UNDERSTANDING MANIC DEPRESSION
Copyright 1996 National Alliance for the Mentally Ill
Manic depression--also referred to as bipolar disorder--is a medical disorder that afflicts more than two million Americans. Manic depression is highly treatable, and new options are continually improving the outlook for those who have the disorder.
Despite impressive progress, two thirds of people with manic depression are not properly diagnosed or treated. With accurate diagnosis, effective medication, and proper support, many people with manic depression can lead normal, productive, and fulfilling lives.
When left untreated, however, bipolar illness can have destructive and costly effects on the lives of those who suffer, their family members, and society. Roughly 40 percent of people with untreated bipolar illness abuse alcohol or drugs, and 60 percent will have marriages that end in divorce.
Job loss is not uncommon, and suicide is too often a consequence of the illness. Because of the wide range of potentially damaging symptoms and behaviors that accompany the disease, people with bipolar illness are often unnecessarily stigmatized by society.
Taking the time to read this booklet is an important first step to answering questions and seeking proper medical care for manic depression. Research is yielding important results about manic depression, and doctors understand more about the disease's social, physiological, and psychological effects.
In most cases, manic depression can be successfully treated with medication. This booklet will explain the symptoms and causes of bipolar illness, discuss treatments, and provide information about successfully managing the disorder.
RECOGNIZING MANIC DEPRESSION
WHAT IS MANIC DEPRESSION?
Manic depression, or bipolar disorder, is an illness of the brain. It affects an individual's mood and is therefore known as a mood or affective disorder. Manic depression involves mood swings with some degree of depression alternating with periods of mania or elation.
The euphoric side of the illness is the mania, while the down side is the depression. The manic side is called hypomania when it is the lower, more productive end of the manic swing. It is called hypermania when it is the chaotic upper end of the manic upswing.
Some people with untreated manic depression have only an occasional episode of mania and repeated episodes of depression. Others may experience mania or hypomania as their main symptom and have few or no episodes of depression. Symptoms of mania and depression can also occur together in what is known as a mixed state of bipolar disorder.
Manic depression often begins in adolescence or early adulthood and continues throughout life.
A catastrophic life event may trigger an individual's first episode of manic depression. In its early stages, manic depressive illness may masquerade as a problem other than mental illness, such as alcohol or drug abuse or poor functioning at work or school. If it is untreated, the disorder tends to get worse, and the symptoms become more pronounced.
Bipolar illness is a chronic illness, much like diabetes, that requires ongoing treatment. With proper treatment, the disease can be controlled. Recognition of the disease at its various states is essential so that the appropriate treatment can be introduced and the harmful consequences of the disease can be avoided.
WHAT CAUSES MANIC DEPRESSION?
While no one knows the exact cause of manic depression, it is believed to be the result of a chemical imbalance that affects certain parts of the brain. Researchers are continuing to explore the basis for this chemical imbalance and have uncovered a strong genetic link to the illness.
Because manic depression tends to run in families, close relatives of someone with the disorder are more likely to be affected by the disease. Hereditary factors, however, are not apparent in the families of all persons with manic-depressive illness; and not everybody with the genetic predisposition to bipolar disorder has the illness.
A serious loss, chronic illness, relationship or financial problems, or any major change in life can play a role in triggering an episode of illness. However, the cyclical nature of the illness can result in episodes without an obvious trigger.
WHAT ARE THE SYMPTOMS?
People with manic depression experience mood swings that alternate from periods of severe highs (mania) to lows (depression). These abnormally intense moods may last for days, weeks, or months.
Periods of fairly normal moods can be experienced between periods of mania and depression and can last for days, weeks, months, or even years. Although no single pattern of symptoms fits every person diagnosed with manic depression, some symptoms are common.
In the manic phase, symptoms can include hyperactivity, explosive temper, impaired judgment, increased spending and sex drive, aggressive behavior, grandiose notions, and often delusions. People on the "high" side of bipolar disorder have increased energy and little need for sleep.
They may feel on top of things, productive, very sociable, and
self-confident--but the feelings are exaggerated. As the mood swing
intensifies, these people lose control, become disorganized, highly
irritable, and eventually unable to function. Unfortunately, they may deny that anything is wrong.
Many people have described the "highs" of mania as feeling better than any other time of their lives. They cannot understand why anyone would call their experience abnormal or part of an illness.
They feel excited, have surges of energy, describe feeling more creative, active, intelligent, and sexual; and they are often able to accomplish tremendous amounts of work. Life plans and decisions, however, are often out of proportion with the individual's realistic abilities and resources. The ill person may have a false sense of self that can be difficult to give up.
Decisions made during periods of mania are often reckless. Spending sprees, alcohol and drug abuse, and hypersexuality are common. These periods of perceived self-importance and unencumbered empowerment can cause confusion and loss of contact with reality for the ill person.
More often than not the patient is oblivious to the negative consequences of his or her actions. People with manic depression may not seek treatment during a manic episode because they do not recognize that anything is wrong.
The "lows" of depression are often physically debilitating. Individuals may find it difficult to even get out of bed. The feeling of depression goes beyond a sense of sadness to a feeling that life is totally without pleasure.
The outward behavior of the person who is depressed may remain relatively normal--the exaggerated activity of mania is absent. When they are depressed, people with manic depression are often in a profoundly sad or irritable mood. They may feel their life is over.
When depressed, persons with manic depression feel sad and lose interest in their usual activities. They lose their capacity to experience pleasure. Even eating and sex are no longer enjoyable. Former interests seem boring or unrewarding, and the ability to feel and offer love may be diminished or lost.
During cycles of depression, symptoms may include changes in sleep patterns. The changes can go in either direction. Typically depressed individuals have difficulty falling asleep, waken throughout the night, and waken an hour to several hours earlier than desired in the morning. Approximately 20 percent of individuals experiencing depression sleep more than the usual amount. In
either case, individuals awaken without feeling rested.
Most persons in a depression experience a decrease in appetite and weight loss that can be significant. About 15 percent will experience an increased desire to eat and will gain weight, but most of these people will still report that the food they are eating does not actually appeal to them.
The inability to concentrate, remember, and make decisions experienced by depressed individuals can be the most frightening aspect of their disorder.
In the midst of a severe depression, individuals may find that they cannot follow a newspaper story or a television comedy. Major decision-making is impossible. Even minor decisions such as what to have for dinner can seem overwhelming.
The energy level of someone with manic depression is high during a cycle of mania, but loss of energy and extreme fatigue are experienced in a cycle of depression by both those who sleep more and those who sleep less during depressed episodes.
Mental speed and activity are usually lowered, as is the ability to perform normal daily routines. Ideas are fewer; there is a poverty of thought; and responses to the environment are painfully slowed.
Self-esteem is very low in a depressed person. Individuals often dwell on memories of losses or failures. They feel guilty and helpless. "I am not worth much" or "the world is a terrible place" are common negative thoughts.
The symptoms of depression often come together in a strong feeling of
hopelessness, a belief that nothing will ever improve, and exaggerated pessimism. Periods of depression can lead to the wish to die or thoughts of suicide--or actual suicide.
It is important to realize, however, that not everyone with manic depression experiences periods of mania and depression with the same intensity. Individuals will more often seek treatment during a depressive episode because the symptoms are perceived as more disruptive to daily life.
Suicide is always a danger, sometimes because these people may become
overwhelmed by what they have done while in a manic state and sometimes because of the depth of the depression.
Bipolar illness can be difficult to diagnose. If a person with manic
depression patient seeks treatment during a depressed period, he or she may be misdiagnosed with clinical depression, especially if the physician is unfamiliar with the person's previous life events and moods.
Alternatively, individuals in a manic episode rarely seek treatment because they do not recognize that they have a problem. A correct diagnosis is possible when the physician is aware of the patient's history and can observe mood-swing patterns. If left untreated, these mood swings often increase in frequency and intensity.
HOW IS MANIC DEPRESSION TREATED?
Medication is an essential part of successful treatment for people with manic depression. In addition, psychotherapy and support groups are important to help people understand the impact the illness has on their and their families' lives and to learn ways to cope with the stresses that can trigger episodes.
The person with manic depression--and his or her family--should be
knowledgeable about and involved in the treatment plan during its
implementation and throughout all its stages or adjustments. Changes in medications or dosages may be necessary, and treatment plans may change during different stages of the illness.
Currently, only two medications are approved by the Food and Drug
Administration (FDA) for the treatment of manic depression, lithium and Depakote. Lithium has been the primary medication used in the treatment of mania because of its mood-stabilizing benefits.
Lithium has been shown to be effective in preventing episodes from occurring and treating an episode after it has begun. Manic and depressive episodes occur less frequently and are less severe when medication is taken regularly. Response to lithium can take approximately 14 days.
The side effects of lithium, including hand tremors, excessive thirst, excessive urination, and memory problems often lessen as the body adjusts to the medication. In a small percentage of patients, long-terms lithium use can interfere with kidney functioning. Patients then need to work with their physician to identify another treatment option.
Blood tests are required to determine the therapeutic dose of lithium for individual patients. If the lithium level gets too high, it can cause a toxic reaction.
It is important to keep fluid and salt intake steady while taking lithium. Low-salt diets are not advisable. Also, lithium should not be taken while pregnant. When taken regularly and at a correct dosage, there is no sedation or other effect on mental functioning from lithium.
Some persons with manic depression do not respond to lithium or have
intolerable side effects. These side effects may cause patients to cease treatment.
Depakote is the first treatment in 25 years to be approved by the FDA as a treatment for manic-depressive illness. Research has shown that Depakote appears to be equally effective as lithium in the treatment of mania--with fewer side effects.
Response to Depakote is typically seen five to ten days after treatment begins. In addition to a favorable side-effect profile and rapid onset of action Depakote appears to be effective in all types of manic-depressive illness, including rapid cycling and mixed mania.
Known chemically as divalproex sodium, Depakote has been used as a treatment for epilepsy since 1983, and it was cleared as a treatment for the manic episodes of bipolar disorder in 1995.
A third drug, carbamazepine (Tegretol), has been used by some physicians as a treatment for those with rapidly changing cycles of mania and depression or for those who cannot take lithium.
It sometimes takes from one to a few weeks to become effective, and there are few side effects. (Dry mouth and nausea are among the more common side effects, and they may be controlled by chewing sugar-free gum or changing the time the medication is taken.)
Patients should not take any of these mood stabilizers while rregnant.
Individuals with manic depression may need antidepressant medication during periods of depression. Five groups of drugs are most often prescribed for depression: tricyclic antidepressants; monomaine oxidase inhibitors (MAOIs); lithium; serotonin selective reuptake inhibitors (SSRIs); and serotonin and norepinephrine reuptake inhibitors (SNRIs).
Electroconvulsive therapy (ECT) may be used if an individual is suicidal, cannot take antidepressant medication, or does not respond to antidepressants.
Tricyclic antidepressants--such as amitripyline (Amitril, Amitriptyline, Elavil, and Endep); desipramin (Pertofrane, Norpramine); doxepin (Sinequan); imipramine (Antipress, Imavate, Imipramins, Presanubem SK-Praamine, Tofranil); nortripyline (Aventyl, Pamelor); or protripyline (Vivactyl) are widely used medications for serious depression.
Venlafaxine HCl (Effexor) is the newest antidepressant, and it can be used in combination with other psychiatric medications. It has a favorable profile for side effects.
Fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are among the newly developed antidepressants known as SSRIs, which act selectively on serotonin. They also have a favorable profile for side effects.
Buproprion (Wellbutrin) is a relatively new medication that seems to be as effective in the treatment of depression. There can be considerable variation from person to person in terms of the effectiveness of specific medications.
Although antidepressant medications elevate mood and activate behavior, it often takes three to four weeks for an individual to respond. Some physicians will try a variety of antidepressants and various dosages before finding the drug or drug combination that best fits the individual. Antidepressant medications are not habit forming.
Medications--and sometimes specific combinations of medications--control mental illnesses, often quite effectively; but individuals must learn to recognize their own patterns of illness and develop ways to cope.
Taking the medication prescribed by a doctor is one way; supportive
counseling is another. Sometimes both are needed. It is important, too, to maintain a balanced lifestyle.
Psychosocial therapies--the "talking" therapies or ones that concentrate on behaviors, current conflicts, or interpersonal relationships--come in many variations and are offered for groups, families, couples, or individuals. Psychotherapy can be useful for individuals and families, but its effectiveness has not been well researched.
HOW SUCCESSFUL ARE TREATMENTS FOR A PERSON WITH MANIC DEPRESSION?
After accurate diagnosis, people with manic depression can be successfully treated with medication in 80 percent to 90 percent of all cases. Early treatment may help keep the illness from becoming more severe or chronic, and for many patients continued treatment is key for maintaining normal mood.
How well treatment works depends on the severity of the manic depression, how long it has been going on, how an individual responds to the medical and psychological interventions offered, and how much responsibility he or she has assumed for recovery and for maintaining a balanced lifestyle.
In combined treatment, medications treat the symptoms of manic depression while psychotherapy helps with the problems the illness causes in daily living.
More intensive treatment may be needed when the symptoms of manic depression are extreme or when they continue for long periods.
Although most persons with manic depression can be treated successfully as outpatients, severe episodes may require brief hospitalization for careful evaluation, protection, and medication adjustment. Sometimes people with this disease have other serious symptoms and antipsychotic or neuroleptic drugs are also prescribed.
CAN MANIC DEPRESSION BE CURED?
No, manic depression cannot be cured, but it can be controlled. It is a chronic disease that requires ongoing treatment, but almost all people with manic depression can obtain substantial relief from their symptoms with proper therapy.
Medication is often prescribed indefinitely to maintain a normal pattern of mood. While no cure exists, most who seek and comply with treatment can lead reasonably stable and satisfying lives. But without proper treatment, many persons experience repeated episodes of illness that worsen with loss of productive living.
Manic depression is a medical illness that produces emotional symptoms, so both medication and supportive counseling may be needed to treat it. The objective of treatment is to lessen the duration and intensity of the episodes of illness and to prevent their recurrence.
WHAT PROFESSIONALS ARE QUALIFIED TO HELP WITH MANIC DEPRESSION?
Family physicians, clinics, and health maintenance organizations (HMOs) all may refer individuals to mental health specialists who provide therapy for manic depression. A psychiatrist is a medical doctor who specializes in mental disorders and is the only one of the mental health professionals who can prescribe medications.
It is important to find a psychiatrist who is experienced in up-to-date psychopharmacology and new treatments for manic depression. It may be helpful, too, if the doctor is familiar with the treatment guidelines established by the American Psychiatric Association for bipolar disorder.
A clinical psychologist conducts psychotherapy and works with individuals, groups, and families to resolve problems associated with bipolar disorder. Psychiatric or clinical social workers have advanced degrees in social work and are trained in counseling and psychotherapy.
They are also trained in client-centered advocacy including information, referral, and direct intervention with governmental and civic agencies. Mental health counselors provide professional counseling services that involve psychotherapy, human development, learning theory, and group dynamics.
Their main goal is the promotion and enhancement of healthy, satisfying lifestyles. These counselors can be found in mental health centers, private practice, or other community agencies.
Pastoral counselors are members of the clergy who--when trained--work with their parishioners to help them understand their illness, solve problems, and manage situations that could result in another episode of manic depression.
Many persons who have manic depression or are trying to help an ill friend or family member start by seeking help from a family doctor. Because the symptoms of mental illness can be caused by other illnesses, a complete physical examination is essential for an accurate diagnosis.
When other medical conditions are ruled out, the family practitioner can either treat the individual or refer the ill person to a mental health specialist for further evaluation and treatment. The treating physician, however, should have experience with manic depression, its diagnosis, and the use of the full range of appropriate medications.
Community mental health centers provide help at a cost based on a person's ability to pay, and some hospitals and universities have special research centers that study and treat manic depression.
WHAT OTHER KINDS OF SUPPORT ARE HELPFUL?
As mentioned, psychotherapy can be helpful for learning to deal with the disruption bipolar illness can cause in everyday living, but emotional support from others with the illness and from family members and friends is also an important part of treatment for manic depression.
Too often, people with this disorder are unaware that there are others who have the illness and have encountered similar experiences. It is helpful for individuals to realize there are people with manic depression with whom they can share their thoughts, fears, and questions.
Family, friends, the community, and healthcare professionals are important sources of support, especially when those with manic depression are too ill to carry out their normal activities.
Family and friends can encourage people with manic depression to seek and continue treatment. They can be very supportive and helpful, especially if they are educated about the illness.
Family and friends can also try to create a low-stress, comfortable
environment for the ill person by reducing stimulation, keeping life
predictable, talking calmly and clearly, and promoting self-esteem and confidence.
Maintaining as normal a relationship as possible, pointing out distorted thinking in a noncritical way, and offering kindness and affection are ways to show caring and respect for the ill person.
Family members and friends also need support. The disruption to daily living caused by a family member or loved one with manic depression can be enormous and can create tremendous stress.
Groups like the National Alliance for the Mentally Ill (NAMI) provide support for both consumers and family members. By sharing experiences, individuals often learn new or different coping skills and are kept up to date about current treatments and services.
MANAGING AND COPING WITH MANIC DEPRESSION
WHAT CAN A PERSON WITH MANIC DEPRESSION DO TO COPE?
Everyone learns to cope with bipolar illness differently; however, accepting the diagnosis of manic depression is critical. Proper diagnosis and treatment will help an individual with manic depression, and so will knowledge about the illness.
Getting information from physicians, inserts in medication packages,
libraries, support-group programs, and community lectures will make the illness less of a mystery.
Over time, people become more familiar with their illness and learn to recognize abnormal patterns of behavior. Learning to recognize these signs is important so individuals can seek appropriate and timely care.
The patient-doctor relationship is also critical in the overall management of manic depressive illness. People with manic depression should view their physician as a partner in treatment.
The physician should play an active role in an individual's recovery and provide counsel and education to help the patient develop skills for managing side effects and coping with the disorder.
Taking responsibility for one's own treatment regime is helpful. Once the illness is under control, reporting side effects, changes in mood, and changes in lifestyle should be routine for the person with manic depression.
The doctor-patient relationship should allow for give and take when it's time to change medication, dosage, or any aspect of treatment that represents the fine-tuning often necessary for good and prolonged results or successful "maintenance."
WHAT CAN A FAMILY MEMBER OR FRIEND DO TO COPE?
Friends and family should be willing to listen to the person with manic depression talk through feelings and to help him or her recognize the need for professional treatment.
They should also be willing to find out more about bipolar disorder, to recognize the symptoms, and to help with treatment. Family members should be aware that others in the family can develop bipolar disorder or major depressive disorder and be prepared to help these persons get early and appropriate treatment.
Acceptance is the first step in coping with a loved one's manic depression. Recognize that building trust may take time. Be honest with yourself about your feelings and communicate these feelings to appropriate others.
It will help to discuss the illness, its symptoms, and treatment with
children exposed to a family member with manic depression. Asking questions and learning more about bipolar illness will make it easier to become an active part of the recovery process. One of the best places to learn about bipolar illness is through support groups, such as NAMI.