INTRODUCTION

Bipolar disorder, formerly called manic depression, is a mental health condition

that causes extreme mood swings that include emotional highs (mania or
hypomania) and lows (depression).

When you become depressed, you may feel sad or hopeless and lose interest
or pleasure in most activities. When your mood shifts to mania or hypomania
(less extreme than mania), you may feel euphoric, full of energy or unusually
irritable. These mood swings can affect sleep, energy, activity, judgment,
behavior and the ability to think clearly.

Most people experience mood changes at some time, but those related to
bipolar disorder are more intense than regular mood changes, and other
symptoms can occur. Some people experience psychosis, which can include
delusions, hallucinations, and paranoia. Between episodes, the person’s mood
may be stable for months or years, especially if they are following a treatment
plan.
SYMPTOMS
Episodes of mania and hypomania (less severe mania) are prevalent features of bipolar
disorder. While the signs of mania may at first be a pleasant diversion from the dark
depressive episodes, the manic phase can also be destabilizing and self-destructive.
Depressive episodes can also emerge without warning. Some of the triggers for these
depressive periods include lack of sleep, excessive stress, or a negative life event, but
often there is no known cause for the depression. The depressive episodes must be
carefully monitored, as there is an increased risk of suicidal behavior during these
phases.

4 TYPES OF BIPOLAR DISORDER

According to the National Alliance on Mental Illness there are four types of bipolar
disorder. These include:

Bipolar I. Bipolar I disorder is the most common of the four types. Bipolar I involve one
or more manic episodes, with or without depressive episodes occurring. The mania
must be severe enough that hospitalization is required and lasts a week or longer.

Bipolar II. Bipolar II disorder is characterized by the shifting between the less severe
hypomanic episodes and depressive episodes.

Cyclothymic disorder. Cyclothymic disorder, or cyclothymia, involves repeated mood

shifts between depressive and hypomanic that persist for more than two years. The
depressive and mania episodes do not meet the diagnostic criteria for bipolar disorder
episodes. There may be periods of normal mood as well, but those periods last less
than eight weeks.

Unspecified bipolar disorder. Bipolar disorder not otherwise specified is present when
the symptoms do not fit the other three categories, but still involve episodes of
unusual manic mood.

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The Dutch Offspring Study
An Observational Longitudinal Study in Offspring of Parents
with Bipolar Disorder
Evidence suggests that it is important to identify people at risk for developing bipolar
disorder before they develop the full-blown illness.
Recent data indicate that disability associated with bipolar disorder begins increasingly
at age 15 to 19 years and becomes increasingly severe up to the age range of 25 to 29
years, suggesting that the presence of psychosocial impairment is an additional
dimension that can be used to identify patients who are likely to show a deteriorating
course of illness over time.

OBJECTIVE
Offspring of bipolar parents have a genetically increased risk of developing mood
disorders. In a longitudinal study, the authors followed a bipolar offspring cohort from
adolescence into adulthood to determine the onset, prevalence, and early course of
mood disorders and other psychopathology.

METHOD
The Dutch bipolar offspring cohort is a fixed cohort initiated in 1997 (N=140; age range
at baseline, 12-21 years). Bipolar offspring were psychiatrically evaluated at baseline
and at 1-, 5-, and 12-year follow-ups. Of the original sample, 77% (N=108) were
followed for the full 12 years.

RESULT
Overall, 72% of the bipolar offspring developed a lifetime DSM-IV axis I disorder, 54% a
mood disorder, and 13% bipolar spectrum disorders. Only 3% met DSM-IV criteria for
bipolar I disorder. In 88% of the offspring with a bipolar spectrum disorder, the illness
started with a depressive episode. In total, 24% of offspring with a unipolar mood
disorder developed a bipolar spectrum disorder over time. Mood disorders were often
recurrent (31%), were complex (comorbidity rate, 67%), and started before age 25.

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CONCLUSION
Even after 12 years of follow-up, from adolescence into adulthood, bipolar I disorder
was rare among bipolar offspring. Nevertheless, the risk of developing severe and
recurrent mood disorders and other psychopathology was high. Future follow-up of
this and other adult bipolar offspring cohorts is essential to determine whether
recurrent mood disorders in bipolar offspring reflect the early stages of bipolar
disorder.

WHAT CAUSES BIPOLAR DISORDER?

Scientists don’t know what causes bipolar disorder. Abnormal physical characteristics
of the brain or an imbalance in certain brain chemicals may be among the main causes.
As with many medical conditions, bipolar disorder tends to run in families. If you have
a parent or sibling with bipolar disorder, your risk of developing it is higher. The search
continues for the genes which may be responsible for bipolar disorder.
Researchers also believe that severe stress, drug or alcohol abuse, or severely
upsetting experiences may trigger bipolar disorder. These experiences can include
childhood abuse or the death of a loved one.
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HOW IS BIPOLAR DIAGNOSED?
Bipolar disorder cannot yet be diagnosed physiologically by blood tests or brain
scans. Currently, diagnosis is based on symptoms, course of illness, and family
history. Clinicians rule out other medical conditions, such as a brain tumor,
stroke or other neuropsychiatric illnesses that may also cause mood disturbance.
The different types of bipolar disorder are diagnosed based on the pattern and
severity of manic and depressive episodes. Doctors usually diagnose brain and
behavior disorders using guidelines from the Diagnostic and Statistical Manual of
Mental Disorders, or DSM.

Some people may be diagnosed with rapid-cycling bipolar disorder. This is

when a person has four or more episodes of major depression, mania,
hypomania, or mixed symptoms within a year.

While no cure exists for bipolar disorder, it is treatable and manageable with
psychotherapy and medications. Mood stabilizing medications are usually the
first choice in medication. Lithium is the most commonly prescribed mood
stabilizer. Anticonvulsant medications are usually used to treat seizure disorders,
and sometimes offer similar mood-stabilizing effects as antipsychotics and
antidepressants. Bipolar disorder is much better controlled when treatment is
continuous. Mood changes can occur even when someone is being treated and
should be reported immediately to a physician; full-blown episodes may be
averted by adjusting the treatment.

In addition to medication, psychotherapy provides support, guidance and

education to people with bipolar disorder and their families. Psychotherapeutic
interventions increase mood stability, decrease hospitalizations and improve
overall functioning. Common techniques include cognitive behavioral therapy,
psychoeducation, and family therapy.

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 IMPACT OF COVID 19 PANDEMIC ON
INDIVIDUALS WITH BIPOLAR DISORDER-
HOSPITAL BASED CASE STUDY
Data on the status and outcomes of people with bipolar disorder during the
COVID-19 pandemic remain sparse; however, it is reasonable to infer that for
many people living with bipolar disorder, the secondary consequences of the
pandemic have increased their vulnerability to a mood episode and other
negative outcomes. The high prevalence of psychiatric comorbidities in those
with bipolar disorder at baseline potentiates an increase in risk of destabilization
during the COVID-19 pandemic. Lifetime prevalence of substance use disorders in
those with bipolar disorder is estimated to be around 50%. Furthermore,
research examining substance use disorders impact on illness course in people
with bipolar disorder has consistently shown them to negatively effect outcomes.

ABSTRACT
COVID-19 has adversely affected the lives of people with bipolar disorder (BD).
We collected the hospital reports of two patients with BD admitted in THRISSUR
GOVERNMENT MEDICAL COLLEGE who suffered from relapse after being
diagnosed with COVID-19. Patient X is a 54-year-old man who developed manic
episode and Y is a 52-year-old woman who developed severe depression after
being hospitalized for COVID-19. In this case series, the patients with BD who
developed manic or depressive episodes during COVID-19 infection have been
described. Adequate liaison between consultation–liaison psychiatrist and
primary medical team was done. Rational pharmacotherapy along with
psychosocial interventions led to favorable outcomes in both the cases.

CASE 1
X, a 58-year-old man with BD, diabetes, and COVID-19 pneumonia (reverse
transcription–polymerase chain reaction [RT-PCR] positive), was admitted due to

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fever, cough, and breathlessness. He had 20 episodes of depression and mania in
the last 25 years. He was maintaining well on sodium valproate 1500 mg/d and
chlorpromazine 100 mg/d for the last 3 months. After admission, parenteral
amoxicillin, dexamethasone 18 mg/d, and remdesivir 600 mg (over 5 days) were
administered. On day 2 of admission, he appeared excessively cheerful and over-
talkative. His sleep reduced to 4–5 h/night, and he reported multiple grandiose
ideas. After 1 week, his physical condition improved, but behavioral disturbances
persisted. On mental status examination (MSE), he was oriented, had increased
psychomotor activity, increased volume of speech, exalted mood, prolixity of
thought, ideas of grandiosity, and poor insight. He was diagnosed as BD, current
episode mania without psychotic symptoms. Chlorpromazine was stopped, and
haloperidol 10 mg was started. Sodium valproate 1500 mg was continued.
Gradually, his sleep improved; psychomotor activity and behavior returned to
normalcy. Within 7 days, Young Mania Rating Scale score reduced from 26 to 6
and he was subsequently discharged. In follow-up consultations, he was found to
be maintaining well after 4 weeks of discharge.

CASE 2
Y, a 52-year-old woman, known case of BD and interstitial lung disease, was
admitted after being diagnosed with COVID-19. She had BD for 13 years, and the
last episode (severe depression) was 10 months back. She was maintaining well
on sodium valproate 800 mg/d and lurasidone 40 mg/d. On the 2nd week of
admission, she developed persistent and pervasive sadness, excessive tiredness,
and decreased interest in activities. Her interaction with others reduced, and she
reported decreased sleep and appetite. She was often irritable and refused to
take food and medications. She expressed pessimistic views regarding her health
and suicidal ideation. On MSE, she was tearful, had reduced psychomotor
activity, ideas of hopelessness, and helplessness. They made a diagnosis of BD,
current episode severe depression without psychotic symptoms, and lurasidone
up to 40 mg/d was restarted. Supportive sessions were taken. Gradually, she
improved, and HDRS score reduced from 24 to 8 in 10 days. Regular

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telepsychiatry consultations were done after discharge, and she maintained well
after 3 months of discharge.

RESULT
Anxiety symptoms and syndromes have been found to be common among people
with bipolar disorder with a prevalence estimates as high as 50%. Anxiety
disorders in bipolar disorder are associated with increased likelihood of suicide
attempts and deaths.

LIVING WITH BIPOLAR

DISORDER
Bipolar disorder is best described as a disorder of the
energy of the brain. People with a bipolar disorder
diagnosis experience unusual and intense changes in mood
and behavior. There are two extremes in bipolar disorder:
mania and depression. During a manic episode, people feel “up,” and may be much
more energetic than usual. Mania is much more extreme than a sudden burst of
energy or a good mood. Manic episodes may be associated with high-risk behaviors
including substance abuse, sexual promiscuity, excessive spending, and even violence.
During a depressive episode, people feel “down,” have low energy, and neglect
obligations. Bipolar disorder often causes problems in work, school, and relationships
and may require hospitalization.

The frequency of bipolar disorder ranges from 1% for bipolar I disorder, to around
4.5% when all subtypes are included. Bipolar disorder affects men and women equally,
and typically begins in early adulthood. When bipolar disorder begins in later life, it is
often a result of physical changes in the brain.

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MENTAL HEALTH CONDITIONS SIMILAR BUT
DISTINCT FROM BIPOLAR DISORDER
There are other mental disorders besides bipolar disorder, which can produce
mood swings. For example, mood swings can be caused by general medical
conditions or other physical illnesses that affect the body's regulatory systems.
Suspect medical conditions include various brain chemical imbalances, hormone
disorders (such as hyper- or hypothyroidism), bacterial or viral infections, and
autoimmunity conditions (leading to body rhythm dysregulation). Such illnesses
could cause people to experience bipolar-like mood swings even though they
don't have actual bipolar disorder.
Equally confusing is the use of street drugs and/or alcohol, which can lead to
altered mood states. As previously mentioned, manic people tend to show poor
judgment and to be pleasure-seeking in the extreme. For this reason, it is not at
all uncommon for people in the midst of a manic disorder episode to take drugs
and/or drink alcohol. Similarly, people experiencing a depressive episode tend to
feel awful, and sometimes will "self-medicate" with street drugs and/or alcohol
in an attempt to help themselves feel better. Though some short-term relief may
be gained by such self-medication attempts, substance abuse and addiction
problems can result in the long-term, which compounds the existing mental
disorder.
There is perhaps a weak bi-directional causal relationship between substance
abuse disorders and bipolar disorder. People who have bipolar affective disorder
have an increased risk for developing substance abuse problems, and people
who use substances may help to release whatever inborn potential or
vulnerability they may have for developing bipolar disorder.
Complicating bipolar diagnosis further is the possibility that an individual with
mood swings is suffering from a mental illness other than bipolar disorder.
A number of other mental disorders are associated with mood swings. Mental
disorders which may be commonly confused with bipolar disorder include

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Borderline Personality Disorder, Schizoaffective Disorder, Unipolar Depression,
and Premenstrual Dysphoric Disorder.

BIPOLAR
Bipolar disorder causes strong shifts in energy, mood, and activity levels. A
person with bipolar disorder will switch between extreme excitement, or mania,
and depression. These shifts can affect your ability to perform daily activities. In
some cases, a person with bipolar disorder may also experience hallucinations
and delusions (see below).

Schizophrenia causes symptoms that are more severe than the symptoms of
bipolar disorder. People with schizophrenia experience hallucinations and
delusions. Hallucinations involve seeing or hearing things that aren’t there.
Delusions are beliefs in things that aren’t true. People with schizophrenia may
also experience disorganized thinking in which they are unable to care for
themselves.
People with bipolar disorder can experience psychotic symptoms during a manic or
depressive episode. These can include hallucinations or delusions. Because of this,
people may mistake their symptoms of bipolar disorder for those of schizophrenia.
The symptoms of schizophrenia are divided into two groups, generally referred to as
“positive symptoms” and “negative symptoms.” This isn’t based on whether a
symptom is good or bad, but on whether the symptoms involve what could be
described as “adding” or “removing” a behavior. Positive symptoms involve adding a
behavior, such as delusions or hallucinations. Negative symptoms involve removing
behavior. For instance, the symptom of social withdrawal involves removing social
interactions.
There are no blood tests for diagnosing bipolar disorder or schizophrenia. Instead, the
doctor will do a physical and psychological exam. During the exam, they’ll ask about
any family history of mental disorders and symptoms. The doctor may want to do a
complete blood test to help rule out other conditions. They may also request an MRI or
CT scan. Finally, they may ask to agree to a drug and alcohol screening.

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 TREATING BIPOLAR
DISORDER
Treatment is best guided by a medical doctor who
specializes in diagnosing and treating mental health
conditions (psychiatrist) who is skilled in treating bipolar
and related disorders. You may have a treatment team
that also includes a psychologist, social worker and psychiatric nurse.
Depending on your needs, treatment may include:
 Medications - Often, you'll need to start taking medications to balance your
moods right away.
 Continued treatment - Bipolar disorder requires lifelong treatment with
medications, even during periods when you feel better. People who skip
maintenance treatment are at high risk of a relapse of symptoms or having
minor mood changes turn into full-blown mania or depression.
 Day treatment programs - Your doctor may recommend a day treatment
program. These programs provide the support and counseling you need while
you get symptoms under control.
 Substance abuse treatment - If you have problems with alcohol or drugs, you'll
also need substance abuse treatment. Otherwise, it can be very difficult to
manage bipolar disorder.
 Hospitalization - Your doctor may recommend hospitalization if you're behaving
dangerously, you feel suicidal or you become detached from reality (psychotic).
Getting psychiatric treatment at a hospital can help keep you calm and safe and
stabilize your mood, whether you're having a manic or major depressive
episode.
The primary treatments for bipolar disorder include medications and psychological
counseling (psychotherapy) to control symptoms, and also may include education and
support groups.
MEDICATION
A number of medications are used to treat bipolar disorder. The types and doses of
medications prescribed are based on your particular symptoms.
Medications may include:

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  Mood stabilizers - You'll typically need mood-stabilizing medication to control
manic or hypomanic episodes. Examples of mood stabilizers include lithium
(Lithobid), valproic acid (Depakene), divalproex sodium (Depakote),
carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).
 Antipsychotics - If symptoms of depression or mania persist in spite of
treatment with other medications, adding an antipsychotic drug such as
olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole
(Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may
help. Your doctor may prescribe some of these medications alone or along with
a mood stabilizer.
 Antidepressants - Your doctor may add an antidepressant to help manage
depression. Because an antidepressant can sometimes trigger a manic episode,
it's usually prescribed along with a mood stabilizer or antipsychotic.
 Antipsychotic - The medication Symbyax combines the antidepressant
fluoxetine and the antipsychotic olanzapine. It works as a depression treatment
and a mood stabilizer.
 Anti-anxiety medications - Benzodiazepines may help with anxiety and improve
sleep, but are usually used on a short-term basis.

HOW CAN WE HELP?

Educate yourself
The more you know about bipolar disorder, the more you’ll be able to help. For
instance, understanding the symptoms of manic and depressive episodes can help you
react appropriately during severe mood changes.
Listen
Simply being a good listener is one of the best things you can do for someone with
bipolar disorder, especially when they want to talk to you about the challenges they’re
facing.
Be active in their treatment
Treatment for people with bipolar disorder usually consists of many therapy sessions
and doctor visits. While you shouldn’t necessarily attend these appointments, you can
help someone with bipolar disorder by coming with them and then waiting for them
until their appointment is over.
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Make a plan
Bipolar disorder can be unpredictable. It’s important to have an emergency plan in
place if you need to use it during severe mood episodes. This plan should include what
to do if the person feels suicidal during a depressive episode, or if the person gets out
of control during a manic episode.
Support, don’t push
Your support can be very helpful to a person with bipolar disorder. However, you need
to know when to step back and let a medical or mental health professional intervene.
Be understanding
It can be hard for people with mental disorders to understand what they’re
experiencing. Those with bipolar disorder may not know why their moods are shifting.
Trying to understand what the person is going through and offering your support can
make a big difference in how they feel.
Don’t neglect yourself
While you’re caring for someone with bipolar disorder, it can be easy to forget to care
for yourself. But before you help someone, you need to make sure you have the time
and emotional capability to do so.
Be patient and stay optimistic
Bipolar disorder is a long-term condition, so the symptoms will come and go
throughout a person’s life. The disorder is unpredictable, with symptom-free periods
alternating with extreme mood episodes. For the sake of the person with bipolar
disorder, try to stay patient and optimistic. This can help them stay on track to living a
full, healthy life.
Know when it’s too much
No one knows how to handle bipolar disorder better than the specialists trained to
treat it. If you’re helping a person with bipolar disorder and it feels like things are
getting too difficult to handle, reach out to a medical or mental health expert right
away. Call 911 if the person becomes abusive or threatens to harm themselves or
others.
If you make the effort, you can make an enormous difference in the life of your friend
or loved one. Knowing they can rely on you can help them stick with their treatment plan
and stay more positive. It can also be rewarding for you to know that you’re helping your
friend or loved one cope with the ups and downs of life with bipolar disorder.
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