Dr. David Miklowitz Answers Critical Questions About Bipolar Disorder
Q: How is bipolar disorder different from depression?
A: Bipolar depression, when it manifests as depression, is more severe and more recurrent than major depression. It also tends to have an earlier age of onset than depression. On average, people with this disorder are symptomatic half of all the weeks of their lives, with one quarter of that time in a manic state and three quarters in depression.
Q: What are the defining characteristics of this disorder?
A: In the manic phase: elated or irritable mood, decreased need for sleep, grandiosity, distractibility, high energy, pressure of speech, racing thoughts, impulsive or risky behavior. In depression: sad mood, loss of interest, suicidal feelings, fatigue, insomnia, inability to concentrate or make decisions, and feelings of worthlessness.
Q: Is there any upside to bipolar disorder?
A: There is some evidence that this disorder is associated with creativity and artistic talent. The challenge is to keep the mania under control while allowing an outlet for one’s creativity. That can be a tough balance to maintain.
Q: Is bipolar disorder underdiagnosed?
A: For a long time it was. But recent studies suggest that the pendulum may be swinging in the other direction, and that now it is being overdiagnosed. There is some evidence that kids with explosive temper outbursts are incorrectly being labeled bipolar. The diagnosis in kids has increased forty-fold over the past 10 years.
Q: So how do you get an accurate diagnosis?
A: One should call the American Psychiatric Association to ask for a referral to a psychiatrist who specializes in mood disorders. The Depression and Bipolar Support Alliance, the National Alliance on Mental Illness, and the Child and Adolescent Bipolar Foundation also have lists of providers.
Q: Is bipolar disorder more common in men or women?
A: Bipolar 1 is equally common in men and women. Bipolar 2, with major depressive episodes alternating with hypomania, is more common in women.
A: Mood stabilizers and antipsychotics cut relapse rates by at least half, but they don’t stabilize all of the symptoms. Most patients do need medications, but which medications work can change over time. Some people can get away with one, whereas some need three or more. The other component of treatment is psychotherapy. There is emerging evidence that psychotherapy and medication together work better than either alone.
Q: It sounds like bipolar disorder is an expensive disease to have.
A: It is. And there are hidden costs as well: losing places to live, losing employment, broken relationships. There are no statistics for how many people with bipolar disorder slip through the cracks in getting treatment, but only one in five patients who have depressive episodes gets adequate treatment.
Q: Why do so many bipolar patients fail to get the correct diagnosis?
A: The typical scenario is that someone is admitted to the hospital with delusions or hallucinations, agitation, and severe irritability. He or she gets diagnosed with schizophrenia or drug abuse, and the diagnosis of bipolar disorder is missed. Or, the person comes in depressed and no one thinks to ask if they have had a manic episode in the past. Or, the person is in a manic state, feeling euphoric, and manages to convince an overtaxed health care provider that all is well.
Q: Why do some people call bipolar disorder manic depression?
A: That is an older term. Part of the reason it changed was that not everyone with bipolar disorder has full manias. Some have depression and mania simultaneously (known as mixed episodes), or hypomanias. We now think about bipolar disorder as a spectrum of disorders, although where to draw the boundaries between bipolar disorder and severe moodiness is not always clear.
Q: The stereotypical bipolar patient is unpredictable and unreliable. Is this accurate?
A: If the person is not being treated and his or her mood is rapidly varying between depression and mania, then yes, he or she can be unpredictable and unreliable. If the person is getting treatment there is no reason he or she can’t live a stable productive life. Those stereotypes can be very unfair to people doing their best to lead healthy lives despite the illness.
Q: How can someone help a bipolar loved one or friend?
A: First thing is to learn to identify when the person is escalating into mania. There is a brief window when you should get on the phone with the physician. Signs of an oncoming manic episode can include sleeping less and less, making plans that don’t make sense, or getting increasingly irritable and agitated. When the person is already manic and denying any need for help, it may be too late.
Q: Do bipolar patients do better if they follow a special diet or lifestyle regimen?
A: Sleep regularity is essential. A bipolar person should generally err on the side of taking jobs that give them regular sleep-wake cycles. If you are bipolar and working as a happy-hour waitress one day and working the breakfast shift the next, you will not do well. Generally we also think exercise is a good treatment for depression. And it is important to stay away from alcohol and drugs. We suspect that certain kinds of high sugar foods can make people higher when they are already getting manic.
Q: Is the risk for suicide higher in bipolar patients than in the general population?
A: Risk for suicide in bipolar disorder is 30 times higher than the general population. As many as one out of seven dies by suicide. Suicide usually happens in the depression phase or mixed phase. Lithium treatment, other mood stabilizers, and psychotherapy can reduce the risk of suicide considerably.
Q: What percentage of bipolar patients can live normal, productive lives?
A: I think it is very painful to live with a psychiatric diagnosis, because there is a lot of prejudice. But there are many people who do quite well. It's hard to quantify this in terms of percentages, because many people lead productive lives and then get ill again, and have to start over. But with good treatment your chances of leading a healthy life go up considerably.