Frequently asked questions about Bipolar Disorder

There is a certain myth as regards the relationship between creativity and mental illness, which does not always correspond with the reality. It is a fact that some very famous artists suffered from bipolar disorder and that, in general, the percentage of poets, painters, or writers with some type of psychiatric disorder appears to be higher than in the rest of the population, but it must not be inferred from this that bipolar disorder means being a genius.

The studies that associate creativity and bipolar disorder point out the high presence of people with artistic talent among patients’ relatives, who very often suffer from very mild forms of the illness. The majority of experts agree in pointing out that that discipline or ability to work is also very important in the creative process. Bipolar disorder could help the inspiration—in persons gifted in art—but, if not treated correctly, it impedes all the regularity of work, notably interfering in the outcomes.  

In principle, no. An individual that suffers from bipolar disorder—if the treatment is taken correctly and the illness is kept stable—can carry out any type of profession, regardless of the responsibility that it involves (do not forget that, after all, the world was saved from the fascist horror, among others, by the adept British leader Winston Churchill, recognised bipolar). Anyway, those professions that involve very irregular hours like on-call doctors or nurses, police officers, firefighters, workers in a factory that make constant changes in shifts, nightclub workers, would be not be recommended for people that suffer from bipolar disorder, since the change in sleep hours is a factor that can aggravate the course of the illness.

Stimulant drinks that contain caffeine, like coffee itself and cola refreshments have two problems as regards bipolar disorder, as they are noradrenergic agonists, which means that they active the nervous system and can cause anxiety and, for the same reason, can affect the quality and quantity of sleep hours. In general, they are completely advised against if there is the minimum suspicion that you are starting a mixed, hypomanic or manic episode, or if the therapist indicates to us that we are in an episode of these characteristics. It is also not advisable in habitually anxious people. On the other hand, in a depressive phase that occurs without anxiety and with much apathy and fatigue, one or two coffees can help us “get started” and carry out an acceptable activity. When there are no symptoms of the illness—periods of euthymia—we must not exceed two cups of coffees or cola drinks per day, taking into account that their effects last about eight hours and that, thus, the last one that we have must always be eight hours before we go to bed, so as not to alter our sleep. Sure, there are many people that profess to “sleep like a log” after drinking a cup of coffee: perhaps they can sleep the same number of hours, but the quality of their sleep, although they are not aware, will never be the same, and that can, in the medium term, have an impact on their physical and mental health and on other variables like, for example, memory and attention. Furthermore, in bipolar disorder, all the so-called “energy drinks” (perhaps they should be called “anxiogenic drinks”) that contain taurine, glucuronolactone, and other psychoactive agents, which, paradoxically are publicised with the argument that “they improve mood”, are all contraindicated.

The fact that it may rain or the sun shines can make a person feel more or less animated may or may not be a bipolar disorder. The fact is that, in this sense, it appears the weather has little effect on bipolar disorder. What does affect between 10% and 20% of people with bipolar disorder are the changes in season. It is what we call a “seasonal pattern", and it appears to be related to the number of hours of sun per day, and for this reason it is more pronounced in Scandinavia than, for example, in Spain, where the variations are less. The most characteristic pattern consists of winter depression, and mania in spring/summer, but there is also the inverse pattern.

To have strong religious convictions can confer greater security to the believer, and a greater capacity to accept the illness. This does not mean religion may be therapeutic per se, nor the only form of feeling sure of oneself and to accept the reality may be having religious beliefs. Although they can be a help for whoever may have the religious beliefs, neither faith or praying are treatments for bipolar disorder.

The constant oversights of the medication used to be in relation to a low awareness of the illness, that is to say, with not completely believing that one suffers from the bipolar disorder. Despite this, even in patients absolutely convinced of their illness, there is the possibility there may be some oversights. There is no infallible method to prevent these, and each patient has their own way of remembering each dose. A good method is to associate the taking of the medication with some unavoidable routine activity, like meals or brushing teeth. There are more sophisticated methods consisting of pill boxes with an alarm, as well as more rudimentary methods, like using “reminders” (changing the wrist of the watch, etc.). Anyway, the best method is the acquired habit.

If it is in an asymptomatic period, to forget a single dose of lithium, carbamazepine, or other stabiliser in isolation does not involve any harm, as long as this oversight does not tend to be repeated. The same happens with antidepressants. To forget an anti-mania medication may exacerbate the symptoms, and for this reason—given the characteristic distractibility of the mania—it is especially recommended that during this phase the patient should not be the only one responsible for their medication.

Any period in which environmental stress or stimulation may be particularly elevated, is period of risk. Times of great pressure at work or of examinations are periods of risk. Very positive events (job promotion, social success), or very negative ones (death of a loved one, sentimental rupture) can also precipitate an episode. On the other hand, it is considered that the six months following a mania or mixed phase are a period of great risk of a relapse, in terms of suffering a similar phase as well as suffering from a depression. The recovery from a depression can convert into the onset of a hypomanic or manic phase if antidepressants are not withdrawn in time. In the case of women, the 6 months after childbirth are a period risk both for mania as well as for depression, due to the hormonal changes that accompany pregnancy and childbirth, more than the psychological reasons.

Above all, do not stop taking the medication at any time. By mutual agreement with your psychiatrist or your psychologist, you can increase the frequency of your visits with them. Maximise your precaution measures (particularly as regards sleep, and avoid toxic habits, including alcohol, and your self-observation. Perhaps it would be useful to revise the day to day checklist of your possible relapse signs, that you must have previously prepared with the help of your psychologist or your psychiatrist, in order to detect a new episode as soon as possible. If your risk of relapse is associated with work stress, try to dedicate some time to leisure, regularly every day.

If a bipolar disorder is not treated correctly, it can lead to death by suicide in almost 15% of cases, and this is the most worrying data about this disorder. It is important to understand that ideas of suicide are a symptom of the depressive phase, and at no time are they expressed by the free will of the individual. “To respect” the ideas of suicide of a friend or relative is to be an accomplice of their disorder. As health professionals we cannot enter into philosophical digressions on whether or not a person has the right to take their life, but it is clear that if someone decided to kill themselves during a depressive phase, it is the disorder that is deciding for them. For this reason, it is advisable to prevent it with a temporary hospital admission, if necessary, or other measures that would allow the risk situation to be reversed.

None of them, at the moment, have demonstrated to be effective. Among the psychological therapies, only the psycho-education for patients and for families, cognitive-behavioural therapy, and inter-personal therapy have demonstrated their effectiveness in the field of bipolar disorders.

The practice of moderate physical exercise is highly recommended for mental and physical health. In the periods of euthymia (stability), to practice a sport or, if unable, to walk a minimum of 30 minutes per day, can help us to be less tense and anxious, to feel more full of energy and to increase our feeling of well-being. Practising a sport can be very stimulating for our body and mind. This, which in principle, is a benefit, can be a problem if it ends up stimulating us so much that it impedes our sleep. It is advisable, therefore, not to practice sport in the last hour of the day, since it can alter our sleep.

Physical exercise is particularly recommended during the mild-moderate depression phases, in which it could be a great help in alleviating the symptoms, although at first the person that is depressed could believe the opposite. On the other hand, if there are suspicions that the person is starting a hypomanic or manic phase, it is advisable to stop the practice of physical exercise for a time, since it may make these phases worse.

If we thought this was the case, we would not have written this material. You have the right to information in general, and in particular to this information, which has much to do about you. Information is always positive if it is used correctly. In this case “correctly” means without becoming obsessive about it and without dramatising, trying to obtain the practical consequences of the fact of knowing that you suffer from this illness. To be informed enables us to have more options to control the illness and, above all, it is a good antidote against fear.

In the past, when it was not possible to determine lithium levels in blood and the dose was adjusted in a less precise way, there was chronic exposure to toxic levels of lithium, in some cases, seriously harmful for the kidneys. Nowadays, serious kidney complications are extremely rare, although the so-called “polyuria-polydipsia syndrome”, which means a tendency to drink and urinate in excess, is quite common, although it is not associated with serious complications apart from the discomfort arising from the symptoms. In some cases, lithium can reduce thyroid activity, and lead to a “sub-clinical hypothyroidism”, which can be satisfactorily treated with thyroid hormone, and without the need to withdraw the lithium, if adequate. As always, your doctor should inform you of the potential benefits and risks of the medication.

The new anti-manic drugs, such as quetiapine, paliperidone, asenapine, olanzapine, risperidone, ziprasidone, or aripiprazole, cause much less side-effects than the classic anti-manic drugs like haloperidol. Despite this, none of these are completely exempt from inducing some discomfort, such as sedation—which, in some cases, is precisely the effect desired and is not a discomfort—, weight increase, hormonal problems—inhibition of menstruation, reversible when the treatment is withdrawn—, tremor and muscle stiffness, increase in salivation, or hypotension. Not all patients that takes these treatments have these problems, and their presence or not does not always depend on the doses used. What is clear is that the advantages of these drugs far exceed their potential disadvantages, since they help to end the manic episode, prevent, or shorten hospital admissions, and can improve the course of the illness and the quality of life of the individuals that have a bipolar disorder.

Again, drugs like the SSRIs (fluoxetine, paroxetine, sertraline, and others), and the SNRIs (venlafaxine, duloxetine, or desvenlafaxine) have the advantage of causing less problems than their predecessors, without reducing the efficacy. Despite this, the most serious adverse effect that an antidepressant can induce in an individual that suffers from a bipolar disorder is to induce a change in phase—to go from the depression to mania or a mixed state—, and for this reason they must be used with caution. Other discomforts that can be caused by antidepressants, are gastrointestinal problems, nausea, headaches, or sexual dysfunction, with all these appearing much more frequently with the first doses, and usually disappear after a few days. The therapeutic effects act inversely, since an antidepressant does not usually begin to act until around 15 or 20 days. For this reason, many patients have the sensation of “feeling worse” when they start to take antidepressants, since they have side-effects and still do not feel the positive effects. Our advice must always be, never stop the medication and have patience until a few weeks have passed, when the majority of depressive episodes usually start to improve.

Yes, it is. Although psychiatrists attempt to use the minimum medication necessary, more than half of the patients will need more than one drug to remain stable. In manic phases, an anti-psychotic is often combined with a mood stabiliser. In the depressive ones, an antidepressant is occasionally added. The combination of several stabilisers provides, in general, more stability. On the other hand, sometimes anxiety or insomnia also require a specific medication. To take more medication does not necessarily mean being a more severe case. The treatment must always be personalised.

For some drugs it is worth periodically determining if their concentration in blood is adequate. These are, essentially, lithium, valproate, and carbamazepine. It is generally not necessary to do this for the rest of them. The medication levels in blood help the doctor to decide if the levels of medication have to be maintained, increased or reduced. In general, it is recommended to look at the levels of these drugs every six months, and after each dose adjustment, although that frequency may vary depending on the individual circumstances of the patient. There is a special drug, clozapine, which requires very frequent controls of blood analysis, because, exceptionally it can cause a decrease in the blood defences, with potentially serious effects.

The administration of any medication is always subject to a risks-benefits assessment. In the case of bipolar disorder, it has been perfectly well-demonstrated that the consequences of not treating the illness are much worse than treating it. In order to be approved and marketed, the drugs that the doctor can prescribe have to first demonstrate a reasonable level of tolerance in numerous studies. However, in some cases, discomforts can appear that may oblige withdrawing or changing a particular medication. For the great majority of patients, it is possible to find an effective treatment that may be reasonably tolerated; but it is difficult for them not to produce some kind of adverse reaction, although it might only be a slight tremor or a slight gain in weight, for example.

Weight increase can be a characteristic of some treatments, but it is always due to several factors. In order to avoid it, it is essential to have some good dietary habits and practice exercise or a sport regularly. Some drugs can induce a weight increase, but not in all patients. In the same way that the effectiveness is not predictable beforehand in a particular patient, neither is it possible to deduce who will gain weight with a determined treatment. It is true that there are anti-psychotics, such as clozapine, or olanzapine, that tend to induce weight increases more often, as well as others, although generally to a lesser extent, like lithium, valproate, quetiapine, risperidone, and the antidepressant mirtazapine. Then there are drugs that occasionally induce a certain weight gain, although they do not generally, and are even associated with a slight weight loss.

It is not advised to take drugs during pregnancy, but they must always be weighed up with the risks and benefits of not being medicated. In general, the majority of anti-psychotic, antidepressant, and anxiolytic (benzodiazepines) drugs are reasonable safe for the foetus. For many years, it was believed that lithium had a high risk of causing heart malformations in the foetus, but recent data indicate that the risk is relatively low, and that each case has to analysed individually, since the risk of relapse for the mother is greater than 50% in the weeks following childbirth if adequate preventive treatment is not followed. Valproate is the drug with a greater risk of teratogenesis (malformations of the foetus), reaching 5% of cases of spina bifida, as well as cognitive deficits in the long-term in the newborn. It is for this reason that valproic acid must be taken with extreme caution, or preferably avoided, in women of reproductive age. The other anti-epileptics seem less problematical, but are not free of risks. If it is necessary to keep taking an anti-epileptic during pregnancy, a prior diet rich in folic acid is advised, and frequent ultrasound controls during the pregnancy. In any case, it is always important to plan the pregnancy (and the treatment to follow) beforehand, by consulting with the psychiatrist of reference.

Bipolar disorder is a cyclic and recurrent illness. Although a patient may go more than 10 years asymptomatic, nobody can guarantee that there will be no more relapses. For this reason, the treatment is generally chronic and, in many cases, for life. Obviously, the duration of the treatment not only depends on the diagnosis, but also the frequency and severity of the previous relapses, of the response to the treatment, as well as its tolerability. Attention must also be paid to individual circumstances. Very often, the long-term treatment can be substantially simplified and be relatively comfortable. It is not advised to set yourself a goal of not taking medication; the main objective must be health and prevention of relapses, regardless of whether it necessary to take medication to achieve this.

The illness tends to get worse if suitable treatment is not received: the episodes are increasingly longer and intense, and the periods without symptoms are shorter or disappear completely. An untreated manic episode, apart from being a fatal result for emotional, social and working life of the one that suffers from it, can bring about catatonia and this, in very extreme cases, to death. An untreated depressive episode may lead to a suicide attempt.

The first thing that families must do is to inform themselves exactly about the illness. A sincere and responsible attitude must be adopted with the patient through open conversation. The doctor, although he/she can inform about the general concepts associated with bipolar disorder, he/she is not authorised to comment on individual aspects of the illness with the families (except if the severity of the case may require it or the patient is not in a competent state). Finally, it will be the patients who will consent that the doctor may share aspects of their illness with relatives during periods of stability. During the stability phases the relatives must avoid being overprotective and hypervigilant, although this is very common in families of patients whose illness is relatively recent. With these attitudes we will convert the patient into “the different one”, and it’s just about doing the opposite. Excessively critical postures are also not recommended. In times of stability, it is important to encourage freedom of the patient and, also, that the families look after themselves.