World mental health day is observed on 10^th October every year with the objective of raising awareness on mental health issue around the world. This year, a meeting between President Trump and rapper Kanye West, held the day after world mental health day, brought “bipolar disorder” into the spotlight. In this televised meeting Mr. West stated he was misdiagnosed as bipolar disorder when in fact he suffered from “sleep deprivation.”

The purpose of this post is not to agree or disagree with Mr. West’s diagnosis but to utilize this opportunity to create discussion and raise awareness about this mental illness. Often associated with creativity, eccentric personality, and unstable moods, the illness is not “a disease of the rich” or “a modern world problem.”

• What is Bipolar Disorder?
• Causes of Bipolar Disorder?
• Bipolar Disorder Symptoms
• Types of Bipolar Disorder
• Bipolar Disorder Test
• Bipolar Disorder Treatment
• Resources

The two extremes of mood, “melancholia” and “mania” have been documented by ancient Greek physicians and philosophers. French psychiatrist Jean-Pierre Falret created the first concept of a new psychiatric disorder which he termed “folie circulaire” (1851) or “circular insanity”, a mental disorder characterized by a continuous cycle of depression, mania, with symptom-free intervals of varying lengths between the two extremes. It has been speculated that Vincent Van Gough (1853-1890) might have suffered from bipolar disorder. He lived an extraordinary life but committed suicide at the age of 37 after spending the last years of his life in a psychiatric hospital.¹ Several celebrities like Mariah Carey, Catherine Zeta-Jones, and Jane Pauley have revealed details of their battle with this illness in an effort to raise awareness and decrease stigmata about mental illness.

People with BD experience unusually intense emotions, changes in sleep patterns and energy levels, unusual behaviors, and in severe cases even symptoms of psychosis-like hallucinations and delusions.

The intense pattern of emotions ranges from mania or “high highs” to depression or “low lows.” Hypomania is a less severe form of mania that doesn’t include psychotic symptoms and people can function well in social situations. It is often said that overachievers might be functioning in a “hypomanic” state. Those with hypomanic episodes are classified as having Bipolar Type II.

These distinct periods of mania, hypomania, and depression are known as “mood episodes” and the severity varies from person to person. These episodes don’t necessarily follow a pattern. For example, an individual diagnosed as unipolar depression all his/her life may end up experiencing only one manic episode in their lifetime, thus changing the diagnosis to bipolar disorder. The duration of each mood episode can last from days to weeks to months. In between these mood episodes, individuals can also be symptom-free.

According to the NIMH, the characteristics of mania and depression are shown in the table below.⁵

People having a manic episode may:	People having a depressive episode may:
Feel very “up,” “high,” or elated Have a lot of energy Have increased activity levels Feel “jumpy” or “wired” Have trouble sleeping Become more active than usual Talk really fast about a lot of different things Be agitated, irritable, or “touchy” Feel like their thoughts are going very fast Think they can do a lot of things at once Do risky things, like spend a lot of money or have reckless sex	Feel very sad, down, empty, or hopeless Have very little energy Have decreased activity levels Have trouble sleeping, they may sleep too little or too much Feel like they can’t enjoy anything Feel worried and empty Have trouble concentrating Forget things a lot Eat too much or too little Feel tired or “slowed down” Think about death or suicide

Bipolar I: One has had at least one manic episode and this may have been preceded or followed by hypomania or major depressive episode. But the latter are not required for diagnosis. Sometimes mania can be severe leading to a break from reality or psychosis and need for inpatient admission to a psychiatric unit.

Bipolar II: At least one major depressive episode and at least one hypomanic episode but NEVER a manic episode. This is NOT a milder form of bipolar I. The depressive episodes in Bipolar II can be very severe.

Individuals can also experience a “mixed” state in either type of BD, where there is co-occurrence of mania or hypomania or depression.

Unfortunately, there is no blood test or brain scan that would lead to the diagnosis of bipolar disorder. The gold standard continues to remain a detailed history and examination which should be performed by a trained physician, usually a psychiatrist. A psychiatrist might recommend blood tests and review any medicines as certain illnesses (like thyroid issues) and medications (like steroids) can resemble bipolar disorder.

For an episode to be diagnosed as mania, the symptoms must be present every day for at least 1 week and cause significant impairment in functioning. Hypomania, as mentioned above, is less severe, and symptoms should be notable for at least 4 days for the episode to be characterized as hypomania. The depressive symptoms that obstruct a person’s ability to function must be present nearly every day for a period of at least two weeks for a diagnosis.

Sometimes individuals with BD may find the manic or hypomanic episodes appealing (leading to hesitation in seeking help in a timely manner), especially if these episodes succeed the dark cloud of depression or led to an increase in productivity. Some patients might have little to no recollection of their behaviors or risky decisions made during these episodes. Learning from prior episodes and family support is crucial in preventing future relapses.

The best treatment is a combination of medication and counseling or psychotherapy. I routinely tell my patients that just like diabetes or high blood pressure, bipolar disorder is a chronic illness. So in addition to taking medicines, regular exercise, establishing a routine, healthy eating and sleeping habits, avoiding drugs and alcohol, minimizing stress, and having a supportive network of friends and family can really help an individual remain symptom-free.

Medications commonly used for treatment can include antipsychotics, antidepressants, and mood-stabilizers like valproic acid which is also an anticonvulsant. The most widely used medication is lithium carbonate which is known to be effective in the management of both mania and depression.

It is important to take these medications only as prescribed as some might require routine blood tests and monitoring. People with bipolar disorder must avoid stopping a medication abruptly or without discussing with their doctor.

If you (or a family member or friend) are experiencing thoughts of harming yourself or suicide, call someone right away. You can also call 911, present yourself to the nearest emergency room, call your doctor, or call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

National Alliance on Mental Illness (NAMI) [1-800-950-NAMI (6264) or [email protected]] has information and support groups for families and individuals struggling with mental illness.⁶

Suggested Books

An Unquiet Mind: A personal memoir by Dr. Kay Redfield Jamison, Ph.D., details this psychiatry professor’s struggle with bipolar disorder. The author is a professor of psychiatry at the Johns Hopkins University.

The Bipolar Disorder Survival Guide: This book by David J. Miklowitz, Ph.D., focuses on patients helping them recognize the symptoms and coming to terms with the disease. The author is a professor of psychiatry at UCLA Semel Institute.

References:

1. Blumer D. The illness of Vincent van Gogh. Am J Psychiatry. 2002 Apr;159(4):519-26. PubMed PMID: 11925286.
2. https://www.nimh.nih.gov/health/statistics/prevalence/file_148124.pdf
3. Vieta E, Berk M, Schulze TG, Carvalho AF, Suppes T, Calabrese JR, Gao K, Miskowiak KW, Grande I. Bipolar disorders. Nat Rev Dis Primers. 2018 Mar 8;4:18008. doi: 10.1038/nrdp.2018.8. Review. PubMed PMID: 29516993
4. National Institute of Mental Health (NIMH) https://www.nimh.nih.gov/health/statistics//bipolar-disorder.shtml
5. National Institute of Mental Health (NIMH) https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
6. National Alliance on Mental Illness (NAMI) https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder/Support