Bipolar disorder

What is bipolar disorder?

Bipolar disorder, also called bipolar affective disorder and once known as manic depression, is a long-term mood condition. A person has episodes of abnormally high or irritable mood and energy, called mania (or a milder form, hypomania), and usually episodes of depression too. Between episodes, many people feel completely well.

These are not ordinary ups and downs. Episodes last days to weeks, change sleep, energy, thinking and behaviour, and can seriously affect work, money and relationships. Bipolar disorder is not caused by weak character, bad upbringing or anything the person or family did wrong.

In India, the National Mental Health Survey 2015–16 found that about 3 in every 1,000 adults had bipolar disorder at the time of the survey, and many of them had significant difficulty with daily life because of it. Symptoms usually begin in the late teens or early adulthood. Under-18s are seen with a parent or guardian.

Doctors describe two main types:

• Bipolar I disorder: at least one manic or mixed episode, usually with episodes of depression as well
• Bipolar II disorder: milder highs (hypomania) along with episodes of depression, but no full mania

Signs of mania and hypomania

During a manic episode, a person may:

• Need very little sleep but still feel full of energy
• Feel extremely cheerful and excited, or very irritable and quick to anger
• Talk fast, jump from topic to topic, and be hard to interrupt
• Have racing thoughts and be easily distracted
• Feel unusually confident, important or powerful, with unrealistic plans
• Spend heavily, take loans, give money away or make big business decisions on impulse
• Take risks they normally wouldn’t, such as reckless driving, heavy drinking or unsafe sex
• Start many projects without finishing them
• Become unusually talkative with strangers, or lose their usual social limits

Hypomania is a milder form that lasts at least several days. The person may simply feel productive and sociable, and family often notice that they are “not themselves” before the person does. Because it can feel good, hypomania is often not mentioned to doctors.

In severe mania, some people develop psychotic symptoms, such as hearing voices or holding strong false beliefs, for example having special powers or a divine mission. This needs urgent care.

Signs of a depressive episode

Depressive episodes in bipolar disorder look much like other depression:

• Low mood, emptiness or hopelessness
• Loss of interest and pleasure
• Tiredness, slowed thinking and poor concentration
• Sleeping too much or too little, and changes in appetite
• Feelings of guilt or worthlessness
• Thoughts of death or suicide

When highs and lows mix

Sometimes symptoms of mania and depression happen at the same time. A person may feel hopeless and low while also being restless, agitated, sleepless and full of racing thoughts. These mixed features are very distressing and can be a time of higher risk, so they need prompt attention.

Why is it often first diagnosed as depression?

Many people with bipolar disorder are first told they have depression. This happens because:

• Depression is often the first episode, sometimes years before the first high
• People seek help when they feel low, rarely when they feel energetic
• Hypomania can feel like a good phase, so it goes unnoticed or unreported
• Past highs may not come up unless the doctor asks and family can add details

This matters because treatment is different. In a person with bipolar disorder, an antidepressant taken on its own, without a mood-stabilising medicine, can sometimes trigger a high or lead to more frequent mood swings. If you are being treated for depression, tell your doctor about any past periods of little sleep, unusual energy or impulsive behaviour, and whether bipolar disorder runs in your family. Please don’t stop an antidepressant on your own; discuss any concern with your psychiatrist.

Why does it happen?

There is no single cause. Several factors usually combine:

• Genes and family history. Bipolar disorder often runs in families, although most relatives never develop it.
• Brain changes. Differences in the brain systems that control mood, energy and sleep make some people more vulnerable.
• Triggers. In someone who is already vulnerable, certain events can set off an episode, as described below.

Triggers and early warning signs

Common triggers

• Loss of sleep. Night shifts, overnight travel, late-night studying, a new baby, or weddings and festivals that disrupt routine. Losing sleep can set off a high, and a high then reduces sleep further.
• Alcohol, cannabis (bhang, ganja, charas) and other drugs.
• Major stress. Family conflict, exams, bereavement or money problems, and sometimes even happy events.
• Stopping medicines or regularly missing doses.
• Some antidepressants taken without mood stabilisation, as explained above.

Early warning signs

Each person tends to have their own pattern of early signs before an episode. Common early signs of a high include sleeping less without feeling tired, talking more, sending many messages, spending more, irritability and a rush of new plans. Early signs of a low include withdrawing from people, losing interest, sleeping more and feeling heavy or tired.

Spotting these signs early and contacting your psychiatrist quickly can often stop a full episode from developing.

Bipolar disorder, alcohol and cannabis

Alcohol and drug problems are common among people with bipolar disorder. Some people drink or use cannabis to calm a high, lift a low or get to sleep. It may seem to help briefly, but:

• Alcohol disturbs sleep and deepens depression
• Cannabis can bring on or worsen manic and psychotic symptoms in some people
• Substance use is linked to more frequent mood swings, mixed episodes, more severe depression and suicidal thoughts
• People who use alcohol or drugs are less likely to take their medicines regularly

When both problems are present, treating them together, by the same team, works better than treating one at a time. This is known as dual diagnosis care.

When to see a psychiatrist

Consider speaking to a psychiatrist if:

• You have had periods of unusually high energy, little sleep or impulsive behaviour, even if they felt good
• Depression keeps coming back or hasn’t improved with treatment
• You felt unusually high, agitated or sleepless after starting an antidepressant
• You have depression and a close relative has bipolar disorder
• Your mood swings go together with heavy drinking or cannabis use
• Family members are worried about big changes in your behaviour or spending

How bipolar disorder is diagnosed

A first consultation is a conversation, not a judgement. The psychiatrist will ask about your mood episodes over the years, sleep, energy, behaviour, spending, alcohol and drug use, physical health and family history. Input from a family member is especially helpful, because highs are often remembered better by others.

A physical examination and blood tests, such as thyroid function, help rule out medical causes and give a baseline before some medicines are started. A mood chart, where you note mood and sleep each day, can make patterns clearer. The diagnosis follows international criteria (ICD-11), and it sometimes becomes clearer over time.

Treatment

Bipolar disorder is a long-term condition. Treatment aims to settle the current episode and, just as importantly, to prevent future ones.

1. Mood-stabilising and other medicines

• Mood-stabilising medicines are the foundation of long-term treatment. They reduce both highs and lows and help prevent relapse.
• Antipsychotic medicines are used to control mania and psychotic symptoms, and some also help with bipolar depression or prevent relapse.
• Antidepressants are used with caution, and only alongside a mood-stabilising medicine.
• Short-term calming or sleep medicines may be given briefly during a severe episode.

Finding the right combination can take time. Medicines are usually continued long after you feel well, because stopping them raises the chance of a new episode. They should only be started, changed or stopped with your psychiatrist.

2. Regular monitoring

• Follow-up visits to review mood, sleep, side effects and early warning signs
• For some mood-stabilising medicines, regular blood tests to check medicine levels and kidney and thyroid function
• Checks of weight, blood pressure and blood sugar for some medicines
• Telling every doctor you see about your medicines, as some everyday medicines can interact with them

3. Psychoeducation and talking therapies

• Psychoeducation: learning, with your family, about the illness, medicines, triggers and warning signs. It is a core part of treatment.
• Cognitive behavioural therapy (CBT): managing unhelpful thoughts, stress and depressive symptoms
• Interpersonal and social rhythm therapy: keeping daily routines steady and handling relationship stress
• Family-focused therapy: improving communication and problem-solving at home

4. Sleep, routine and an early-warning plan

• Sleep and wake at the same times every day, including weekends and holidays
• Plan ahead to protect sleep during exams, travel, weddings and festivals
• Keep a simple mood and sleep diary
• Make a written early-warning plan with your psychiatrist: your personal warning signs, what you will do, whom to call, and practical steps agreed in advance, such as handing over bank cards to a trusted person during a high

5. Family involvement

Families are often the first to notice early warning signs. With your consent, involving a family member helps with understanding the illness, supporting medicine routines and acting early. A calm, supportive home helps recovery, while frequent criticism and conflict can make relapse more likely.

6. Treating other conditions together

Anxiety, ADHD, alcohol use and cannabis use often occur alongside bipolar disorder. Treating them at the same time improves stability.

Outpatient, online or inpatient care?

• Outpatient care suits most people, with regular consultations while living at home.
• Online consultations are convenient for follow-up, mood chart reviews and family guidance.
• Hospital admission may be needed for severe mania, psychotic symptoms, a risk of suicide or violence, or when someone cannot look after themselves.

Dr. Tarwani sees patients at Sukoon Health in Gurugram and South Delhi, and online.

Living well long term

Bipolar disorder is a long-term condition, much like diabetes: it needs ongoing care, but it can be managed well. Many people have long stable periods and go on to study, work, marry and raise families.

People with bipolar disorder have a higher risk of suicide, especially during depressive or mixed episodes. Such thoughts are a symptom that responds to treatment. If they appear, contact your psychiatrist, Tele-MANAS on 14416 or 112 straight away.

An episode after a long stable period does not mean treatment has failed. It is a signal to review the plan together, not to give up.

For families

Living with someone through mania and depression can be frightening and exhausting. A few things help:

• Learn about the illness together, ideally in psychoeducation sessions
• During a high, stay calm and avoid arguing about grand plans
• Agree, while your loved one is well, on steps to protect money and safety during an episode
• Keep regular mealtimes and bedtimes at home
• Never reduce, stop or secretly give medicines
• Take any talk of death or hopelessness seriously
• Look after your own health and seek support for yourself

You are welcome to consult Dr. Tarwani first, on your own, to plan the next steps.

Common myths

• “Bipolar disorder is just being moody.” It is a medical condition with distinct episodes that change sleep, energy and behaviour for days to weeks.
• “He is so energetic and happy, he can’t be ill.” Mania can feel good, but it leads to harmful decisions and is often followed by depression.
• “Once you feel well, you can stop the medicines.” Stability usually depends on continuing treatment; stopping raises the risk of relapse.
• “Marriage will settle it.” Marriage is not a treatment. Steady medical care is what keeps mood stable.
• “A drink or a smoke of ganja calms the mind.” Alcohol and cannabis make episodes more likely and harder to treat.
• “People with bipolar disorder can’t lead normal lives.” With regular treatment, many people work, study and have fulfilling family lives.