Bipolar / Manic-Depressive Disorder

What is it?

People with bipolar disorder (also known as manic-depressive disorder) have bouts of major depression and periods of mania—euphoria, poor judgment, and extreme risk-taking activity—in a debilitating cycle. It may in mid-to-late adolescence, though there are some childhood cases.  Managing the episodes of depression and mania is a lifelong undertaking.

Signs and Symptoms

Adolescents with bipolar disorder show signs of depression (prolonged sadness, lack of affect and interest in things they previously enjoyed, sleeping too much) and mania (periods of excitability or irritability and exaggerated self-confidence). For some, the onset of bipolar disorder is marked by a depressive episode; in others, it is a manic episode. Onset can also be a less severe, chronic form of depression called dysthymia or a milder form of mania called hypomania. The duration of and intervals between depressive and manic episodes are variable.

A young person might be in a manic episode if his personality seems to change drastically, he develops an inflated sense of his abilities, he displays grandiose thinking, or starts sleeping much less than he normally does, or he becomes extremely energetic and takes risks. Breaks from reality – psychotic episodes – can occur during manic and severe depressive episodes. During a manic episode, these can include impossible assessments—“I can fly”—or delusions. A psychotic episode may be the first sign of the disorder.

Identifying symptoms of mania is important if someone already has depressive symptoms. Bipolar disorder with an unnoticed manic component can be misdiagnosed as major depressive disorder. When a manic episode happens, a teen may be elated, display poor judgment, and doesn’t know that his behavior is irrational. Depression and bipolar disorder are not the same thing and should be treated differently.

Children with a family history are more likely to develop bipolar disorder.

Diagnosis and Treatment

The presence of a manic episode helps establish diagnosis, though depression is often established as part of the disorder.

A manic episode is a sustained period of “abnormally and persistently elevated, expansive, or irritable mood” in a distinct shift from normal functioning. Some of the following symptoms may also be present: grandiosity; decreased need for sleep; increased talkativeness; racing thoughts; scattered attention; drive to achieve goals; and risk-taking behavior. These symptoms must significantly interfere with normal activities—social life, school, work—or a psychotic episode must be present.

A teenager in a major depressive episode will be either depressed or irritable most of the time, or lose interest or pleasure in things he once enjoyed. He’ll also show some of the following symptoms: marked weight loss or gain; sleeping too much or too little; restlessness or lethargy; fatigue; feelings of hopelessness, helplessness, worthlessness, or excessive or inappropriate guilt; cloudy or indecisive thinking; and a preoccupation with death, plans of suicide, or an actual suicide attempt. This describes the most severe form of the condition, called bipolar I disorder. Bipolar II disorder has less severe episodes of hypomania replace manic episodes.

Medication is essential to treating bipolar disorder, as is involvement of the whole family. Psychotherapy helps limit and manage manic and depressive episodes and their consequences, which can severely affect a young person and everyone around him. Even when on an effective course of medication, people with bipolar can relapse, so a support network of family, friends, and professionals to monitor behavior is vital.

Bipolar is often treated with cognitive behavioral therapy in addition to medications. Therapy helps children and adolescents with the disorder understand what triggers their episodes, how their thoughts influence their feelings, and how to control and manage them. Family therapy is often employed to engage parents and other family members in keeping track of symptoms and managing stress levels in the home, which can lead to episodes.

Other helpful therapies include “prodrome detection,” which encourages early detection and prevention of an episode, and social rhythm therapy, which uses a codified daily schedule to head off mania or depression.

The first-line medication used to treat bipolar disorder is often a mood stabilizer. This includes lithium and various anticonvulsants, which are generally effective at treating manic symptoms and lowering the frequency and severity of both manic and depressive episodes. A young person diagnosed with bipolar disorder might take lithium for the rest of his life. Other drugs can be prescribed to treat symptoms like psychosis (antipsychotics) or trouble sleeping (anti-anxiety drugs). If a mood stabilizer does not adequately address depressive symptoms, a doctor may prescribe an antidepressant, but will do so with extreme caution and almost always in conjunction with a mood stabilizer, as antidepressants can trigger a manic episode.

Many people with bipolar disorder take more than one medication and the medications can have complex interactions, leading to significant side effects if they are not effectively monitored by an experienced clinician.

In some cases where medication and therapy aren’t providing the hoped-for result, electroconvulsive therapy, or ECT may be considered. In ECT, the patient is anesthetized briefly while electrical current is passed through a part of the brain. This causes a seizure, though there are few, if any, external signs of a seizure, and no danger to the patient, who has also been given a muscle relaxant. ECT is rarely used in adolescents, and there is little information about its use in children, but the therapy effectively treats both manic and depressive symptoms of bipolar disorder.

What are the risk factors for children?

Children and adolescents diagnosed with bipolar disorder often have ADHD as well, and they are also at elevated risk for anxiety disorders and alcohol and substance dependencies.

Children and adolescents with bipolar disorder are at increased risk of committing suicide—the third leading cause of death among adolescents and young adults aged 15 to 24. Signs of suicidal behavior include: drastic changes in eating habits, sleep patterns, or personality; marked neglect of personal appearance; giving away personal belongings; sudden happiness after a period of depressed mood; and, of course, talk of suicide or of “going away” or “not being a problem anymore.”

If you think your child or adolescent is suicidal, call the National Suicide Prevention Lifeline at 1-800-273-8255 or 911 if there is an emergency.