Bipolar Disorder

S. Nassir Ghaemi, MD MPH

Dr. S. Nassir Ghaemi is Director of the Bipolar Disorder Research Program at Emory University. He studies the underdiagnosis of bipolar disorder and the use of mood stabilizers in treatment protocols.

Bipolar disorder is vastly underdiagnosed. On average, it takes 20 years or until a person is almost 40 years of age, before bipolar disorder is diagnosed. Dr. Ghaemi explains that Bipolar disorder is overlooked for many reasons. Most people have a classic picture of a euphoric person as being manic. However two-thirds of manic episodes are not elated, but an irritable or depressed mood. To complicate matters, half of all people with bipolar disorder have lack of insight, so they do not even realize they are ill.

Family support for bipolar disorder is critical, yet scarce. One half of people with bipolar disorder are not medication compliant. In his clinical practice, the divorce rate for bipolar disorder is 90%. Dr. Ghaemi explains how important it is for families to help, especially with medication issues.

How many people have bipolar disorder?
Do more men or women have bipolar disorder?
Is bipolar disorder hereditary?
What is bipolar disorder and how does it usually present itself?
What is mania?
What is the difference between mania and hypomania (type II)?
How does depression present in bipolar patients?
Do the symptoms of bipolar disorder differ much among people?
How often do manic or hypomanic episodes occur?
How long does it usually take for someone to be diagnosed for bipolar disorder?
How often are people misdiagnosed and why?
What is lack of insight?
How do you diagnose patients if half of them have a lack of insight?
How can families help when their loved ones with bipolar disorder?
What should families do if they think someone is manic and are fearful?
Which type of medication is used to treat bipolar disorder?

How many people have bipolar disorder?
About ten or fifteen years ago, we thought that 1% of the population had mania or type I bipolar disorder. But, the definitions of bipolar disorder have changed since then, to include hypomania and milder versions. The general prevalence is now thought to be 3% to 5% of the population.

Do more men or women have bipolar disorder?
For type I bipolar disorder, it is equally split among men and women. For hypomania or type II bipolar disorder, and rapid-cycling bipolar disorder, it is more common in women.

Is bipolar disorder hereditary?
Yes, bipolar disorder runs in families; it is the most genetic major psychiatric condition. It is more genetic than schizophrenia and major depression. If you have a parent or sibling with bipolar disorder, then there is a 10-15% likelihood that you will develop it. If you have a second-degree relative like a grandparent or aunt, then the likelihood is half that amount (5-10%).

In twin studies, 60% of the likelihood is due to genes, but 40% is environmental (such as life events, like a divorce or job loss that triggers an episode). In other words, you may have a genetic susceptibility to bipolar episodes, which are only triggered when you experience environmental stressors. So, it is important to have good family support.

What is bipolar disorder and how does it usually present itself?
The official definition of bipolar disorder involves the occurrence of at least one manic or hypomanic episode during one's lifetime. The onset for bipolar disorder is late teens, compared to major depression, in which the onset is usually in the late 20s or early 30s.

Bipolar patients have depression, so they often appear no different than patients with unipolar or major depression. Bipolar patients usually seek treatment when they are depressed. At some point though, they have manic or hypomanic episodes.

What is mania?
Mania is defined as a mood change with seven symptoms. You only need three or four of the symptoms to meet the definition. The symptoms are:

Mood change (either extremely irritable or euphoric). In the classic mania, people are euphoric, but just as many are irritable.
Distractibility. You can't concentrate very well; you initiate projects, but get distracted so that you can't finish them.
Decreased need for sleep. You sleep less or the same, but have more energy than usual.
Grandiosity. You are more self-confident than usual, out of proportion to your circumstances. It doesn't have to be extreme or delusional.
Racing thoughts. Your thoughts are running through your head rapidly; they are not necessarily illogical or abnormal thoughts, just fast ones.
Increased goal-directed activities. You are doing more activities than normal. Maybe instead of working 40 hours a week, you work 50 to 60 hours a week. Instead of going out with friends one night a week, you go out five to six nights a week. The classic scenario is someone waking up at two or three in the morning and cleaning the house. You have a lot of energy.
Pressured speech or increased talkativeness. You speak very rapidly or speak a lot. For example, you are up late making long distance phone calls for hours on end.
Risk-taking behavior. You are engaging in impulsive activities. You go on spending sprees, or spend impulsively. It is common for people to spend a lot of money or go bankrupt. Other common behaviors are sexual indiscretions, such as affairs or unsafe sex; reckless driving at high speeds; and impulsive traveling. Also you may get into arguments or particularly men may get into fights.
Significant social or occupational dysfunction. Some of the risk taking behaviors or manic symptoms lead to trouble for you with your spouse, your coworkers, or your boss. The divorce rate for bipolar disorder is quite high. You lose relationships and have serious conflicts with family members. You don't have to be psychotic; you don't need to have the classic impulsive behaviors; you just need to have serious problems with relationships.

What is the difference between mania and hypomania (type II)?
Hypomania is a milder mania, but the depression is just as severe. The difference is mainly around how well someone functions. If you don't have risk-taking behaviors or significant social or occupational dysfunction, but have the other symptoms, then you have hypomania. Many people with hypomania are functioning quite well when they are not depressed.

Also for mania to be diagnosed, it needs to occur for a minimum of one week and for hypomania, it is only four days.

In both cases of bipolar disorder, people have severe depressions that are usually recurrent. In type I, they have at least one episode of mania for a week, and in type II, they have at least one hypomanic episode. However, a person with mania can also have hypomania symptoms; their diagnosis is still type I. Type II bipolar disorder means a person has experienced at least one hypomanic episode but has never experienced even one manic episode (major depression also has to occur in type II bipolar disorder).

How does depression present in bipolar patients?
Bipolar depression can look different in some ways from unipolar (major) depression. Symptoms that are more common in bipolar patients than in unipolar depression include:

Brief depressions. In bipolar depression, the average length is three to six months, but in unipolar depression it is six to twelve months. Some depressions are only 2 to 3 weeks in length. The shorter the depression, the more likely it is to be bipolar.
Atypical depression. You may sleep more and eat more as opposed to typical depressions where patients sleep less and eat less.
Psychotic depression. You have delusions or paranoid delusions. Or, you hear voices or see things. Psychotic depression is more common in bipolar disorder.
Post partum depression. Compared to unipolar depression, post partum depression is more common in bipolar disorder.
Recurrent depression. The more episodes of depression you have, the more likely you are to be bipolar rather than unipolar. More than 95% of bipolar patients have recurrent episodes, versus unipolar patients, of which only two-thirds have recurrent episodes.
Antidepressant effects. If you've had multiple trials of antidepressants and they don't work, you could have bipolar disorder. If you experience mania or hypomania while on an antidepressant, you usually have bipolar disorder. If you get better on an antidepressant, but then relapse into recurrent depressions, you may have bipolar disorder.

Also, the earlier the onset of the depression, and the more family history, the more likely it is that it is bipolar disorder (rather than major depression).

Do the symptoms of bipolar disorder differ much among people?
Yes, the symptoms differ a lot. People tend to have a classic picture of a person who is manic and if someone doesn't fit that definition, they think the person is not manic. That is a big mistake. One third of manic episodes are euphoric and two-thirds are irritable or a depressed mood. There are also mixed episodes, which are a depressed mood and an irritable mood at the same time, with other manic symptoms and depressive symptoms at the same time. One-half of manic episodes are mixed episodes.

How often do manic or hypomanic episodes occur?
They are almost always recurrent. There is no set number of episodes that someone may have.

How long does it usually take for someone to be diagnosed for bipolar disorder?
Twenty years on average. It tends to take ten years for a patient to get help. Nineteen years old is the mean age level of onset. So, someone may develop bipolar disorder at 19 years old, and then it takes him or her 10 years to seek help, so the person is 29 years old. Then it takes another ten years for the person to actually get diagnosed with bipolar disorder. Patients are usually diagnosed first with major depression.

How often are people misdiagnosed and why?
About 40% of people with bipolar disorder are misdiagnosed with unipolar (major) depression. This excludes people who just have depression before they show any manic symptoms.

There are many issues around misdiagnosis. First, patients may only experience depression for years before having any manic episodes. Second, clinicians often just don't know about manic symptoms or don't ask about them. Third, patients often don't describe the manic symptoms. They have what is called a 'lack of insight.'

What is lack of insight?
Lack of insight means a lack of awareness of your illness, that there is something wrong with you. Some bipolar patients and many patients with schizophrenia have a lack of insight. 50% of bipolar patients have lack of insight and do not realize they are ill. For example, bipolar patients may just think they are a high-energy person.

Half of bipolar patients do not describe their manic symptoms, because they do not realize they are abnormal. These patients will deny their symptoms. On top of that, when patients are depressed when they come in, they may have a hard time remembering their manic symptoms in the past.

How do you diagnose patients if half of them have a lack of insight?
Clinicians need to talk not only to patients, but also to their family members. Half of bipolar patients appear to be extremely informed when I talk to them. But, when I pick up the phone and talk to a spouse, parent, sibling, or a good friend who has known the patient for a while and ask about the manic symptoms, in five to ten minutes I can find that the patient has manic symptoms, but doesn't realize it. I need the patient's permission to talk to their families.

How can families help when their loved ones with bipolar disorder?
It is really important for family members to remain involved in their bipolar family member's care. This means the family member should come at least to the first doctor's appointment. I need the information from the family member from the beginning. Some family members come to the meetings often with the bipolar patient. Usually it is very helpful for them to be involved on an ongoing basis. The older psychiatric care protocol just treated the patient and ignored the family, but now we encourage family members to help manage treatment. Family members have valuable insight into the symptoms and help patients comply with their medication.

One half of bipolar patients stop taking their medication or rarely take their medication. They need family support to remain compliant. Research has shown that a supportive family environment greatly improves the outcome of bipolar disorder. Families need to help, become very educated about treatment, and ensure the patient is not misdiagnosed.

What should families do if they think someone is manic and are fearful?
First of all, very few bipolar patients are dangerous. Only half of patients with mania have psychotic symptoms at some point in their lifetime. Without treatment, manic episodes are very brief and usually only last a few weeks to a few months maximum. With medication, manic episodes only last a few weeks. Usually these manic symptoms are not dangerous or scary.

If the patient is dangerous, usually it means the patient is not well and is not taking medication, or the medication isn't working. So, family members need to get the patient into medical treatment. This may sometimes mean calling the police or trying to get guardianship for involuntary treatment. It is very hard, if not impossible, to convince someone that they have bipolar disorder if they lack insight completely. Being supportive, nonjudgmental, but also being willing to intervene when necessary - this is the difficult balance families have to keep. There is no easy answer, but I think the bottom line is a balance between keeping some kind of alliance or at least communication with the patient and at the same time making judgments about what is in the patient's best interest even if the patient disagrees.

Which type of medication is used to treat bipolar disorder?
The correct diagnosis of bipolar disorder is extremely important because there is such a difference between bipolar treatment and treatment for unipolar or major depression.

For unipolar (major) depression, antidepressants are prescribed. In unipolar depression, 50% of people respond after a month on the first antidepressant. If they need to try more than one antidepressant, by the third trial, 80% of people respond. They usually completely respond, recover, and are back to normal.

For bipolar disorder, mood stabilizers are the cornerstone of treatment. Mood stabilizers work for both the depressive and manic symptoms. In bipolar depression, antidepressants also work in the depressive stage. But, once bipolar patients are well, antidepressants have not been proven to prevent future depression. Antidepressants may or may not be used in bipolar treatment. There is a disagreement among psychiatrists whether antidepressants should be used in bipolar disorder and it is a focus of my research. We generally use it for the acute depression that is unresponsive to mood stabilizers alone or during suicidal periods.

The risk of antidepressants in bipolar patients is that it can induce mania. This is a common occurrence. Also, there is some risk that antidepressants could worsen the course of bipolar treatment. Bipolar patients on antidepressants may have more episodes of depression or mania and rapid cycling episodes. The antidepressants may act as mood destabilizers, counteracting the benefits of the mood stabilizers. In my opinion, and I think most of the scientific literature supports this view, it is important to not use the antidepressant chronically in everyone in long-term treatment. The important point is to make sure bipolar patients receive an effective mood stabilizer, since some clinicians prescribe not enough or no mood stabilizers. Antidepressants should be used, but cautiously.

Brief depressions. In bipolar depression, the average length is three to six months, but in unipolar depression it is six to twelve months. Some depressions are only 2 to 3 weeks in length. The shorter the depression, the more likely it is to be bipolar.
Atypical depression. You may sleep more and eat more as opposed to typical depressions where patients sleep less and eat less.
Psychotic depression. You have delusions or paranoid delusions. Or, you hear voices or see things. Psychotic depression is more common in bipolar disorder.
Post partum depression. Compared to unipolar depression, post partum depression is more common in bipolar disorder.
Recurrent depression. The more episodes of depression you have, the more likely you are to be bipolar rather than unipolar. More than 95% of bipolar patients have recurrent episodes, versus unipolar patients, of which only two-thirds have recurrent episodes.
Antidepressant effects. If you've had multiple trials of antidepressants and they don't work, you could have bipolar disorder. If you experience mania or hypomania while on an antidepressant, you usually have bipolar disorder. If you get better on an antidepressant, but then relapse into recurrent depressions, you may have bipolar disorder.

Also, the earlier the onset of the depression, and the more family history, the more likely it is that it is bipolar disorder (rather than major depression).

How often do manic or hypomanic episodes occur?
They are almost always recurrent. There is no set number of episodes that someone may have.