What bipolar disorder is

Bipolar disorder is a mood disorder defined by episodes of elevated or irritable mood and energy, called mania or hypomania, usually alternating with depression. In bipolar I, at least one manic episode lasts a week or more, or is severe enough to need hospital care. In bipolar II, the highs are milder (hypomania, lasting at least four days) and the depressions tend to dominate. Cyclothymia is a milder, longer-running pattern. In a national survey, about 4.4% of US adults had a bipolar spectrum disorder at some point in their lives (Merikangas et al., 2007).

Why it is so often missed

People seek help when they are depressed, not when they are hypomanic, because hypomania can feel like the best version of yourself: energetic, productive, confident, needing little sleep. A large patient survey found that 69% of people with bipolar disorder had been misdiagnosed at first, most often with unipolar depression, and the average delay before the correct diagnosis was about ten years (Hirschfeld et al., 2003).

The consequences are not small. Bipolar depression treated with an antidepressant alone can trigger mania, rapid cycling, or mixed states in which depression and agitation hit together.

What I look for

• Stretches of days with much less need for sleep but plenty of energy, as opposed to insomnia where you are tired and cannot sleep

• Racing thoughts, fast speech, periods of hypersexuality or hyper religiosity, an unusual burst of ideas, plans, or spending sprees

• Depression that started young, comes in repeated episodes, or came with heavy sleeping and slowing

• A family history of bipolar disorder, suicide, or severe postpartum illness

• An antidepressant that made you wired, irritable, or unusually revved up

• Mood episodes tied to the postpartum period

How I evaluate it

I take a full mood history, going back through the episodes of your life and what they looked like at the time. Where possible I add the view of someone close to you, because people in a high often cannot see it. I check sleep, substance use, thyroid and other medical contributors, and any medications that can push mood, including steroids and stimulants. I also separate bipolar disorder from conditions it gets confused with, including ADHD, borderline personality traits, anxiety, and trauma, which can each look like bipolar disorder on the surface.

Treatment

Treatment is usually long-term, because the goal is preventing the next episode, not only treating this one. The CANMAT and ISBD guidelines lay out first-line options by phase of illness, including lithium, quetiapine, lamotrigine, lurasidone, cariprazine, and valproate in selected patients (Yatham et al., 2018).

Lithium deserves a special mention. An updated meta-analysis found that lithium lowered the risk of suicide and self-harm in people with mood disorders compared with placebo and other treatments (Cipriani et al., 2013). It needs monitoring of blood levels, kidney, and thyroid function. I would rather do that monitoring than withhold the option.

On antidepressants, a task force of the International Society for Bipolar Disorders advised against using them on their own in bipolar I disorder, and against using them when mixed features are present (Pacchiarotti et al., 2013). I use them rarely and carefully.

Medications that cause weight gain or metabolic changes come with routine tracking of weight, blood sugar, and lipids. Sleep and routine are part of treatment too: regular sleep and wake times, steady daily rhythms, and limiting alcohol protect against relapse about as dependably as anything in my toolbox.

Women and childbearing

Bipolar disorder and pregnancy deserve planning. Valproate carries significant risks to a developing baby, so I avoid it in women who could become pregnant unless there are no good alternatives. Lamotrigine and lithium can be managed through pregnancy with a plan. The postpartum period is the highest-risk time for relapse and for postpartum psychosis, which is why I like to meet before conception when possible. See my page on postpartum mental health.