symptoms. These are symptoms that are not severe or extensive enough to be classified as bipolar disorder. This is referred to as an episode of “mixed depression” or a unipolar (major) depressive episode with mixed features.

Most people are in their teens or early 20s when symptoms from bipolar disorder first start. It is rare for bipolar disorder to develop for the first time after age 50. People who have an immediate family member with bipolar are at higher risk.

What Are the Symptoms of a Mixed Features Episode?

Mixed episodes are defined by symptoms of mania and depression that occur at the same time or in rapid sequence without recovery in between..

Mania with mixed features usually involves irritability, high energy, racing thoughts and speech, and overactivity or agitation.
Depression during episodes with mixed features involves the same symptoms as in “regular” depression, with feelings of sadness, loss of interest in activities, low energy, feelings of guilt and worthlessness, and thoughts of suicide.
This may seem impossible. How can someone be manic and depressed at the same time? The high energy of mania with the despair of depression are not mutually exclusive symptoms, and their co-occurrence may be much more common than people realize.

For example, a person in an episode with mixed features could be crying uncontrollably while announcing they have never felt better in their life. Or they could be exuberantly happy, only to suddenly collapse in misery. A short while later they might suddenly return to an ecstatic state.

Mood episodes with mixed features can last from days to weeks or sometimes months if untreated. They may recur ,and recovery can be slower than during episodes of “pure” bipolar depression or “pure” mania or hypomania.

What Are the Risks of Mixed Features During Mood Episodes of Bipolar Disorder?

The most serious risk of mixed features during a manic or depressive episode is suicide. People with bipolar disorder are 10 to 20 times more likely to commit suicide than people without bipolar disorder. Tragically, as many as 10% to 15% of people with bipolar disorder eventually lose their lives to suicide.

Evidence shows that during episodes with mixed features, people may be at even higher risk for suicide than people in episodes of bipolar depression.

Treatment reduces the likelihood of serious depression and suicide. Lithium in particular, taken long term, may help to reduce the risk of suicide.

People with bipolar disorder are also at higher risk for substance abuse. Nearly 60% of people with bipolar disorder abuse drugs or alcohol. Substance abuse is associated with more severe or poorly controlled bipolar disorder.
What Are the Treatments for Mood Episodes With Mixed Features in Bipolar Disorder?

Manic or depressive episodes with mixed features generally require treatment with medication. Unfortunately, such episodes are more difficult to control than an episode of pure mania or depression. The main drugs used to treat episodes with mixed features are mood stabilizers and antipsychotics.

Mood Stabilizers

While lithium is often considered a gold standard treatment for mania, it may be less effective when mania and depression occur simultaneously, as in a manic episode with mixed features. Lithium has been used for more than 60 years to treat bipolar disorder. It can take weeks to work fully, making it better for maintenance treatment than for acute manic episodes. Blood levels of lithium and other lab test results must be monitored to avoid side effects.

Depakote is an antiseizure medication that also levels out moods in bipolar disorder. It has a more rapid onset of action, and in some studies has been shown to be more effective than lithium for the treatment of manic episodes with mixed features

Some other antiseizure drugs, such as Lamictal and Tegretol, are also effective mood stabilizers.

Antipsychotics

Many atypical antipsychotic drugs are effective FDA-approved treatments for manic episodes with mixed features. These include aripiprazole (Abilify), asenapine (Saphris), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon). Antipsychotic drugs are also sometimes used alone or in combination with mood stabilizers for preventive treatment.

Electroconvulsive Therapy (ECT)

Despite its frightening reputation, electroconvulsive therapy (ECT) is an effective treatment for any phase of bipolar disorder, including manic episodes with mixed features. ECT can be helpful if medication fails or can’t be used.

Treatment for Depression in Mixed Bipolar Disorder

Common antidepressants such as Prozac, Zoloft, and Paxil have been shown to worsen mania symptoms without necessarily improving depressive symptoms when depressive and manic symptoms occur together. Most experts therefore advise against using antidepressants during episodes with mixed features. Mood stabilizers (particularly Depakote), as well as atypical antipsychotic drugs, are considered the first-line treatments for mood episodes with mixed features.

Bipolar disorder usually involves recurrences of mixed, manic, or depressed phases of illness. Therefore, it is usually recommended that medications be continued in an ongoing fashion after an acute episode resolves in order to prevent relapses.

Treatment for bipolar depression has come a long way from the days (not so long ago) when patients were given sedatives and medications with numerous side effects. Today, mood stabilizing drugs are a mainstay treatment for bipolar disorder. Doctors may prescribe lithium, an antimanic drug, or an antipsychotic drug — or a combination of both — in order to alleviate symptoms of depression without triggering a manic episode.

While depression episodes are far more common than manias and have a tremendous effect on the lives of patients, there are only a few established treatments for bipolar depression.

What’s the standard treatment for bipolar depression?

Lithium and the anticonvulsants lamotrigine and valproate are mood stabilizers that are sometimes used “off label” as treatments for bipolar depression, although none of these has been established as an FDA-approved first-line treatment for bipolar depression. For many years, psychiatrists have traditionally added an antidepressant to a mood stabilizer if a mood stabilizer alone is ineffective; however, research shows that antidepressants are often not effective for bipolar depression.

A mood-stabilizing medication works on improving social interactions, mood, and behavior and is recommended for both treatment and prevention of bipolar mood states that swing from the lows of depression to the highs of hypomania or mania. According to the American Psychiatric Association (APA), lithium, lamotrigine, valproate, carbamazepine, and most atypical antipsychotic medications are approved by the FDA for treating one (or more) phases of bipolar disorder.

In some patients with bipolar disorder, a mood stabilizer may be all that’s needed to modulate the depressed mood. However, in bipolar patients who do not respond to one mood stabilizer, another mood stabilizer or an atypical antipsychotic is sometimes added to the treatment regimen.

Are antidepressants used to treat bipolar depression?

While antidepressants are effective treatment for people with major depressive (unipolar) disorder, antidepressants they are not always as effective for bipolar depression, and generally should not be given alone (monotherapy) in people with bipolar I disorder. When antidepressants are given alone to someone with bipolar disorder, there’s a risk the drug might ignite a manic episode in some patients. Knowing this, most doctors may avoid using antidepressants as monotherapy for bipolar depression.

A very large randomized study sponsored by the National Institute of Mental Health (NIMH) called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) showed that mood stabilizers alone produced a stable improvement only in about 1 in 4 people with bipolar depression, and surprisingly, adding an antidepressant to the mood stabilizer did not increase the chances for improvement. The STEP-BD study underscored the need to find treatments other than mood stabilizers or antidepressants for bipolar depression.

How are antipsychotic medications used in treating bipolar depression?

Studies have shown that some (but not all) antipsychotic drugs are in themselves effective treatments for bipolar depression. Seroquel and Seroquel XR are used for the treatment of depressive episodes associated with bipolar disorder. Another effective drug with rapid onset for the treatment of bipolar depression is Symbyax, a combination medication of the atypical antipsychotic Zyprexa (olanzapine) and the selective serotonin reuptake inhibitor (SSRI) Prozac (fluoxetine), an antidepressant. The atypical antipsychotic Latuda(lurasidone) is FDA-approved for use alone or with lithium or valproate for treating bipolar depression. These three drugs are currently the only FDA-approved treatments for bipolar depression.
These medications work by affecting brain receptors involved in mood and behavior, and helping to restore the balance of certain natural chemicals in the brain (neurotransmitters).

Your doctor will weigh the benefits and risks of the available medications to help you get relief from the bipolar depression without the risk of mania and/or drug interactions.

How do the CNS depressants help with bipolar disorder depression?

Central nervous system (CNS) depressants, which include the benzodiazepines, act on neurotransmitters to slow down normal brain function. CNS depressants are commonly used to treat anxiety and sleep disorders and may be an effective alternative or adjunctive therapy in some bipolar patients with acute mania.

Some commonly used benzodiazepines include clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium). These drugs all can be habit-forming/addictive and can cause sluggish thinking. They generally should be used only to treat agitation or sleep problems during the acute phase of the illness and not as long-term medications. They typically should be tapered off rather than stopped abruptly, in order to minimize the risk of drug withdrawal.

Is electroconvulsant therapy (ECT) a viable treatment for bipolar depression?

Guidelines from the American Psychiatric Association suggest that ECT is a reasonable alternative in those patients who may have suicidal ideation or psychosis. In addition, ECT may benefit women who are pregnant and suffer with severe bipolar depression or mania.

What about psychotherapy for help with bipolar depression?

Along with medications for bipolar depression, patients may benefit from ongoing psychotherapy. This one-on-one therapy combines interpersonal psychotherapy with behavioral techniques to help patients learn how to diminish interpersonal problems, stay on their medications, and normalize their lifestyle habits. The STEP-BD study mentioned earlier found that in addition to medications, adding a structured psychotherapy — such as cognitive behavioral therapy, interpersonal/social rhythm therapy, or family-focused therapy — can speed up treatment response in bipolar depression by as much as 150%.

How Is Depression Diagnosed?

Although very common, depression is often ignored or misdiagnosed and left untreated. Such inattention can be life-threatening; major depression, in particular, has a high suicide rate.

If you or a loved one have symptoms of depression, seek help from a qualified health care provider. Many primary care doctors diagnose and treat depression. Screenings for depression are now often part of a routine visit to your doctor. But if your symptoms get significantly worse or do not improve within four to eight weeks of treatment, ask your health care provider for a referral to a psychiatrist for diagnosis and treatment. Clearly, for more severe symptoms — and always if you have thoughts about death or hurting yourself or someone else — you should see a psychiatrist as soon as possible.

To diagnose depression, your health care provider will ask you questions about your symptoms and family history. You may be asked to fill out a questionnaire about your symptoms. You may be given medical tests to rule out other conditions that may be causing your symptoms, such as nutrient deficiencies, underactive thyroid or hormone levels, or reactions to drugs (either prescription or recreational) and/or alcohol.

What Are the Treatments for Depression?

The stigma depression carries drives many people to hide it, try to tough it out, or misuse alcohol, drugs, or herbal remedies to get relief. To effectively treat depression, it is important to seek care from a health care provider such as your primary care doctor or a licensed mental health professional. Both of these types of providers can help you get a correct diagnosis and develop a treatment plan. Many treatments for depression are available and typically include a combination of psychotherapy and medication.

Psychotherapy teaches patients how to overcome negative attitudes and feelings and helps them return to normal activities.

Drug therapy is intended to treat symptoms that are thought to result from abnormalities in brain circuits that regulate mood, thinking and behavior. It may take several weeks for an antidepressant to fully work to ease depression symptoms, so it’s important to stay on the medication.

As with any chronic illness, getting an early medical diagnosis and medical treatment may help reduce the intensity and duration of depression symptoms. It may also reduce the likelihood of a relapse.

Medication for Depression

The group of antidepressants most frequently prescribed today consists of drugs that regulate the chemical serotonin. Known as selective serotonin reuptake inhibitors (SSRIs), the group includes Paxil, Prozac, Celexa, Lexapro, and Zoloft. Serotonin norepinephrine reuptake inhibitors (SNRIs) including Effexor, Khedezla, Pristiq, Fetzima, and Cymbalta, also act on serotonin and norepinephrine but in a different way than SSRIs. The drugs Brintellix and Viibryd affect the serotonin receptor (like SSRIs) but also affect other receptors related to serotonin function. Other antidepressants include Wellbutrin, a drug that appears to affect dopamine and norepinephrine regulation, and Remeron, which increases levels of serotonin and norepinephrine by a different mechanism than SNRIs. For children and adolescents, the SSRIs are among the best-studied and therefore often the drugs of choice.

The tricyclic antidepressants (TCAs), which have been used to treat depression since the 1950s, are another option, although they are apt to have more side effects than the SSRIs. Like all antidepressant drugs, you must take them for a while before they take effect. TCAs include Amitriptyline, Amoxapine, Desipramine, Doxepin, Imipramine, Nortriptyline, Protriptyline, and Trimipramine.

Because adolescents do not tolerate side effects well and tend to stop taking their medication, TCAs are not recommended for them as first-line treatments. In addition, heart rhythm problems have been seen in children and adolescents taking desipramine, a TCA, so caution should be taken when this medication is prescribed to this population.

The third group of antidepressants, the monoamine oxidase inhibitors (MAOIs), like Parnate, Nardil, and the skin patch EMSAM, have also proved effective. MAOIs may sometimes work more quickly than the TCAs, but they require avoiding certain foods (such as aged meats and cheeses) and certain other medicines that can also affect serotonin or raise blood pressure. MAOIs are usually prescribed only if the SSRIs and the TCAs or other depression medicines that can be simpler to take fail to bring improvement.

Lithium carbonate, which is a drug commonly used for manic depression, is also sometimes used to treat depression in combination with an antidepressant. Today, atypical antipsychotics have become the most widely prescribed class of medications that are added on to an antidepressant after an incomplete initial response. Two in particular, Seroquel XR and Abilify, are FDA-approved as add-on therapy for antidepressants, regardless of the presence or absence of psychosis (delusions or hallucinations). However, atypical antipsychotics can have many possible side effects, including weight gain, changes in blood sugar and cholesterol, sedation, and abnormal movements.

Your health care provider can recommend the best medicine for you.

Psychotherapy for Depression

Psychotherapy is an important part of treatment for depression. In cases of mild-to-moderate depression, psychotherapy may be used alone to relieve symptoms. More often, it is used in conjunction with medication to alleviate depression.

Commonly used forms of psychotherapy are cognitive, behavioral, and interpersonal therapies.

Cognitive therapies challenge the negative thought patterns that accompany depressed moods and teach you new ways to think more positively.
Behavior therapies concentrate on changing patterns of behavior.
Interpersonal therapies help you examine how relationships affect your moods.
Other Treatments for Depression

Electroconvulsive Therapy (ECT)

ECT involves the application of an electric current through electrodes on the head. These are not felt by the patient, who is asleep under general anesthesia. Although doctors are still uncertain exactly how ECT works, it is thought that by producing a brief seizure, a course of several treatments of ECT conducted over a few weeks can bring about relief from depression. Its techniques have been refined in the past 20 years in order to minimize side effects, such as memory loss, and today ECT is considered to be as safe, or even safer, than many drugs used to treat depression and for some people, more effective.

ECT is usually considered after a number of other options have been tried because it may require hospitalization and general anesthesia. It’s also considered if rapid results are vital, as with suicidal patients or those who refuse to eat or drink. ECT should not be thought of as a “last resort”; it is extremely effective and may work before other treatments have been tried and failed.
Usually given three times a week for two to four weeks, treatments generally involve 6 to 12 sessions and are sometimes followed by a gradual “taper down” in frequency over several weeks. Some people benefit from ongoing “maintenance” treatment over longer periods to prevent relapse when medicines alone may be ineffective.

Repetitive Transcranial Magnetic Stimulation (rTMS)

rTMS, which involves passing strong magnetic currents through the brain, is another option for treating depression. rTMS has been used effectively at times to treat major depression and depression that does not respond to other forms of treatment (treatment-resistant depression). However, to date, studies have not found rTMS to be as effective as ECT.

Vagal Nerve Stimulation (VNS)

VNS is used to treat select cases of severe or recurrent, chronic depression that does not respond to at least two antidepressant trials. This surgical treatment involves the use of a pulse generator implanted under the collar bone that sends out pulses of electricity to stimulate the vagus nerve in an attempt to affect the brain’s mood centers. It typically takes at least several months for VNS to begin to show a benefit for treating depression.

Exercise for Depression

Exercise should be a part of any therapy for depression. It improves blood flow to the brain, elevates mood, and relieves stress. Even if used alone, it can often bring favorable results. Studies show that jogging for 30 minutes three times a week can be as effective as psychotherapy in treating depression. Pick an exercise you like and do it daily, if possible. Any exercise is fine; the more energetic and aerobic, the better. The key is getting your heart rate into the right range for your age for 20-30 minutes three to four times a week.

Nutrition and Diet for Depression

Because symptoms of depression can be exacerbated by nutritional deficiencies, a healthy diet is important. Eat a well-balanced diet. Some people have noticed an improvement of depression symptoms when they eliminated wheat, dairy, alcohol, sugar, and caffeine from their diets. But this is not proven to treat depression. You can try eliminating those foods one at a time from your diet and note whether your depression improves. It may help to keep a symptom diary. Quitting smoking is also advised.

Alternative Medicine for Depression

As with any alternative or complementary medicine, check with your health care provider before starting it, especially if you are taking other medications or treatments.

Herbal Remedies for Depression

Several studies show that the herb St. John’s Wort is as successful at improving symptoms of mild-to-moderate depression as prescription medications, often with fewer side effects. However, other reports show that the herb isn’t any better than placebo (or sugar pill) in treating depression. Although it is considered safe, St. John’s Wort can be potentially dangerous if taken with other antidepressants (especially SSRIs), including certain medications used for treating HIV, cyclosporine, a drug used in organ transplant patients, or anticoagulant drugs. It can also interfere with the efficacy of oral contraceptives and medications used for heart disease and seizures.

S-adenosyl-methionine (SAM-e), another herbal remedy, is also sometimes considered to be a useful treatment option for depression, although existing medical studies have not been conclusive about its effectiveness.

Although ginkgo biloba is typically used as an “alternative medicine” strategy that might help to improve memory and ease confusion, it has proven in some cases to work better than placebo for the symptoms of depression, and is approved by the German government’s Commission E for this purpose.

Whatever herbal remedy you may decide to take to treat a medical condition, it is always best to consult your health care provider first. This is especially true if you are taking prescription medications for the same or other conditions.

Mind/Body Medicine for Depression

Many mind/body practices can be helpful with depression. Music and dance can lift the spirits and energize the body. Meditation and relaxation techniques, such as progressive muscle relaxation, both stimulate and relax. Other choices include transcendental meditation, visualizations, and the Asian exercise techniques of yoga, tai chi, and qigong. Choose one or two that suit you and practice often.

Massage for Depression

Massage not only relaxes you, it may help reduce your anxiety and depression. When groups of depressed adolescents received massage therapy, their stress hormone levels changed, their brain activity was positively affected and their anxiety and depression eased. Because it has no side effects, massage could be a safe and positive addition to your depression treatment program. However, by itself, massage is not considered to be a proven or evidence-based treatment for depression.

Acupuncture for Depression

The World Health Organization lists depression among the conditions for which acupuncture is effective. Some studies have shown it markedly lessens symptoms of depression. Acupuncture may be a viable alternative from therapy if you are unable to take antidepressants or have not found them helpful.

Traumatic events are a shock to the mind and body, and lead to a variety of emotions. Coping with grief takes time, help from others, and the knowledge that grieving isn’t easy.

Grief is an emotion that takes time to deal with, but you can get through it and eventually move on. Grieving is a healthy response to tragedy, loss, and sadness, and it’s important to allow yourself time to process your loss.

Coping With Grief: The Range of Emotions

Grief doesn’t just happen after someone dies. Any traumatic event, major life change, or significant loss — a rape, a divorce, even major financial losses — can cause grief. Throughout the grieving process, you may find yourself feeling:

• Guilty
• Sad
• Angry
• Fearful
• Disbelief or in denial
• Depressed
• Numb

Coping With Grief: Accepting It

“Don’t try to run away from it; rather, face it head on,” advises Sally R. Connolly, a social worker and therapist at the Couples Clinic of Louisville in Louisville, Ky. In more than 30 years of practice, Connolly has helped many individuals and couples deal with grief and various traumatic events.

“Acknowledge that something traumatic has happened and that it has had a profound effect on you,” Connolly advises. Give yourself time to grieve, but seek help when you need it.

Coping With Grief: Finding Help

You may want some time alone to process your thoughts and struggle with your grief, but it’s important to recognize when you need help from others.

“You might need more help if you find that, after some time, you are not able to get back to normal activities, you have trouble sleeping or eating, or have thoughts and feelings that interfere with everyday life,” says Connolly.

A grief counselor or other therapist may be able to help you cope with grief, and finally start to move past it. Getting your grief out in the open is an important first step.

“Talk about it with someone — a friend, family, a support group. Support groups can be wonderful,” Connolly says. There, you can relate to other people who understand your situation, and you can get advice on what helped them through their grief.

Of course, expressing your emotions doesn’t have to be done out loud. “Write about it,” suggests Connolly. Rather than allowing thoughts to swirl in your head, put them down on paper. This is a great way of getting out your feelings if you are shy or embarrassed about sharing them with another person.

Coping With Grief: Getting Closure

Closure is also an important part of coping with grief and may help you move through the grieving process.

“Depending on the event, developing a ritual to say farewell may be helpful. We have funerals when someone dies and they are a healthy step on the road to acceptance. Rituals can be helpful for other traumas as well,” Connolly says.

Coping With Grief: When Will I Feel Better?

There is no set timeline for grieving. And unfortunately, you may never completely get over your loss. But your loss shouldn’t keep you from enjoying life, even with occasional periods of sadness.

“Let yourself grieve as long as you need to. You do have to resume normal life, but know that it’s going to take a while,” says Connolly.

Look for small signs that you’re coping with grief and getting past it. “Happy times signal that you’re progressing,” she says. When you realize that you aren’t always dwelling on the sadness or don’t think about it as frequently as you once did, that means that you’re finally moving on — at your own pace.

Your mind and body need time to grieve after a traumatic event. If you deprive yourself of the grieving process, you may find that you have more difficulty accepting what has happened or that unresolved feelings and issues may flare up later on. Allow yourself to feel sad and even selfish; eventually you’ll find yourself feeling better a little bit at a time. Even though part of you may always feel sad about your loss, you’ll find yourself happy and laughing again one day.

A woman on ProjectBeyondBlue.com, my depression community, recently asked me this: “You exercise daily and eat the right things. You research and write this stuff for a living. But what about those of us who can’t get out of bed in the morning? What about when you are too depressed to exercise, eat right, or work. How do you simply get out of bed?”

The honest answer is that I don’t know.

My bed has never been a sanctuary. Not because I’m disciplined, but because I have very painful memories of my mother’s severe depression — her living in her bed — that I experienced as a grade-schooler. When I was much younger than my kids, I woke myself up for school, made my breakfast and lunch, and walked to school. When I returned to the house, around 3 pm or so, sometimes she was still in bed, oftentimes crying.

I don’t fault her for her depression — I have cried hours and hours in front of the kids and wish I could take back those memories. However, I promised myself somewhere in that pain that I would never use my bed as an escape, especially when I had young children. The thought of a pajama day even today makes me ill.

Therefore, I posed the how-do-you-get-out-of-bed question to my community and to an expert. Here’s what they had to say.

1. Be Depressed Upright (or Prepare For the Voices)

Robert Wicks, psychologist and author of the bestselling book Riding the Dragon, has debriefed professionals in Cambodia following years of torture and was responsible for the psychological debriefing of relief workers evacuated from Rwanda during the country’s bloody civil war. I figured he would be a good one to ask about the bed debacle.

“A depressed person did say to me, ‘I couldn’t do anything you asked in our last session. I was too depressed to get out of bed,’” Wicks told me. “I said, ‘Ah, that is my fault.  I should have cautioned you that those voices would be there and to respond by saying: Yes, I am depressed but I am going to be depressed outside. Activity and depression don’t like to live together.”

When I really don’t want to do something, I try my best to stop the cerebral activity known as thinking, put myself in automatic mode, and “just show up,” as a running coach once told me. Preparing in advance for these thoughts is also helpful, like Wicks said, so you won’t be taken off guard when they try to manipulate you to stay under the covers. And once your body is in motion, it is much easier to keep it in motion.

2. Just Make It to the Shower (or Break Things Down Into Tiny Steps)

My standard words of advice to anyone who is heading into the Great Hole of Depression is this: “Take it 15 minutes at a time. No more than that.” Because every time I do just that — think about only those things that need to be handled in the next 900 seconds — I breathe a sigh of relief and can sometimes even touch an edge of hope.

Michelle, from Project Beyond Blue, uses the same system to get herself out of bed. I thought her self-talk was worth passing on to others:

“What works for me on bad days is to break things down into tiny, tiny steps. So I started saying to myself, ‘I don’t have to go to work, I just need to get into the shower.’  Then, ‘I don’t have to go to work, I just need to eat some breakfast.’ Then, ‘I don’t have to go to work, I just have to brush my teeth.’  Then, ‘I don’t have to go to work, I just need to get on the train.’  It made me feel like I could back out as soon as something became too much, and I would usually end up at work by taking it slowly like this. It sounds insane and overly simple, but it did make a big difference for me when I struggled to get out of bed.”

3. Bribe Yourself

Laurie, from the community, gets herself out of bed by reminding herself how much better she’ll feel after coffee, and by recalling how much she loves to listen to music on her iPod on the ride in. Her wisdom reminded me of the tricks that Ben, my 85-year-old running buddy (I’m a slow runner), used to pull out to get me to jog 18 miles as we trained for a marathon. An hour or so before our run, he would plot out the course and hide bonbons and refreshments behind the trees every two miles. Toward the end, when I didn’t think I could run any further, all I had to do was visualize the watermelon Jolly Ranchers at the next stop. And I wondered why running made me gain weight.

4. Get a Reason (or a Purpose)

I apologize in advance for the irate comments this point will probably provoke: “You think it’s my choice to be depressed?” “You think I’m in bed because I don’t have a reason to get up?” Well, no. I know of people with psychomotor impairment who literally cannot get out of bed without help. However, I also know that most of the people who responded to this question — how to get out of bed — told me that they needed something to do to get them vertical in the morning. Even though they hatehaving to get up at some ungodly hour five times a week for a job they don’t love, they are glad they have the job, because their work gives them the structure that is critical to their recovery.

When my mom was trying to climb out of her darkness, a therapist recommended she get a job — any kind of job — to get her mind off of her sadness. So she became a hostess at nice restaurant, and worked the late breakfast and lunch shift. I believe that was the beginning of her healing process. I know it made for much happier kids. It doesn’t have to be a 9-to-5 stressful job, of course. Agreeing to look after an elderly neighbor or take care of a friend’s pet, or volunteering your time at the Boys & Girls Club can give you a sense of purpose that demands rising from your bed.

Join the conversation “Getting Out of Bed in the Morning” on Project Beyond Blue, the new depression community.