Depression comes in several forms-some people have recurrent bouts of terrible sadness, often coupled with loss of interest in the world around them, helplessness, hopelessness, and suicidal thoughts. They suffer from what the current psychiatric nomenclature calls "major depressive disorder, recurrent." Others suffer from a nearly constant, low-grade of depression that saps life of much of its joy for years at a time. The current clinical name for their illness is "dysthymic disorder." This article focuses on a different disease, or rather pair of diseases: "bipolar I disorder" and "bipolar II disorder." People with bipolar I disorder usually suffer from periods of major depressive lows which alternate with manic highs, during which they may overspend, behave recklessly, and even become delusional, believing, for instance, that they are the Messiah. Bipolar II disorder is a similar problem, except that, although the lows are just as low as in bipolar I disorder, the highs are "hypomanic," with fast, pressured speech, racing thoughts, and mild euphoria or irritability which is not as severe as that seen in bipolar I disorder. Taken together, bipolar I and bipolar II disorders are what used to be called "manic depressive illness."
Bipolar disorder is a common, serious, and treatable problem. According to the World Health Organization's study entitled "The Global Burden of Disease," in 1990 bipolar disorder was the sixth leading cause worldwide of years lived with disability. The natural course of bipolar disorder is quite variable. Some individuals with the illness suffer from months of depression followed by years of no symptoms, only to then experience several weeks of a hypomanic or manic state. Others suffer from more or less continual ups or downs or from "rapid cycling," in which their lows and highs may each last only a few days or even only a few hours. This very rapid cycling pattern seems to be particularly common in adolescents who suffer from bipolar II disorder. Still other people with bipolar disorder experience the seemingly paradoxical problems of feeling sad, irritable, and lethargic at the same time that they feel that their thoughts are racing; such individuals may cry and talk excitedly and rapidly simultaneously. At such times, they are said to suffer from a "mixed" bipolar state.
Although the cause of bipolar disorder is still unknown, it is clear from studies of families, including twin studies, that there is a strong genetic component of the illness. If one member of a pair of twins has bipolar disorder, the likelihood that the other will develop the illness is higher if the twins are identical, having the exact same complement of genes, than if they are fraternal, in which case they have the same degree of correspondence in their genes as is usual for brothers and sisters.
Suicide is unfortunately a serious risk in individuals with bipolar disorder, particularly if the illness is poorly controlled. Statistics indicate that between one-quarter and one-half of all patients with bipolar disorder attempt suicide, and up to 15% of patients with the disorder succeed in a suicide attempt. Untreated bipolar disorder is estimated to lower life expectancy by nine years. Fortunately, though, individuals with properly treated bipolar disorder are estimated to have about a seven-year improvement in life expectancy compared to untreated persons with the disorder.
Mood stabilizing drugs such as lithium carbonate, divalproex sodium (Depakote) and lamotrigine (Lamictal) are mainstays of the pharmacological treatment of bipolar disorder. Antidepressant medications such as fluoxetine (Prozac) or bupropion (Wellbutrin) are sometimes used in addition to mood stabilizing drugs, but there is some risk in certain patients with bipolar disorder of their being "flipped" from depression into mania with antidepressants or of their developing rapid cycling of their mood disorder on antidepressants, particularly if a mood stabilizer is not given concurrently with the antidepressant. Atypical antipsychotics such as risperidone (Risperdal) and olanzapine (Zyprexa) are useful in the treatment of psychotic symptoms in bipolar disorder, and they may also help to "slow down" rapid thoughts in hypomanic patients. Some atypical antipsychotics, though, can cause weight gain and the early appearance of obesity-associated (Type II) diabetes in certain patients, so the medications much be used with discretion.
People who experience wide mood swings, and the loved ones of people who experience mood swings, should seek professional help. Psychiatric physicians are trained in the pharmacological treatment of bipolar disorder, and can also help patients cope with their illness through psychotherapy. Clinical psychologists and many social workers are also trained in the psychotherapy of patients with bipolar disorder, but most patients with the illness will need to have medication prescribed by a physician. Because of the suffering which untreated depression and mania cause bipolar patients and their families, and because of the risk of suicide in bipolar patients, it is important that the illness be diagnosed and treated properly. In emergency situations, a call to a crisis line such as 211 or (414) 257-7222 in Milwaukee County can be lifesaving for a person considering suicide.
Although the biological cause of bipolar disorder is not yet well understood, research in brain biology and functional imaging of the brain is bringing us closer to an understanding of the illness. Fortunately, despite our incomplete understanding of the cause of bipolar disorder, it is one of the most successfully treatable major psychiatric illnesses. With proper treatment, most patients with bipolar disorder can lead full, rewarding lives.
Joseph B. Layde, M.D., J.D.
Associate Professor
Department of Psychiatry and Behavioral Medicine
Medical College of Wisconsin