Depression - Overview of Bipolar Disorder and Its Symptoms

Overview of Bipolar Disorder and Its Symptoms

Depressive and manic depressive illness are the two major types of depressive illness, also known as affective disorders, or mood disorders, because they primarily affect a person's mood. Different terms, respectively, include unipolar and bipolar disorder. You may have heard of other forms of depressive illness such as dysthymia, a type of chronic moderate depression, or cyclothymia, a form of manic depression in which the cycles (mood swings) are not quite as severe. In this booklet, we will predominately discuss major depressive disorder and manic depression, which encompasses symptoms of depression and mania or hypomania, a more moderate syndrome than full-blown mania.

It is estimated that over 17.4 million adults in the U.S. suffer from an affective disorder each year--that's one out of every seven people. If you are not affected now, chances are that at some point in your life, you yourself or someone you know will become affected. If you are a woman, you are twice as likely as a man to experience major depression while manic depression occurs equally among the sexes. Although these illnesses can occur at any age, many have their onset within the 25-44 age range.

Where do these illnesses come from Genetic, biochemical and environmental factors can each play a role in onset and progression. While we all experience occasional highs and lows, affective disorders are characterized by their extremes in intensity and duration. Even at their most intense, the symptoms are often mistaken for other medical problems or dismissed as a reflection of someone's personality, age, social influence or background.

Research indicates that only one third of those with major depression will get proper treatment, and two thirds of those with any kind of affective disorder who do receive treatment will be misdiagnosed. These statistics reflect the insidiousness of the illness and the importance of both public and physician education. A lag in diagnosis and treatment could prove deadly; people with severe, untreated depression have a suicide rate as high as 15 percent. In fact, the number one cause of suicide in the U.S. is untreated depression.

Don't be overwhelmed by these sobering statistics. Of all psychiatric illnesses, affective disorders are among the most responsive to treatment. If given proper care, approximately 80 percent of patients with major depression demonstrate significant improvement and lead productive lives. Although the treatment success rate is not as high for bipolar disorder, a substantial number experience a return to a higher quality of life.

It is crucial that you learn the symptoms and act early!

Symptoms of Depression

  • prolonged sadness or unexplained crying spells
  • Significant changes in appetite and sleep patterns
  • Irritability, anger, worry, agitation, anxiety
  • pessimism, indifference
  • Loss of energy, persistent lethargy
  • Feelings of guilt, worthlessness
  • Inability to concentrate, indecisiveness
  • Inability to take pleasure in former interests, social withdrawal
  • Unexplained aches and pains
  • Recurring thoughts of death or suicide

Symptoms of Mania

  • Heightened mood, exaggerated optimism and self confidence
  • Decreased need for sleep without experiencing fatigue
  • Grandiose delusions, inflated sense of self-importance
  • Excessive irritability, aggressive behavior
  • Increased physical and mental activity
  • Racing speech, flight of ideas, impulsiveness
  • poor judgment, easily distracted
  • Reckless behavior such as spending sprees, rash business decisions, erratic driving, sexual indiscretions
  • In the most severe cases, hallucinations

Anyone experiencing four or more of the above symptoms of either or both depression or mania should seek help if symptoms persist for longer than two weeks.

The Cause of Affective Disorders: It's Not Just in Your Head

Research shows that some people may have a genetic predisposition to affective disorders. If someone in your family has had such an illness, that does not necessarily mean you will develop it, nor does it explain conclusively why you did. It does increase your chances of experiencing depression of an endogenous nature (biological in basis). This is commonly referred to as clinical depression to distinguish it from short-term states of depressed mood or unhappiness. Even if you don't have a genetic predisposition, your body chemistry can trigger the onset of a depressive disorder, due to the presence of another illness, altered health habits, substance abuse, or hormonal fluctuations.

Depression can also be triggered by distressing life events, resulting in reactive depression. Losses and repeated disillusionment, from death to disappointment in love, can cause anyone to feel depressed especially if they have not developed effective coping skills. If these symptoms persist for more than two weeks, maintaining or increasing in intensity, this reactive depression may actually have evolved into a clinical depression.

Regardless of its cause, the presence of depressive or manic depressive illness indicates an imbalance in the brain chemicals called neurotransmitters. In other words, the brain's electrical mood regulating system is not working as it should. proper treatment will vastly improve your level of functioning and can usually restore you to your "old self." Many people require long-term, even life-long, maintenance treatment which significantly decreases the likelihood of recurrences.

Bipolar Disorder: Rapid Cycling and Its Treatment

Begin Your Recovery...Today

Every journey begins with a single step. For some, that first step may be reading this brochure. for others, it may be calling National DMDA to ask for help. After proper diagnosis and treatment, the support of others is vital to a lifetime of wellness. No one has to feel alone with bipolar disorder, also known as manic depression. After all, two and a half million adults in the United States develop bipolar disorder at some point in their lives. More than 17 million Americans experience some form of a depressive illness annually.

National DMDA offers a national network of local chapters. Each chapter is associated with at least one support group, where consumers can share their feelings and experiences in a safe, confidential setting and may even impact the lives of others.

Your journey to recovery can begin today with one phone call to National DMDA or continuing to look through our Web site. Callers will be able to receive free educational materials and referrals to our support groups.

Are There Different Types of Bipolar Disorder

Researchers and physicians have always commented on the wide variety of forms of bipolar disorder (manic depression). Most people who have bipolar disorder experience episodes of mania--intense highs of energy or euphoria--and periods of depression--extreme lows. The length, frequency, and pattern of episodes varies. Some of these variations may not be scientifically significant, while others are signs of subtypes of bipolar disorder that affect the patient's experience of the illness and the physician's approach to treatment.

For instance, patients who experience hypomania, a less sever form of mania with limited impairment; cyclothymia, characterized by numerous, mild manic episodes and often less severe depressive episodes for at least two or more years with no major depressive or manic episode; and rapid cycling, the focus of this booklet.

What is Rapid Cycling

Rapid cycling is defined as four or more manic, hypomanic, or depressive episodes in any 12-month period. Depressive episodes last two weeks or longer; hypomanic episodes last four days or longer; manic episodes last one week or longer or require hospitalization. However, episodes may be much more frequent and shorter.

While the term "rapid cycling" may lead some people to believe the episodes occur in cycles, they often follow a random pattern. Some patients with rapid cycling appear to experience true manic, mild manic, or depressive episodes that last only for a day. Typically, however, someone who experiences such short mood swings (ultrarapid cycling) has undergone longer episodes as well.

There is an indistinct boundary between rapid cycling and mixed states. Most physicians, however, believe that mixed-state bipolar disorder is distinct from rapid cycling, and do not diagnose rapid cycling unless full-length mood episodes take place.

For some people, rapid cycling is a temporary occurrence. That is, they may experience rapid cycling for a time, then return to a pattern of longer, less frequent episodes. Others, however, may continue in a rapid-cycling pattern indefinitely.

Who Develops Rapid Cycling

As many as 15-20% of all individuals with bipolar disorder may develop rapid cycling at some time during their illness. Individuals with Bipolar I (those with manic or mixed episodes alternating with major depression) and Bipolar II (those with recurrent major depressive episodes and hypomania) have equal rates of rapid cycling. While there are no absolute rules about who will develop this pattern, up to 90% are women, despite bipolar disorder generally being equally common in both sexes. Several studies have also shown that rapid cycling occurs more frequently in people with bipolar disorder who have evidence of, or history of, hypothyroidism.

Use of antidepressants in bipolar disorder can bring on or worsen rapid cycling, although the cycling often decreases when the antidepressants are discontinued. Therefore, physicians should prescribe antidepressants cautiously.

There may also be a genetic or other physical link between rapid cycling and drug or alcohol abuse. Some studies show that substance abuse is more common in families of those with rapid-cycling bipolar illness than in families of bipolar patients without rapid cycling. Furthermore, a history of substance abuse may make an individual more prone to cycling with episodes that are sorter than usual.

When rapid cycling starts, it typically follows one of these patterns:

  • Some individuals experience rapid cycling at the beginning of their illness.
  • For others, onset is gradual. Most individuals with bipolar disorder, in fact, experience shorter and more frequent episodes as the illness progresses. Eventually, they may meet criteria for rapid cycling, either temporarily or permanently.

What Causes Rapid Cycling

The fundamental cause of rapid cycling remains unknown, but three overlapping theories exist:

  • Kindling (Sensitization). According to this theory, episodes are initially triggered by actual or anticipated life events such as the death of a loved one or an upcoming job interview. As the sequence is repeated, however, the affected individual becomes increasingly sensitive to anything that may be a trigger. Episodes become increasingly frequent and independent of anything outside the patient's brain. Sometimes, the result of this process may be rapid cycling.
  • Biological Rhythm Disturbances. This theory proposes rapid-cycling patients' daily biological rhythms are abnormal and out of sync with typical "time-giving" events such as dawn and dusk. This theory could then account for the sleep disturbances typical of mania and depression and explain other symptoms as well. If biological rhythms are important, a link between rapid cycling and seasonal affective disorder (SAD) may be suggested. SAD is a type of depression that typically develops during the fall and winter months and lessens in intensity or completely subsides during the summer months.
  • Hypothyroidism. This theory proposes that rapid cycling is due to inadequate amounts of thyroid hormone in the brain. However, most people with rapid cycling have adequate blood levels of thyroid hormone. Nevertheless, low blood levels of thyroid hormone are more common among individuals with rapid cycling than among bipolar patients in general. For this reason, thyroid function tests should be carried out before and during treatment.

Are There Effective Treatments for Rapid Cycling

While 60% of other individuals with bipolar disorder will obtain some relief from lithium, the response rate among those with rapid cycling is only 20-40%. Lithium's effectiveness may be reduced by drug or alcohol dependence; however, this relationship does not seem strong enough to account for the great difference in response rates.

The disappointing results obtained with lithium in the treatment of rapid cycling led researchers to seek alternative treatments. When divalproex sodium (Depakote) was approved in 1995 by the U.S. food and Drug Administration (FDA) for the treatment of mania associated with bipolar disorder, it brought new hope to patients experiencing rapid cycling and mixed states. Carbamazepine (Tegretol), although not FDA approved as a treatment for bipolar disorder, sometimes is used as a supplement or alternative to divalproex sodium and lithium.

Divalproex sodium and carbamazepine have been effective in treatment of lithium-resistant rapid cycling and mixed state patients. Their effectiveness appears unconnected to their common identity as anticonvulsants used to treat epilepsy. Not only do the individuals they benefit typically show no sign of epilepsy, but some other drugs that are effective as anticonvulsants provide no help in treating bipolar disorder. Further, whether a patient is helped or not helped by one anticonvulsant does not predict whether that same patient will or will not respond to another. Therefore, people with bipolar disorder should not give up hope if their first course of treatment is not successful.

Reasoning that rapid cycling may be due to inadequate thyroid hormone in the brain, several studies have investigated treating rapid-cycling patients with high doses of the thyroid hormone, thyroxine. Despite their small size, these studies have produced favorable results even in individuals without a history of thyroid problems.

As noted earlier, antidepressants may trigger rapid cycling. While stopping antidepressant use may seem logical in these situations, the results can be frustrating. A person with bipolar disorder often experiences depression when not taking antidepressant medication. The availability of treatments other than lithium suggests the more complex strategy of adding thyroid hormone or an anticonvulsant to antidepressant therapy may be a more promising approach. The limited data available from studies of thyroid hormone and anticonvulsants suggest this may indeed be the case.

Alternatives to divalproex sodium, lithium and carbamazepine are understudy in rapid cycling. They include another anticonvulsant, lamotrigine (Lamictal), and an antipsychotic medication, olanzapine (Zyprexa). These medications are not approved by the FDA for treatment of bipolar disorder, but patients with rapid-cycling illness may want to discuss them with their doctors.

psychotherapy is an important supplementary treatment to medication. Along with continuous vulnerability to future episodes, people with any type of bipolar disorder experience complications as a result of past episodes. For instance, people who cry easily may be dismissed as weak. people who are always "in a bad mood" may appear less attractive. Because people with bipolar disorder are often unfairly judged, they may lose opportunities to develop friendships or romantic involvements, or have trouble achieving their career goals. The struggles people with bipolar disorder face may contribute to self-esteem problems. That's why patients may want to consult their mental health professionals about one-on-one psychotherapy with interpersonal, cognitive or behavioral approaches or the benefits of couples, family, and group therapy.

Helping Yourself, Helping Others
The Value of Local DMDA Support Groups

No one with bipolar disorder--whether of the rapid-cycling pattern or not--needs to feel alone or ashamed. With a grassroots network of 275 chapters and support groups, National DMDA offers one or more support groups associated with each chapter. The groups have medical advisors and appointed facilitators. Most members are patients or have loved ones with depressive illnesses.

As a complement to formal therapy, National DMDA support groups:

  • Can help increase treatment compliance and may help patients avoid hospitalization.
  • provide a forum for mutual acceptance, understanding and self-discovery.
  • Help consumers understand depressive disorders do not define who they are.
  • Give people the opportunity to benefit from the experiences of those who have "been there."

Take the next step toward wellness for your or for someone you love. Call National DMDA to locate the DMDA chapter or support group nearest you or visit our on-line Chapter Directory.


Research increasingly suggests that rapid cycling is significantly different from other forms of bipolar disorder. Individuals with this pattern of mood changes may respond differently to standard treatment than others with bipolar disorder.

Rapid cycling, with its sudden and unpredictable mood changes, may be more difficult to cope with than other types of bipolar disorder. This challenge makes it particularly important for patients to work closely with their physicians and/or mental health professionals toward achieving the best results possible.

progress toward better treatments and the eventual elimination of rapid cycling, and all forms of bipolar disorder, is being made through the cooperation of patients, physicians, clinical researchers, universities, pharmaceutical companies and organizations like National DMDA.

For More Information

There are other sources of information about medications for bipolar disorder. For additional information, you may consult the physicians' Desk Reference (pDR). You can also ask a pharmacist for inserts that accompany medications for which you have questions. The pDR is available through the National DMDA Bookstore. Members who order the pDR through the bookstore will receive a discount. You can also request a copy of the pDR from your local library.

National DMDA publishes books and videos about bipolar disorder. For listings of materials call us at (800) 826-3632, or download it from our Web site www.

production of this booklet was made possible through an unrestricted educational grant from National DMDA's 1998 Leadership Circle::
Abbott Laboratories
Eli Lilly and Company
Glaxo Wellcome Inc.
pfizer Inc
Solvay pharmaceuticals, Inc.

This brochure was reviewed by Joseph R. Calabrese, M.D., a member of National DMDA's Scientific Advisory Board. Dr. Calabrese is professor of psychiatry, director of the Mood Disorders program and vice chairman of clinical affairs for the department of psychiatry at University Hospitals of Cleveland, Case Western Reserve University School of Medicine.

National DMDA members may order up to 10 copies of this brochure for $0.75 each, 11 to 50 copies for $0.70, or more than 50 copies for $0.60 each. Non-members may order this brochure for $1.00 per copy. Shipping and handling charges are extra.

National DMDA does not endorse or recommend the use of any specific treatment or medication listed in this publication. For advice about specific treatment or medication, patients should consult their physicians and/or mental health professionals.

Rev. 1/99
EB 3002

Last updated: June 7, 1999

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