Bipolar Affective Disorder Information about Bipolar Affective Disorder and possible treatments.

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What is Bipolar Affective Disorder? Bipolar affective disorder, also known as bipolar disorder or manicdepression is a term used by many mental health professionals to describe conditions where people experience major shifts in a their mood, energy and activity levels to a degree that effects their ability to function in their regular lives. In particular, it refers to those who experience episodes of very high mood (either described as mania or a milder version known as hypomania) and very low mood (depression). Some people also experience what are known as mixed episodes, where there are elements of both high and low mood. There are a range of difficulties that people might experience that are related to these mood episodes, such as taking unnecessary risks, making unwise decisions, irritability, anxiety, sleep problems, relationship, employment or financial difficulties, substance use and possibly suicidal thoughts or behaviours. Sometimes, particularly when experiencing high mood states, people do not consider themselves to be unwell, even though others may be concerned about their wellbeing. On occasion, people may, however not everyone might experience all of these difficulties, and many people with a bipolar diagnosis also describe positive aspects of their mood episodes (particularly hypomania), such as increased creativity, energy, confidence, productivity and enjoyment.

How common is Bipolar Affective Disorder? Over 1 in 100 people are diagnosed with this condition at some point in their lives, and because the experiences associated with bipolar affective disorder can appear similar to other mental health difficulties and can vary over time, it can sometimes take several years before a diagnosis can be made, and it can affect people of any age, gender, ethnicity or social background. Bipolar affective disorder is usually considered to be a recurrent condition; people with this diagnosis can have any number of episodes of highs and lows throughout their life. The frequency, severity and Page 3

duration of mood swings vary from person to person and even for the same person each episode may be different. In between episodes of highs or lows there may be gaps of weeks, months or years when their mood is relatively normal. Between episodes some people report feeling their mood is somewhat lower than they would prefer it to be, even though they are not depressed. However, some people swing from highs to lows quite quickly without a period of normal mood in between. This is called “rapid cycling” whereby people have at least four mood swings per year. Some people with a bipolar diagnosis consider themselves to have recovered, either because they have not experienced a mood episode for many years, or because they feel able to get on with a fulfilling and rewarding life despite sometimes experiencing mood episodes. However further research is needed in this area to understand what recovery means to different people and how services can best help people recover and live fulfilling and rewarding lives.

What causes Bipolar Affective Disorder? The causes of mood episodes associated with a diagnosis of bipolar affective disorder are complex and not fully understood. It is probably caused by a combination of factors including biological, psychological and social factors. Biological factors that have been suggested as important include genetics, biochemistry, brain function, sleep disruption and substance use. Psychological and social factors that may be involved include thinking styles, distressing memories (e.g. due to childhood trauma or loss), relationships, self-esteem and the ways in which people understand and regulate their emotions. Stressful life events can be a trigger for mood episodes. These can include positive events that are stressful such as succeeding in achieving something important, as well as negative events. Other potential triggers for mood episodes include substance use (e.g. alcohol, cannabis, Page 4

amphetamines), adverse reactions to certain prescribed medications (e.g. antidepressants, blood pressure medication), abruptly stopping prescribed mood stabilisers and disruption to the regular sleep/wake cycle (e.g. shift working, jet lag).

What Bipolar Affective Disorder is not It is not your fault; it is not a character disorder. Neither mania nor depression is a sign of weakness, nor that someone has just given in. It is not something that people are able to just pull themselves out of, although with time, practice and support, people can learn ways to help themselves effectively manage their moods.

What are the symptoms? Mania: Symptoms include abnormally and persistently elevated (high) mood or irritability occurring with at least three of the following; overly inflated self-esteem; decreased need for sleep; increased talkativeness; racing thoughts; distractibility; increased goal directed activity or physical agitation; and excessive involvement in risky behaviours or activities (e.g. unwise spending sprees, reckless driving, sexual affairs). Depression: Symptoms include a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant change in appetite or body weight; difficulty sleeping or over sleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of death or suicide. Mixed state: Symptoms of mania and depression are present at the same time. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic activation. Sometimes severe mania or depression is accompanied by periods of "psychosis". Psychotic symptoms include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not actually there) and delusions (false fixed beliefs that are not subject to reason or Page 5

contradictory evidence and are not explained by a person’s usual cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time (e.g. grandiosity during mania, worthlessness during depression).

What treatments are recommended? Most people with bipolar disorder, even those with the most severe forms, can achieve substantial stabilisation of their mood swings and related symptoms with proper treatment. As this disorder is usually a recurrent condition, long-term preventive treatment is almost always recommended. A treatment strategy that combines medication and psychosocial treatment is recommended for most people. Treatments include: • Medicines, which aim to prevent episodes of mania, hypomania and depression. These are called mood stabilisers. You take these every day, long-term. • Other medications are added when necessary, typically for shorter periods to treat episodes of mania or depression that break through despite the mood stabilizer. Lithium: Lithium has long been used as a first line treatment for bipolar disorder. It is a naturally occurring substance, given as a tablet, which is an effective way of preventing mood swings for many people. It can also strengthen the effect of antidepressants. A psychiatrist usually starts treatment with lithium, although once stabilised it may be taken over by a GP. If this doesn’t work there are other possibilities that you can discuss with your psychiatrist. Common side effects*: These can happen in the first few weeks after starting lithium treatment. They can be irritating and unpleasant but often disappear or get better with time. They may include: • Feeling thirsty, passing more urine than usual, a blurred vision, slight muscle weakness, occasional loose stools, fine trembling of the hands, a feeling of being mildly ill, weight gain • If the level of lithium in your blood is too high, you will experience: • Vomiting, staggering gait, slurred speech - If this happens you must contact your doctor urgently Page 6

* Lithium interacts with some other medication, and you should always check with your doctor or pharmacist - even for medication bought over the counter. Blood tests: At first you need blood tests every few weeks to make sure that you have enough lithium in your blood, but not too much. You will need to have these tests for as long as you take lithium, but less often after the first few months. Monitoring is three monthly once levels are stable. You may also need to have blood tests every few months to make sure that your thyroid gland is working properly. Anticonvulsant medicines: Valproate, carbamazepine and lamotrigine are also used to treat episodes of mania. They are also used long-term as mood stabilisers. (Anticonvulsant medicines are commonly used to treat epilepsy but have been found to work in bipolar disorder too. However it is not clear how they work in this condition), sometimes one of these medications is used alone. Some people take an anticonvulsant in addition to lithium if lithium alone does not work so well. You should consult the information leaflet that comes with your medication for information about possible side effects. Antipsychotic medicines: These maybe used to treat an episode of mania or hypomania either used alone or in combination with lithium or valproate. They can help if you become too active, psychotic (having hallucinations and or delusions) or aggressive when you are manic. There are 2 groups of antipsychotics; the older typical group and the newer atypical group. The older group was more likely to cause muscle stiffness or tremor. The most commonly used antipsychotics are now atypical. They can be used to prevent relapse. These medicines are usually stopped once the symptoms have gone. The atypical antipsychotics (such as: olanzapine, quetiapine and risperidone) have shown efficacy in monotherapy placebo controlled trials in mania. Common Side Effects: All antipsychotics may cause sleepiness or dizziness. If you take them for a long time, you may put on weight. Older drugs from the typical group, such as haloperidol may also cause tremor or muscle stiffness. Pregnancy: If you become pregnant it is usually best to avoid medications like lithium and anticonvulsants. It is essential to ask your Page 7

doctor about this. It is advisable to stop breast-feeding your baby if you need to take such medications. The treatment of depression in people with bipolar disorder is similar to that for people who develop depression without episodes of mania. Antidepressant medicines are commonly prescribed for all types of depression. There are several types of antidepressants, each with pros and cons. For example, they differ in their possible side effects. One problem with antidepressants is that they can sometimes trigger an episode of hypomania in some people therefore it is usually prescribed with a mood stabiliser. Before starting a new medication always talk with your psychiatrist, GP and/or pharmacist about possible side effects. Cognitive Behavioural Therapy (CBT): This is a talking treatment that is recommended by the National Institute of Health and Care Excellence (NICE) as an effective treatment that should be available to people with a diagnosis of Bipolar Affective Disorder. Current research has demonstrated that it is effective when used alongside medication. Other recommended psychosocial interventions are psychoeducational, relapse prevention, family intervention/therapy and interpersonal and social rhythm therapy. Electroconvulsive Treatment (ECT): In situations where medication, psychosocial treatment and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive treatment (ECT) may be considered. Compulsory Treatment: When you have an episode of mania or hypomania, usually you do not realise that you are ill. It is sometimes necessary to give treatment against your will if you have symptoms, which are putting you or other people at a risk of harm. A short admission to hospital is sometimes needed.

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What can I do to help? • Try to avoid stressful situations, which may trigger an episode of mania or depression • Try not to drink much alcohol or take any street drugs • If you are prescribed medication, take it regularly • Consider being quite open to friends and family about your illness • Learn about your illness • When you are well, consider putting some safeguards on your money so that you cannot over spend it when you become high • If you are the main or only carer of children, it is important that someone else who knows you is aware that you may become ill quite quickly and might not be able to care for your children properly.

Help can be found • Hospital departments of Psychiatry/Community Mental Health Teams. • General Practitioners. • Often people with bipolar disorder do not realise how impaired they are, or they blame their problems on some cause other than their mood state and may need strong encouragement from family and friends to seek treatment. • Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment. • Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual. • In some case, individuals with bipolar disorder may agree, when the disorder is under good control to a preferred course of action in the event of a future manic or depressive relapse. • Like other mental health difficulties, bipolar disorder is also hard on spouses, family members, friends and employers. • Family members of someone with bipolar disorder often have to cope with the person’s serious behavioural problems, such as spending sprees during mania or extreme withdrawal from others during depression and the lasting consequences of these behaviours. • Many people with bipolar disorder and their families and friends can Page 9

benefit from joining support groups and it is also worth considering family interventions if these are available from your care team. Many people with bipolar disorder can achieve substantial stabilisation with appropriate use of pharmacological, psychological and psychosocial interventions. Education is also beneficial as it will help you, and your family, manage bipolar disorder and prevent its complications.

For more information: The Royal College of Psychiatrists: www.rcpsych.ac.uk/info Bipolar UK: Tel: 020 7931 6480 Email: [email protected] Rethink Mental Illness: Tel: 0300 5000 927 Mind Infoline: Tel: 0300 123 3393 Email: [email protected] Depression Alliance: www.depressionalliance.org National Institute of Mental Health in England (NIMHE): www.nimh.nih.gov The Wellbeing and Mental Health Helpline provides an information and listening service for people in Lancashire. It is available between 7.00pm and 11.00pm, Mondays to Fridays and from 12.00 noon until 12.00am midnight on Saturdays and Sundays. Telephone: Freephone 0300 222 5931.

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This information is intended as a guide only. If you are concerned about the mental health of yourself or another person, you may wish to consult your GP for further advice.

Other sources of information:

The Wellbeing and Mental Health Helpline This provides an information and listening service for people in Lancashire. It is available between 7:00pm and 11:00pm Mondays to Fridays and from 12:00 noon until 12:00 midnight on Saturdays and Sundays. Other sources of information: Freephone 0300 222 5931. The Mental Health Helpline provides an information and listening service for people in Lancashire. It is available between Customer Care7.00pm and 11.00pm Mondays to Fridays andIffrom 12.00 noon 12.00 you wish to payuntil a compliment about the Trust’s midnight on Saturdays and Sundays. Freephone 0500 639000. services, make a comment, raise a concern or complaint,

pleaseprovides contactadvice the Customer Care Department on The Patient Advice and Liaison Service and 01772PALS 695315, information. Please contact East Lancashire on: freephone 0808 144 1010 or 01282 474178 or 07507 857345 email [email protected]

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