Section 7. Mental Health Disorders

Chapter 101. Depression and Mania

Topics: Introduction | Depression | Mania | Manic-Depressive Illness

Manic-Depressive Illness

In manic-depressive illness, also called bipolar disorder, episodes of depression alternate with episodes of mania or lesser degrees of joyousness or elation.

Manic-depressive illness affects slightly less than 2% of the U.S. population to some degree. The disorder is believed to be hereditary, although the exact genetic defect is still unknown. Manic-depressive illness affects men and women equally. However, women are more likely to have symptoms of depression, whereas men are more likely to have symptoms of mania. Manic-depressive illness is more common among people in upper socioeconomic classes and usually begins in a person's teens, 20s, or 30s.

Symptoms and Diagnosis

Manic-depressive illness usually begins with depression and includes at least one episode of mania at some time during the disorder. Episodes of depression typically last for 3 to 6 months. In the most severe form of the disorder, called bipolar I disorder, depression alternates with intense mania. In the less severe form, called bipolar II disorder, short episodes of depression alternate with hypomania. The depressive and manic episodes often recur according to the season; for example, depression occurs in the fall and winter, and mania occurs in the spring or summer.

In an even less severe form of manic-depressive illness, called cyclothymic disorder, episodes of elation and sadness are less intense, typically last for only a few days, and recur fairly often at irregular intervals. Although cyclothymic disorder may ultimately evolve into a more severe form of manic-depressive illness, in many people cyclothymic disorder never progresses. Having cyclothymic disorder may contribute to a person's success in business, leadership, achievement, and artistic creativity. However, it may also cause uneven work and school records, frequent change of residence, repeated romantic breakups or marital failure, and alcohol and drug abuse. In about one third of people with cyclothymic disorder, these symptoms can lead to a mood disorder that requires treatment.

The diagnosis of manic-depressive illness is based on the distinctive pattern of symptoms. A doctor determines whether the person is experiencing an episode of mania or depression so that the correct treatment can be given. About one of three people with manic-depressive illness experiences symptoms of mania (or hypomania) and depression simultaneously. This condition is known as a mixed bipolar state.

Prognosis and Treatment

Manic-depressive illness recurs in nearly all cases. Episodes may sometimes switch from depression to mania, or vice versa, without any period of normal mood in between. Some people cycle more rapidly through episodes than do others. Up to 15% of people with manic-depressive illness, mostly women, have four or more episodes a year. People who cycle rapidly are more difficult to treat.

All antidepressants can cause swings from depression to hypomania or mania and sometimes cause rapid swings between them. Therefore, these drugs are used only for short periods, and their effect on mood is closely monitored. At the first sign of a swing to hypomania or mania, the antidepressant is discontinued. Optimally, most people with manic-depressive illness should be given mood-stabilizing drugs, such as lithium or an anticonvulsant, when they are treated with antidepressants.

Lithium has no effect on normal mood but reduces the tendency toward mood swings in about 70% of people with manic-depressive illness. A doctor monitors the level of lithium in the blood with blood tests. Possible side effects of lithium include tremor, fine muscle twitching, nausea, vomiting, diarrhea, thirst, excessive urination, and weight gain. However, these side effects are usually temporary, and the doctor can often lessen or relieve them by adjusting the dosage. Lithium can make acne or psoriasis worse and can cause the blood levels of thyroid hormone to fall, requiring the addition of thyroid hormone replacement. Reducing the dosage may lessen side effects, but sometimes lithium must be discontinued, in which case the undesirable side effects resolve. In rare cases, long-term use of lithium can affect kidney function. Therefore, kidney function must be monitored with blood and urine tests every 3 to 4 months.

A very high level of lithium in the blood can cause persistent headaches, mental confusion, drowsiness, seizures, and abnormal heart rhythms. Side effects are more likely to occur in older people. Women who are trying to become pregnant must stop taking lithium, because lithium can in rare cases cause heart defects in a developing fetus.

Newer drug treatments have evolved over the past several years. Sudden manic episodes are increasingly treated with risperidone, quetiapine, or olanzapine (drugs referred to as "atypical antipsychotics"), because they have a minimal risk of serious side effects. Other commonly used drugs for mania include the anticonvulsants carbamazepine and divalproex. However, carbamazepine can seriously reduce the number of red and white blood cells, and divalproex can cause liver damage (primarily in children) and in rare cases can cause severe damage to the pancreas. With close monitoring by a doctor, these problems can be caught in time, making carbamazepine and divalproex useful alternatives to lithium, especially for people who have not responded to other treatments.

Recently, the anticonvulsant lamotrigine has begun to be used to treat manic-depressive illness, especially in the depressed phase. Lamotrigine eliminates the need for antidepressants in some people. Like carbamazepine, lamotrigine can cause a serious rash. Oxcarbazepine and topiramate are other anticonvulsants being used as well.

Psychotherapy is often recommended for people taking mood-stabilizing drugs, mostly to help them stay with their treatment. Group therapy is often useful for helping people and their spouses or relatives understand the manic-depressive illness and better cope with it.

Phototherapy, which involves exposure to artificial light, is sometimes used to treat people with manic-depressive illness, especially those who have milder and more seasonal depression: autumn-winter depression and spring-summer hypomania (seasonal affective disorder). However, if the dose of light is excessive, the person may swing to hypomania or, in some cases, eye damage can occur. Therefore, phototherapy should be supervised by a doctor who specializes in the treatment of mood disorders.