Treating Bipolar – 1 and 2 – Disorders
While it isn’t as common as depression, most people would probably be familiar – at least to a limited degree – with bipolar disorder, or more precisely, what’s referred to as bipolar 1. But that’s not necessarily the case for bipolar 2 disorder.
“Bipolar I disorder is what used to be called classic manic depressive illness,” says Dr. Anthony Rothschild, a professor of psychiatry at the University of Massachusetts Medical School. Those who have it experience periods of mania – that is, “of increased energy, not needing to sleep, talking fast, having what’s called flight of ideas – where they jump from one topic to another,” he says. “They usually are in a very euphoric mood, although occasionally it can be an irritable mood.” During this high-energy, high-activity period, people can sometimes even be delusional. “They can think they’re Jesus Christ or they have to talk to the Pope or the president immediately. That kind of manic episode almost always leads to hospitalization,” Rothschild says.
Those with bipolar usually experience episodes of depression, or low mood, as well typically lasting at least two weeks. “Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible,” according to the National Institute of Mental Health. “They have periods of time when they suffer from depression,” Rothschild says. “They can’t think straight, they’re sad, they have no motivation, they can be feeling suicidal.”
Similarly, mood disturbances characterize bipolar 2 as well. But instead of mania, individuals with bipolar 2 experience what’s called hypomania.
“The primary differences between bipolar 1 and bipolar 2 relate to the intensity of the manic experience,” explains Dr. Melvin McInnis, a professor of psychiatry and director of the Heinz C. Prechter Bipolar Research Program at the University of Michigan. With classic bipolar disorder, the manic episode tends to be incapacitating, so that a person isn’t able to perform day-to-day duties or function at home and work; and it tends to be very noticeable. “The manifestations of this pathologic energy … is typically visible to the person on the street or the person interacting with them,” McInnis says.
“The two kinds of differences between mania and a hypomanic episode are duration and severity,” says Dr. Keming Gao, a professor of psychiatry and co-director of the Bipolar Disorder Research Center at Case Western Reserve University School of Medicine in Cleveland.
A manic episode lasts seven or more days, and symptoms may include:
- Feeling “high” or elated.
- Exaggerated sense of well-being, or euphoria.
- Increased energy and agitation.
- Trouble sleeping.
- Inflated self-esteem.
- Racing thoughts or ideas.
- Getting very little sleep.
- Becoming excessively involved in lots of activities.
- Making poor, impulsive, risky choices.
- Excessive sexual desire, or hyper sexuality.
- A false belief of superiority.
Mania causes dysfunction that can lead to serious consequences, such as interpersonal or professional problems at home or work. And it can include engaging in risky behavior, like reckless driving, shopping sprees or sexual indiscretions, the kind of infidelity that damages an existing relationship.
By contrast the symptoms of hypomania are less severe and they need only last four days to be considered a hypomanic episode. “Bipolar II disorder involves a person having at least one major depressive episode and at least one hypomanic episode,” the American Psychiatric Association notes.
Symptoms of hypomania may include:
- Somewhat elevated mood.
- Increased irritability.
- Exaggerated self-confidence.
- Increased energy.
- Frenzied speaking.
- Moving quickly from one idea or task to another.
- Decreased sleep.
Although it’s not always clear if symptoms are due to mania or hypomania, a person with bipolar 2 who is experiencing hypomania can still generally function. “It’s not the full-blown manic episode. It’s a period of increased energy, increased productivity, decreased need for sleep (and) good mood,” Rothschild says. The person with hypomania “may be a little annoying to people who are at work or their spouse” he adds, but isn’t likely to experience significant problems functioning. “No one with bipolar type II comes to the doctor complaining of hypomania,” Rothschild says. Instead, he says individuals routinely come in complaining of depression.
That said, even hypomania can lead to intrapersonal difficulties or issues in other areas of life, when an agitated state or grandiose ideas meet reality. And those who know the person best or interact with him or her frequently are most likely to take notice. “Often these individuals will run into problems; they will run into relationship problems, they will run into personal issues – either in the home or with others,” McInnis says. They may be making impulsive decisions, for example, that could be rationalized but seem to go a bit too far, like buying a brand new, expensive sports car when simply getting a newer reliable vehicle would suffice.
Past research shows that the majority of people with bipolar disorder are misdiagnosed at some time – and this still seems to be the case, Gao says. Frequently, a person with bipolar 2 or 1 may show up at the primary care doctor’s office feeling depressed. And – especially where time for probing questions is limited (and in the case of bipolar 2, hypomanic symptoms are more nuanced) – they can be misdiagnosed with classic, or unipolar, depression and given an antidepressant, he says. Sometimes people refrain from disclosing if they have symptoms potentially associated with mania or hypomania, or try to hide these – even from clinicians, Gao says, thinking it stigmatizing. “As a society, I think people feel more comfortable talking about depression now. But they still feel uncomfortable talking about bipolar,” he says.
Misdiagnosing and errantly treating someone who has bipolar disorder 1 or 2, for depression alone can be problematic, since the treatment for these mental health conditions differ. For example, while antidepressants may be used in some limited way to treat bipolar disorder, experts say they have to be carefully administered – often in combination with mood stabilizing drugs – to keep from swinging patients from a depressed state to an “up” mood, or mania.
For treatment purposes, it’s also important to distinguish whether a person with bipolar has type 1 or 2. “You’re very reluctant in a bipolar 1 to use antidepressants. You can, but it’s usually down the line if you’re having difficulty getting people out of a depressive episode,” Rothschild says. “Because the concern is that antidepressants can increase the cycling and also swing someone into a manic episode.”
According to the National Institute of Mental Health, an effective bipolar treatment plan for the classic disorder usually includes some combination of medication and psychotherapy (or talk therapy) – like cognitive behavioral therapy – to improve control of mood swings and address other symptoms.
There are various medications that can be used to treat bipolar 1, and frequently different drugs are used in combination. But a standard place to start – and medication that’s widely prescribed to treat many people with bipolar 1 – is lithium bicarbonate, which has been shown to be highly effective in controlling mood swings.
“Bipolar 2 is a little more complicated,” Rothschild says. Individuals spend the vast majority of time they’re ill – or suffering from the mood disorder – in depression. “Sometimes you would use antidepressants. Sometimes you would use the same treatments you use in bipolar 1,” he says, such as lithium or sodium valproate. “It would depend on how often the hypomania occurred. It would depend on how bad the hypomania was, how certain you were that it was occurring.” And though such options have been shown to be effective for treating bipolar 2, less study has been done overall on treating this type of bipolar, experts say, compared with bipolar 1.
Dosing is also a consideration. For example, Gao says if he prescribes a mood stabilizing drug to a patient with bipolar 2, he would be likely to use a lower dose than for a patient with bipolar 1.
In some cases, like for people with bipolar 1 suffering from mania, certain antipsychotics with mood stabilizing properties like Seroquel (quetiapine) or Risperdal (risperidone) may be prescribed.
In general, clinicians say patients need to stay on medications (when it’s determined they work for that patient) over the long term to avoid relapse, or serious mood swings returning. “They would need to have treatment through their lifetime, because this is a serious disorder, but there are excellent treatments,” Rothschild says. “If you’re one of the majority of the people who are fortunate to have a good response to treatment, you can lead a completely normal life.”
Still, with any medication – particularly those taken on an ongoing basis – experts say it’s also important to talk with your provider about side effects. With lithium, those can be minor to severe, from increased thirst and urination to hand tremor (which can be treated with other medication) to weight gain to issues with thyroid or kidney function. However, left untreated, bipolar disorder can be debilitating, severely undermine quality of life and increase the risk for suicide.
If you have concerns that you might have bipolar disorder, see a mental health professional – and, Gao says, share all your symptoms. A family history of bipolar disorder can increase risk for the condition – and should be taken into consideration if a person is experiencing symptoms that could be mania or hypomania.
“There are people who are reluctant to get help. Sometimes my patients feel like they can’t talk to anybody about it,” Rothschild says. “Bipolar disorder is a medical illness. It’s nothing to be ashamed of [and] there’s treatment for it.” But, he and other experts emphasize, it’s imperative that a person not only get treated, but stick with it, like taking medications, to control bipolar – whether 1 or 2.