Introduction

About this site

The purpose of the ISBD Articles page is to provide educational information to patients and families to supplement information provided by a medical professional. We hope you will find the information helpful in managing your bipolar disorder. All the content on this site was written by ISBD Professionals (see Contributors below) and was developed in accordance with strict ISBD guidelines on fair and balanced presentation of educational content. No corporate or external funding was used to develop this material.

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To access the information, simply click on a topic on the left to show related subtopics. Click on any subtopic to open information on that topic. When you are finished with a given article, you may close all subtopics by clicking on the main article title (i.e. What Causes Bipolar Disorder). Please note that we are currently in the process of developing content for all categories and some topics have not yet been uploaded.

Contributors

Francesc Colom, MD, PhD
Univesity of Barcelona
Barcelona, Spain

Michael Berk, MBBch, Mmed
Barwon Health
VIC, Australia

Jan Scott, MD, FRCPsych
Institute of Psychiatry
London, UK

Boris Birmaher, MD
University of Pittsburgh, WPIC
Pittsburgh, PA, US

David Axelson, MD
University of Pittsburgh, WPIC
Pittsburgh, PA, US

Benjamin Goldstein, MD
University of Pittsburgh, WPIC
Pittsburgh, PA, US

Sergio Strejilevich, MD
Favaloro University
Bipolar Disorder Program
Argentina

Zane Wilson
Founder, SA Depression and Anxiety Group
South Africa

Bios and detailed information to come...

 

1.1 WHAT IS BIPOLAR DISORDER?

Bipolar disorders (BPD), also known as manic-depression, are mental disorders involving extreme changes in mood. The mood swings are far beyond what most people ever experience in the course of their lives. The mood changes in BPD may be downswings, as in depression, or upswings when a person might feel very elated. These upswings (sometimes called ‘highs”) are known as manic phases. These different changes or ‘mood swings’ can last for days, weeks or even months.
All BPD are characterized by both high and low phases. They can then be further sub-divided according to the severity of the mood change in the up or downswing and according to the frequency of the mood swings:

  • Bipolar I Disorder- individuals experience episodes of mania and usually have severe depressive episodes (called major depression) .
  • Bipolar II Disorder- the depression is severe, but the upswing is not as extreme as in mania, this less intense ‘high’ is called hypomania. Hypomania tends to have more of the positive and few of the negative features of mania, but it still requires careful management to prevent disruption to a person’s life.
  • Cyclothymia- this describes an unstable mood state with less intense emotional shifts than Bipolar I or II disorders.

Bipolar II disorders and problems such as Cyclothymia are also known as the Bipolar Spectrum Disorders In the bipolar spectrum, people have some mood swings that do not meet all the necessary criteria for one of the formal diagnoses mentioned previously, but still haveenough symptoms to significantly affect their lives.

The nature of episodes in BPD varies considerably, but with the right treatment package, it is possible to reduce the disruption to a person’s day to day life.

A brief note about moods and mood swings…..

Dictionaries define ‘mood’ as a ‘state of mind’ or a ‘prevailing feeling or emotion. Mood states are like the colours of the rainbow, each colour is distinct, but they may blend into one another. Moving through the different shades of emotions is often a normal and appropriate response to day to day life events and experiences.

Some people experience extreme ups and downs in their mood associated with other mental and physical symptoms that make it difficult for them to sustain a good quality of life. Mood swings that may indicate that someone has a bipolar disorder are often:

  • Unpredictable & Uncontrollable
  • More Extreme than normal ups and downs
  • Disruptive of normal activities
  • *Accompanied by specific changes in thinking, behaviours and physical functioning*

* This is important; experiencing mood swings without other symptoms does not mean someone has a bipolar disorder. Also mood changes can occur in some other mental disorders

1.2 What does an episode of Bipolar Disorder feel like?


The experience of bipolar disorder depends on whether the individual is experiencing a manic or depressive episode. This table lists the symptoms of mania or depression listed in textbooks. These two very different experiences are also described separately:

Depression
Feelings of depression are something we all experience from time to time. They can help us to recognise and deal with problems in our lives. But for someone with BPD, their depressive feelings will be worse, go on for longer and will make it harder to tackle their daily tasks and problems of living. Someone with this sort of depression will be more likely to have the psychological and physical symptoms listed below. Not everyone who becomes depressed will have all these symptoms, but they will usually have a number of them:

Mental Symptoms:

  • Feelings of unhappiness that don’t go away
  • Losing interest in things
  • Being unable to enjoy things
  • Finding it hard to make even simple decisions
  • Losing self-confidence
  • Feeling useless, inadequate and hopeless
  • Feeling more irritable than usual
  • Thinking of suicide

Physical Symptoms:

  • Feeling utterly tired
  • Feeling restless and agitated
  • Either loss of appetite and weight, or increased appetite
  • Changes in sleep, either difficulty in getting to sleep and waking earlier than usual, or increased sleep need
  • Constipation
  • Lack of interest in sex

If you become depressed you may find that you aren’t able to do your job or your normal daily tasks properly. It will become harder and harder to think positively about things and to see a hopeful future for yourself. You may feel like bursting into tears for no reason. You may find it harder and harder to be with other people. In fact, sometimes other people may notice that you are not your normal self before you have realised there is something wrong. In mild depression you will usually be able to carry on with some or all of your regular activities, (although they will take more effort than usual). This can be very valuable as it can stop you from getting trapped in a vicious circle of pessimistic thinking that can make you feel worse. However, with more severe depressions it is often wise to reduce your level of commitments for a time to a level you can cope with despite the depression as this will help to decrease your stress level.

 

1.3 Mania

Mania is often the opposite of depression, with feelings of well-being and elation, increased energy and optimism. Surely this can’t be a problem? Well, actually it can. These feelings can be so intense that you can lose contact with reality. When this happens you may find yourself thinking you are superman or wonder woman, believing strange things about yourself, making bad judgements and behaving in ways that you later feel embarrassed or ashamed of, or in harmful and sometimes even dangerous ways. Like depression, it can make it difficult or impossible to deal with life in an effective way. A period of mania can, if untreated, destroy your relationships and work. For other people the main emotion isn’t happiness but irritability. For others it is emotional lability (a word used to describe a roller coaster of up and down moods).  In an episode of mania, you may experience:

Mental symptoms:

  • Feeling very happy and excited
  • Feeling frustrated and irritated with other people who don’t share your optimistic outlook
  • Feeling full of new and exciting ideas
  • Thinking that you have special skills or powers or are a more important person than you used to believe
  • Jumping very quickly from one idea to another
  • Making plans that are unrealistic and coming up with ‘grand’ schemes
  • Speaking very quickly - if your mood is very high, it can be difficult for other people to understand what you are talking about
  • Making odd decisions on the spur of the moment, sometimes with disastrous consequences

Physical symptoms:

  • Feeling full of energy
  • Not needing sleep
  • Being very active and moving very quickly
  • Behaving in a bizarre way
  • Less inhibited about your sexual behaviour
  • Recklessly spending your money
  • Engaging in risky or dangerous activities
  • Not eating and losing weight
  • Being agitated and restless

When someone experiences a manic episode for the first time they initially may not realise that there is anything wrong. It is often friends, family or colleagues who first notice that there is a problem. This is quite understandable because people experiencing a manic mood swing often initially feel happier and livelier than they ever have and/or aren’t aware of how abnormal their mood or behaviour is. When the symptoms aren’t so extreme, doctors may use the word ‘hypomania’ to describe the symptoms.  Sometimes people who are manic feel full of energy and are overactive but their mood is irritable or unpleasant, a state called dysphoric mania

In very severe cases of depression or mania, a person may start to lose touch with the real world and develop what are called ‘psychotic symptoms’. The individual may experience unusual sensations (called hallucinations) such as hearing voices when no one is around or seeing things that no one else can see. Alternatively, these psychotic symptoms may take the form of fixed abnormal beliefs about themselves or their world (termed delusions). The content of the abnormal beliefs is untrue, but is usually influenced by the individuals’ mood state. In mania, people frequently believe that they are special and have the power to change the world. In depression, people have a very negative outlook, often being convinced that they are evil and responsible for many of the injustices in society. In such extreme situations treatment in an inpatient setting is frequently recommended. Psychotic symptoms usually resolve with treatment and/or when the individuals’ mood returns to normal.

1.4 Mixed States and Rapid Cycling

Surprisingly, some individuals also experience lots of the symptoms of mania and depression simultaneously; this is referred to as a mixed state.  In a mixed state, a person can, for example, have depressed mood and suicidal thoughts, yet at the same time be agitated, racy, need less sleep, and have an increased libido. Rapid cycling is a term is used when the frequency of upswings and downswings is increased and a person has four or more episodes of BPD within 12 months.


1.5 How Common Is It?

About one in every hundred adults will suffer from BPD. Bipolar disorders affect about 1-2% of the general population. Unlike other forms of depression, manic depression affects as many men as women. Likewise, mood swings do not respect status; individuals from all walks of life and social backgrounds are equally likely to be affected.

Mood swings often begin in adolescence and the average age of onset of manic depression is the late teens or early 20’s. Most people experience their first episode of BPD before the age of 40 years. Earlier age of onset of BPD is more common in individuals with a family history of manic depression.  Onset after the age of 40 years does occur, but this is less common.

By definition, mood disorders are recurrent. Nineteen out of 20 individuals who experience an episode of mania will experience at least one further episode of mood disorder at some point in their life. There is a 50-50 risk of a further episode of mood disorder in the year after recovery from the last episode.  Treatments that can reduce symptoms of depression or mania and reduce the risk of relapse are described in other papers on this website.

 

1.6 Summary Points

Summary

  • Bipolar disorders (BPD) are also known as manic-depression.
  • BPD are treatable mental disorder that involves recurrent mood swings. These mood swings may down into depression, or up into mania.
  • BPD affects 1-2% of the general population.
  • Men and women are affected equally.
  • The first episode usually occurs between the ages of 20 and 40 years.
  • Bipolar I and Bipolar II are the most common types of BPD.

2.1 Taking Charge of Your Bipolar Disorder: Part 1

This article covers what you can do to keep your mood stable.  The main thing you should do to avoid suffering from acute episodes of bipolar disorder is take the medication daily exactly as prescribed by your doctor. If your medication causes you any problems –usually called “side effects”- you should talk to your doctor, who will be happy to give you advice. Keep in mind that a good number of episodes have to do with the patient failing to follow –partly or completely- the psychiatrist’s instructions.
However, taking care of your bipolar disorder does not mean just taking daily the right medications; there are many other simple things that may help you to keep your mood stable. The following are just some pieces of advice that have proven to be helpful for people suffering from bipolar disorders. Most of the recommendations have come to us through patients, who often are the real experts in the management of bipolar illness:

  1. Do not fight bipolar disorder; do cope with bipolar disorder. Illness denial is a major problem for people suffering from bipolar disorder. While difficult, the sooner a person can accept the diagnosis the better. Suffering from bipolar disorder does not define you as a human being. In other words; you are what you are, but you ARE NOT bipolar. You suffer from bipolar disorder, a medical diagnosis that doesn’t add to or subtract anything from your identity. Illness acceptance is the key for successful treatment and management.
  2. Watch yourself. Learning to identify a bipolar relapse is not always easy. Some patients have very clear warning signs before having a new episode (i.e., they change the way they dress, the kind of books they read, they spend some more money or they start sleeping fewer hours), but in most cases the changes announcing a relapse are quite subtle, which means that you should work to identify your core self, who you are outside of the illness, in order to recognize what is a sensible change in your behavior. In general, any changes in routine may be bad news, as it may suggest an oncoming relapse.
  3. Have a stable sleeping routine.  Good sleep is essential to keep bipolar disorder stable. We recommend sleeping between seven and nine hours each night with a regular “go-to-bed” time and waking time. If you have the habit of having a nap in the middle of the day, this should be short, and never exceed 30 minutes. This routine should be maintained even during holidays or weekends, as this will help further regularity during the working days.
  4. Stay away from alcoholic beverages and other street drugs; the use of alcohol, even in small amounts, increases the risk of having an episode. Some people drink to “cheer up” but, paradoxically, on the whole, the consumption of alcoholic drinks lowers your mood and alters the quality of your sleep. As for other street drugs, they are considered highly dangerous for your mental health. Even the ones that are considered to be “soft” have proved to have devastating effects on the disorder. Similarly, even smoking can increase the risk of developing depression.
  5. Be as regular as possible with your daily activities. Avoid activity peaks. Planning things well ahead may help you to avoid being over-stressed during certain periods.

2.2 Taking Charge of Your Bipolar Disorder: Part 2

  1. Avoid drinking excessive caffeine drinks, as they may cause you to get anxious and may cause difficulty with your sleep. You may allow yourself to drink one or two cups of coffee per day, but you should note that caffeine will be active in your brain for at least 8 hours after you drink it so, you should drink your last cup of coffee at least 8 hours before going to bed. This also applies to soft drinks containing caffeine. As for the so-called “energy drinks”, the advice is to stay away from them, as they usually contain the equivalent of 4-5 cups of coffee apart from being able to cause or worsen many medical conditions.
  2. If you like physical exercise, congratulations, as it will make you feel very good. But make sure that you do not exercise immediately before going to sleep, as sport is usually very stimulating and may cause you some sleeping problems. On the other hand, if you suspect you are starting a manic or hypomanic phase you should stop any kind of physical activity, as it will only worsen the episode.
  3. Do not put yourself on a very strict diet. To suddenly loose weight induces hormonal and metabolic changes that may also enhance the onset of a new episode. Lastly, most of the so called “natural” treatments to loose weight contain some amphetamine, which may also trigger a new episode.
  4. You should work to reduce and control your anger as much as possible, as it is a very stressful experience for your body and brain and it may increase your anxiety and irritability, making you more likely to have a relapse.
  5. Listen to your family and friends. Amongst all your friends and relatives, look for someone that may act as a “Mood-watcher” when needed. Someone who supports you unconditionally, someone who knows about your disorder and who has observed at least one of your episodes. Trust him or her. Very often, the people around us are much more sensitive at observing mood and behaviour changes than we are. Other people’s observations about our behaviour may not always be out of point; consider them, especially if they come from a reliable source. If your mood-watcher tells you that you might be starting a new episode, do not even bother to discuss with him/her: let your doctor decide. If he was right, it will save precious time and lots of suffering. If he was wrong, you will only waste 5 minutes by calling your doctor.
  6. Be open and honest to your doctor. Do not hide any information, as it might be an illness trick to avoid being identified. Mutual trust between you and your doctor is basic.

Following this advice, the likelihood of having a new episode decreases dramatically. But it will never be zero. Then, why bother? You should bother because it may help you in reducing symptoms severity and duration and, at the end of the day, because none of the above mentioned points involves a major sacrifice. This advice would be equally useful for everyone, no matter if he/she suffers from bipolar disorder or not. They are “general mental health” issues. You will be not only more stable, you will be happier.

 

3.2 Stress-vulnerability interactions

Stress is a pressure or demand placed upon us from the environment, such as family conflict, or coming from ourselves such as unrealistically high expectations. Not all stress is bad; a certain amount of stress is necessary to provide just enough of a challenge to have a motivating effect on a person’s life, whereas too much stress for that person can overwhelm them and affect health.  Childhood abuse or neglect increases the risk for most psychiatric illnesses including bipolar disorder. In bipolar disorder, there is an interaction between stress and vulnerability, meaning that some people who would be at a theoretical “biological risk” for developing bipolar disorder may not develop it if certain stressful factors or toxic agents do not impact his/her life.  If the vulnerability factors, such as genetics are strong, a slight stressor, such as sleep deprivation, can spark off the illness. In contrast, major stressors can trigger illness even in people with few vulnerability factors, so managing stress can be an important part of managing illness.

3.3 Genetics

Bipolar disorder tends to run in families. Children of one parent with bipolar disorder have a 20% likelihood to have bipolar disorder, whilst children of parents who do not have bipolar disorder would have a likelihood of 4%.  This also means that the children of someone who suffers from bipolar disorder has exactly an 80% chance of not developing bipolar disorder.

The research on genetics in psychiatry is mostly based on twin and adoption studies. Identical twins share all their genes with their twin, and non-identical twins about half of their genes. If an identical twin has bipolar disorder, the second has a 60 to 80% chance of having bipolar disorder. In siblings or non-identical twins, the risk is only about 20%. If bipolar disorder were purely genetic in its cause, all identical twins would develop the disorder. Clearly, other factors are involved. Multiple genes rather than a single gene are thought to be involved in bipolar disorder, and these genes interact with environmental factors such as stress. Other disorders, particularly depression and schizophrenia are seen more often in relatives of bipolar patients than would be expected by chance, and family members of bipolar patients are also more likely to use drugs and alcohol.

3.4 What is happening in the brain: Part1

There is a flurry of new research in the biology of bipolar disorder. While a complete understanding is still a way off, there are many clues as to the mechanisms underlying this disorder.

Brain chemicals

There are a number of brain chemical changes that have been studied in bipolar disorder. Most of the understanding of these chemical changes results from research that has tried to understand how the medications that we have work. The idea that bipolar disorder is caused by a chemical imbalance is now widely accepted. The treatments that are used for the illness attempt to address these imbalances.

Neurotransmitters

Nerve cells in the brain, also called neurons, use chemical messengers, or neurotransmitters to talk to each other, like chemical emails. There are many different neurotransmitters that cells sends to each other to communicate. These include serotonin, glutamate, nor-adrenaline, dopamine and GABA. These neurotransmitters are involved in the regulation of mood, and changes in their function play a role in mood symptoms. They may be altered in amount, or how they function. Many of the medications that are used in treating bipolar disorder target these transmitters.

These neurotransmitters are released from one nerve cell, and attach to a second target nerve cell.  Once they have attached to the second cell, chemicals inside the cells, called second messengers, are activated. These messenger systems are changed in people with bipolar disorder, and many mood stabilisers such as lithium work on these second messengers.

Nerve growth factors

The brain produces nerve growth factors, which are chemicals that are vital for the survival and functioning of nerve cells in the brain. These are like fertiliser, they assist brain cells to grow and connect to each other. Many of the drugs that work in bipolar disorder boost these chemicals These findings are hopeful, as they suggest that prompt and consistent treatment may protect the brain. They also suggest how treatments improve symptoms and people’s ability to function effectively.

3.5 What is happening in the brain: Part2

Oxidative stress

The brain is the body’s most active tissue, using 20% of its energy. There is evidence that there is excess oxidative stress in the illness, and that most of the treatments that are widely used have antioxidant properties. Oxidative stress happens because your body constantly reacts with oxygen as you breathe and your cells produce energy. This produces highly reactive molecules called free radicals. These interact with other molecules within cells, and can damage proteins, membranes and genes, like when a cut apple is exposed to the air. New treatments that target oxidative stress specifically are being developed.

Immune changes

The immune system is the body’s defence against infections. It uses both immune cells and chemicals to fight infection. There are subtle changes in immunity in people suffering from depression and bipolar disorder. Both in mania and depression, there is an increase in some immune proteins that cause   inflammation, which is one of the body’s defences against infections . While this is well documented, the source and meaning of this is not fully clear.

Hormones

Cortisone is a stress hormone that is secreted by the adrenal glands. There may be excess cortisone in people with bipolar disorder. Cortisone has effects on the brain, and excess cortisone may damage nerve cells. New medications aiming to treat bipolar disorder by working on cortisone are under development.

Brain activity and structure

Nowadays, technology allows us to “see” not only the brain itself but, even more interesting for bipolar disorder research, how the brain works. Brain scans such as CAT scans and MRI scans provide clues about what is happening in bipolar disorder. Changes in activity in parts of the brain that are associated with emotion and movement coordination have been shown. Altered activity in some parts of the brain associated with concentration, attention, inhibition, and judgment is also found. Certain brain regions in people with bipolar disorder are changed in size. What this means is unclear, and is the focus of much research activity. The amygdala is a part of the brains emotional regulation system. Some studies have shown changes in the size the amygdala. Similarly, some studies have looked at the hippocampus, an area of the brain responsible for memory. The findings are often quite inconsistent, and the magnitude of these brain changes are small. Because of this, changes on brain scans cannot be used for diagnosis, but they hopefully will shed light on the processes involved in the illness.

 

3.6 Your Body's Clock

The body has an internal clock. In addition to making us wake and fall asleep at regular times, this clock sets the body’s many cycles, such as the release of hormones and chemicals regulating vital body functions eg. blood pressure, temperature and hormone secretion. A set of genes, the clock genes, plays a role in the setting of the body’s clock. People with bipolar disorder might have changes in the setting of the clock’s speed. Lithium has an effect on the genes that regulate this clock.

The winder that sets the clock are regular activities, social stimulation and regular sleep patterns, in particular having regular sleep and waking times. People with bipolar disorder might be more sensitive to changes in daily rhythms, and changes in rhythms can trigger illness. The hormone melatonin, which helps control sleep-wake cycles, is released in response to light. This in turn is influenced by when you go to sleep and wake up. Disruptions to the daily sleep wake cycle by things like jet lag and shift work may affect mood. This may explain why people with bipolar disorder may be particularly sensitive to sleep disruption, and sleep loss can trigger symptoms of the illness.

Bipolar disorder often has a seasonal pattern, with more episodes of depression when there is a reduction of light in autumn, and hypomania or mania peaking in spring when the daylight hours extend.  Childbirth is a particularly potent trigger, with many people having episodes of illness after childbirth. The mechanism for this is unclear, but may involve hormonal and other biochemical changes that occur with childbirth.

3.7 Lifestyle and Thought Patterns

Lifestyle factors

While this is not extensively researched, there is some evidence that people who are physically active have a reduced risk of developing depression. Smoking appears to increase the risk of developing mood disorders, and might make them more difficult to treat. Alcohol and drug abuse can clearly lead to illness.

Thought patterns

Everyone has set ways about thinking about themselves and the world. These are a core part of who we are as people, and come largely from our upbringing and childhood experiences. Some people have persistent negative ways of seeing themselves and the world. They might for example expect to be rejected or abandoned, or may believe that they have to always do things to perfection. These negative thought patterns play a role in vulnerability to depression in particular. There are specific psychological treatments such as cognitive behavioural therapy, that are able to correct these patterns, and this can both reduce symptoms and the risk of future episodes.

3.8 Summary

  • Paradoxically, more is known about how to treat bipolar disorder than what causes it.
  • Genetic factors play a role in vulnerability.
  • Changes in brain chemicals and the structure and activity of some brain regions are thought to be involved in the disorder.
  • Chemical systems that are involved include neurotransmitters, second messengers, immune and hormonal changes in the body.
  • Changes to the sleep-wake cycle can be a trigger.
  • Stress and psychological factors such as thought patterns play a role.
  • Lifestyle choices, including exercise, smoking and the abuse of alcohol and drugs influences risk of illness.
  • An interaction between a persons underlying vulnerability, and a variety of stressors or triggers, may result in an episode of illness

Suggested reading:
Living with Bipolar. Berk L, Berk M, Castle D, Lauder S. Allen and Unwin, 2008. http://www.allenandunwin.com/livingwithbipolar/

5.1 What are Mood Stabilizers?

Mood Stabilizers are the pillar of the pharmacological treatment of Bipolar Disorders. They are a group of therapeutic drugs which produce a progressive decrease in the frequency, duration and intensity of mood shifts affecting people who suffer from these disorders. Mood Stabilizers are the only drugs which act upon the �core� of Bipolar Disorders, improving the cyclical and inadequate mood shifts, allowing gradually mood stability.

The Mood Stabilizers which have been approved for use due to their effictiveness and safety are:

  • Lithium Carbonate
  • Lamotrigine
  • Sodium Valproate (Valproic Acid)
  • Carbamazepine

5.2 What are the therapeutic effects of mood stabilizers?

Mood Stabilizers have a progressive therapeutic effect. These drugs produce a gradually decrease of mood shifts which affect people who suffer from Bipolar Disorders. In a high percentage of cases, the control over symptoms is of such an importance that it allows for a complete control of the disorder, provided the drugs are taken without interruption.

As shown in the chart below, the continuous exposure to these drugs results in a progressive decrease in the intensity, duration and frequency of mood episodes along the natural evolution of these disorders. They allow mood stability, which gives the name to these medicines.

It is important to point out that the most important effect of Mood Stabilizers is in the improvement of the evolution of Bipolar Disorders. To understand their therapeutic effect we need to see how the disorder evolves, rather than look for an improvement in each particular crisis.

The effects of Mood Stabilizers are clearly noticeable along months of treatment. Although in some cases these drugs produce a rapid control of mood instability, in others it takes more than one year to perceive the complete effect of these medicines.

By analyzing the chart above, we can see that once a person has started the treatment with these drugs, they could suffer new episodes but these will be less intense, shorter or will appear less frequently than before. Gradually, these medicines produce mood stability.

It is important to know that mood stability is necessary to achieve a full recovery of occupational and social abilities.
In the treatment of these disorders the most challenging aim is not to end an episode but to prevent subsequent relapses.

Mood Stabilizers are also very efficient in the control of acute Episodes, manic and depressive. But unlike other kinds of drugs such as antidepressants, in addition to their acute effect, they have the ability of acting concomitantly in the prevention of relapses.

5.3.1 Which drugs are Mood Stabilizers?

There are 4 Mood Stabilizers which have been approved for use due to their effictiveness and safety.

Lithium Carbonate is a natural alkali metal while Lamotrigine, Sodium Valproate and Carbamazepine are synthetic drugs which are also used in the treatment of epilepsy.

By clicking on each Medicine you will be able to access to specific information about them.

There are other drugs which have been put forward as Mood Stabilizers but so far they lack enough scientific evidence and their use has not been approved in the treatment of Bipolar Disorders: Ox-Carbazepine; Topiramate; Gabapentin.

5.3.2. Can Mood Stabiizers be combined?

Yes. Mood Stabilizers can be combined together and with other psychotherapeutic drugs. In fact, it is which usually happens in daily practice. More than 60% of the people suffering from Bipolar Disorders require the combination of more than one Mood Stabilizer in order to improve the control of the symptoms.

Each of the several Mood Stabilizers presents specific profiles in their stabilizing effect.

  • Lithium Carbonate produce an adequate control over both phases of the illness but it is more effective in the prevention of manic phases.
  • Lamotrigine is mostly effective in the prevention of depressive phases.
  • Valproate is mostly effective in the prevention of manic phases.
  • Carbamazepine is mostly effective in the prevention of manic phases but less intensively than Lithium and Valproate.

There are other drugs which have been put forward as Mood Stabilizers but so far they lack enough scientific evidence and their use has not been approved in the treatment of Bipolar Disorders: Ox-Carbazepine; Topiramate; Gabapentin.


5.3.3 Pros and Cons of the Different Mood Stabilizers

All the drugs which are considered Mood Stabilizers have a proven positive effect in the treatment of bipolar disorders. However, each of the mood stabilizers has different profiles of therapeutic effectiveness and side effects which are normally taken into account.

These features should be considered in medical decisions on the choice of mood stabilizer for each person and at every moment of their treatment.

It is important to know that the first question we should answer is about effectiveness. A drug without side effects but without effectiveness is not a good choice.

6.1 What does Bipolar Disorder Look Like in Children?

Until the past decade, Bipolar Disorder (BP) was very rarely diagnosed in a child or an early teenager.  However, many adults with BP recall that their mood symptoms started back in childhood.  Many researchers and clinicians now recognize that BP frequently has its beginnings in childhood.  The brains of children and teenagers are undergoing tremendous changes leading to a mature state of emotional regulation, critical thinking and social development skills. 

The diagnosis of bipolar disorder in children is potentially complex and there are big differences between countries and clinicians as to how to diagnose and manage this problem. One problem is that the symptoms of the disorder look quite different in children and adults. It also is unclear where to draw the line between normal and problematic behavior, as well as between the symptoms of different disorders, such as bipolar disorder, Attention-Deficit Hyperactivity Disorder (ADHD), parent-child problems and pure behavioral problems such as conduct disorder.

A key point in recognizing BP in kids is to think about how manic and depressive symptoms would look in a child given their age and level of development.  For instance, a manic 7 year old would not be at a stage of life when they would be driving a car recklessly, calling friends at 3AM, going on shopping sprees, having many sexual partners, staying up all night writing a novel and believing that they are a prophet.  However, they might believe that they had superpowers and climb up on the roof or jump from heights, stay up all night rearranging their room and doing art projects, impulsively give away possessions, and inappropriately touch the private parts of others. 

6.2 What do Manic Symptoms Look Like in Children?

Elevated and elated mood occurs as part of manic episodes in most children with BP.  During a period of mania, the child may laugh uncontrollably in inappropriate settings such as during class or a religious service.  They may be giddy and laughing while threatening to hurt someone else.  Often, manic children will describe that they feel overly happy and high but do not know why.  Almost all children have irritability and anger when manic, and may have explosive tantrums that are above and beyond what is expected for the child’s age or developmental stage.  Young people with BP can have wild, unpredictable mood changes from euphoria to hours of explosive anger and even violence, to sudden, disquieting calm with little recall of the preceding emotional storm.

Manic children uniformly have lots of energy and are hyperactive to the point that caregivers frequently describe them as “bouncing off the walls”.  Typically they will switch rapidly from one activity to the next, though sometimes they will be goal-directed and complete elaborate projects with building toys or art supplies, or compulsively clean their room or other parts of the house.   This energy and high activity-level may occur late at night or early in the morning, yet the child seems well-rested the next day.  Children when manic often exhibit a boldness in their interpersonal interactions and will be excessively outgoing or bossy with other children and actively defy adult authority figures because they believe rules do not apply to them.  The inflated view of themselves can reach a point where they think they actually are a superhero or have magical powers.  Manic children may engage in impulsive risk-taking behavior such as trying to jump out of moving cars, or walk miles away from home without telling anyone.   At times some children when manic will inappropriately kiss and touch other people or masturbate in front of others.  Speech and thought process is usually very fast at times and caregivers will note that the child is hard to interrupt and that it becomes much more difficult to follow the child’s train of thought.

 

6.3 What does Depression Look Like in a Bipolar Child?

Depression is a prominent feature in most bipolar children.  Often irritable mood is more prominent.  The child becomes very negative about him/herself and others, loses interest in doing things they usually like, and often isolate in their room or sit around moving very little.  They may have a change in sleep pattern and appetite.  Suicidal thoughts and behavior frequently occur.  Depression can be seen in sustained episodes, though bipolar children are more likely to cycle back and forth between depression and mania as compared to bipolar adults or have mixed features .  Mixed features are when a child has some symptoms of both mania and depression at the same time. The cycling patterns can be complex; sometimes within the same day or every couple days.  At times, bipolar children can be mostly depressed with brief mild manic or hypomanic periods mixed in. 

6.4 What are the Common Features of Bipolar Disoder in Kids?

Almost all bipolar children have other co-occuring psychiatric problems in addition to BP.  Most have symptoms of ADHD, which shows up as chronic symptoms of inattention, impulsivity and hyperactivity.  They frequently have disruptive behavior disorders (Oppositional Defiant Disorder and Conduct Disorder) that can lead to substantial discipline problems.  Many have comorbid anxiety disorders. Psychotic symptoms such as hallucinations and delusions are common in youth with BP. 

6.5 Why is it so Hard to Diagnose Bipolar Disorder in Kids?

One problem is that all children in certain situations will show some mild versions of manic symptoms.  A child at an amusement park or a holiday celebration can be extremely happy, talkative, outgoing, more distractible, hyperactive and impulsive.  However, a manic child will have these mood and behavioral changes to a much more intense degree, and in other, non-stimulating environments.  Some symptoms of mania are also present in other psychiatric disorders.  For instance, irritability and explosive anger outbursts are often the most common feature in bipolar children, yet they also occur in many other child psychiatric disorders.  ADHD has many symptoms that overlap with mania.  One way to help separate BP from other disorders is remember that symptoms of mania should occur and intensify with the abnormally elevated and/or irritable mood.  Caregivers of bipolar children who also have ADHD will often describe that when the child is manic, their mood changes and the ADHD symptoms also seem to get much worse. 

The presence of chronic mood and behavior problems and complex cycling patterns can make it difficult to identify distinct Manic, Mixed or Major Depressive Episodes.  Often children will have clear periods of mania symptoms, but they do not last as long as in adults.  In addition, BP may initially surface as depression and it is hard to know whether these youth will develop periods of mania or hypomania in the future. However, if the depression is accompanied by psychosis and there is family history of BP, these children are at high risk to become bipolar.  Also, if psychotic symptoms are present, the child’s illness may be confused with schizophrenia. Finally, Adolescents may be abusing drugs or alcohol and make the diagnosis of BP very difficult.  More research will hopefully provide improvements in diagnosis, but for now, it can be a difficult and time consuming process to make a proper diagnosis in children.

Accurately diagnosing bipolar disorder in children can be difficult and requires detailed assessment and careful observation of the child over time by a clinician well versed in child psychiatric disorders.

  • Bipolar children present with manic symptoms in ways that are consistent with their age and level of maturity
  • Irritability is almost always present, but elevated mood is also common
  • Depression can be prominent in bipolar children
  • Many bipolar children have other concurrent psychiatric problems
  • Clear episodes of mania and depression can be hard to identify in children with bipolar disorder, but are present

6.6 What is the Course of Pediatric BP Over Time?

Fortunately, most studies have found that the vast majority of youth with BP fully recover from the mood episode that brought them into a study.  Some small studies have found relatively quick time to recovery of 1-2 months. Recent large scale studies suggest it often takes 1-2 years for this to occur.  The largest follow-up study of youth with BP found that approximately 50% of youth have recurrences when followed for an average 2 years, most commonly depression.  They spent 60% of the time with significant symptoms.  Whereas subtypes of BP appear to be stable in adults, about 20% of youth with BP-II convert to BP-I, and 25% of those with BP-NOS convert to BP-I or II.  

6.7 Do Social and Demographic Factors Matter?

Low socioeconomic status has generally been associated with poor outcomes in a number of studies. One study found that females have poorer recovery from mania, and that females are more likely to require higher levels of care including hospitalization.  Prepubertal children may experience more difficulty recovering from mood episodes than pubertal children/adolescents.

6.8 What can be Done to Ensure the Best Possible Outcome in Pediatric Bipolar Disorder?

  1. Early identification, diagnosis, and treatment:     

The earlier BP is identified and correctly diagnosed, the better.  Incorrect diagnoses can lead to treatment with medications that can worsen BP if not delivered simultaneously with mood-stabilizing medication.  BP may be easier to treat if it is diagnosed early.

  1. Give specific issues specific attention:

General treatment of BP can help in part, but specific problems such as suicidality, substance abuse, ADHD, and anxiety often require additional targeted medication and therapy strategies.

  1. Take a long-term perspective and approach:

Although improvement might take time, most youth with BP do get better. 

7.1 Introduction

Treatment of Children and Adolescents with Bipolar Disorder (BP)
Boris Birmaher MD, David Axelson MD, and Benjamin Goldstein MD

Introduction
Until recently, there were not too many studies regarding the treatment of children with BP. Taking into account the emotional, cognitive, social and physical developmental stage of the child, the treatment of children and adolescents with bipolar disorder (BP) have drawn on what we know about treating adults with BP. However, not all the treatments that work for adults are effective or tolerated by children. Also, many of the treatments that are used in adults have not been well studied in children.

Most of the treatments described here pertain to children with bipolar disorder (BP) type –I (periods of mania and major depression), but until further studies will be available they can also be used for BP-II (periods of hypomania and depression) and bipolar not-otherwise-specified (BP-NOS), especially if these types of BP are affecting the functioning of the child (for definitions and descriptions of the symptoms of BP, please see the article entitled, “Bipolar Disorder in Children and Adolescents: Diagnosis” (Axelson et al., ) on this website. For this article, unless otherwise specified, the words child or children indicate both children and adolescents.

The treatment of children with bipolar disorder is divided into two phases:
1) The acute phase is aimed at managing the symptoms related to episodes of the illness and
2) The maintenance phase is aimed at preventing episodes in the long-term. 

For these two phases of the treatment, the approach will vary depending on the symptoms of the illness. The treatment depends on whether the child has mania, hypomania, depression, rapid cycling, mixed episodes or if the child has psychotic symptoms (hallucinations and or persistent false ideas).  Also, additional treatments for the common disorders that accompany BP such as attention deficit hyperactive disorder (ADHD) and anxiety disorders and other problems (e.g., school and peer issues) are usually necessary.

The existing treatments for the acute and maintenance phases described above include educative, pharmacological and psychosocial strategies.  Each one of these strategies will be described below.

7.2 Education

The first step for the treatment of children with BP is to educate the child, his family and if appropriate others (e.g., teachers) about the symptoms, outcome, consequences (e.g., suicidal attempts, use of street drugs, legal and academic problems) , nature, and treatment of BP.  An understanding of the illness will help reduce mistaken ideas or beliefs regarding the symptoms, origins, and treatment of this illness.  Education about the illness will also help to increase the likelihood that patient’s will take treatments according to their doctor’s instructions and possibly improve family relationships.  Education should also include information regarding factors that trigger or worsen the symptoms of BP.  Things to look for may include changes in the child’s lifestyle or daily routines (e.g. avoid sleep deprivation and substances that may worsen the child’s mood). The importance of following through with treatment should be stressed.  In addition, education will help the family and others to understand their roles in helping the child with his/her bipolar Illness, other psychiatric disorders that usually accompany bipolar disorder, and ongoing family, social, and academic problems. Finally, education should include a full description of the currently available treatments, their effectiveness, and the potential side effects.

7.3 Psychotherapy

The use of supportive psychotherapy is indicated for all patients at any phase of the treatment and with any subtype of BP. Supportive management includes helping parents and children with daily problems at home or school, helping with implementation of routines, counseling regarding peer problems, talking about worries about the illness and its treatment, and helping children and their parents to cope with stress.  Certain types of psychotherapy may be specific for the acute treatment and prevention of relapses or recurrences of the illness. For example, Family Focus Therapy has been shown to help symptoms of acute depression and reduce the risk of recurrences, particularly depression in adolescents with BP. Other types of psychotherapy such as cognitive behavior therapy (CBT) administered individually or in group, and more recently dialectical behavior therapy (DBT) may also be useful. CBT may help the child control his depression through positive thinking and DBT may help the youth  control the frequent  mood changes, impulsivity and low frustration tolerance  usually found in children with BP.

Specific types of psychotherapy can also be used for the treatment of disorders that typically occur along with BP.  For example, CBT can be used to treat anxiety disorders, family and behavioral therapy can be used to control oppositional and defiant behaviors, and other types of therapy can be used for the treatment of substance abuse.

7.4.1 Pharmacotherapy: Mood Stablizers

Medications are the key treatment of BP. The use of education and specific types of therapies is very important, but without the medications the acute symptoms of the illness cannot be controlled or prevented. There are different types of medications for the treatment of BP depending on the illness’ type of episode (e.g., mania, depression) and the phase of the treatment (acute or maintenance).
               

    Mood stabilizers
. The most commonly used medications include a group called “mood stabilizers.”  The mood stabilizers include lithium and medications that are used for the treatment of seizures, which are referred to as  “anticonvulsivants.”  Researchers have found these anticonvulsant medications to be useful for the treatment of BP. The anticonvulsivants found to be useful for the treatment of BP include valproate, carbamazepine, and lamotrigine.  In contrast, topiramate, oxcarbamazepine, and gabapentin do not seem effective for the acute treatment of children with BP. 

With the exception of lamotrigine, all mood stabilizers work better for the acute and maintenance treatment of mania, hypomania and mixed episodes and to a lesser extent for depression. Lamotrigine seems to be only useful for the prevention of depressive episodes, but not for the acute symptoms of depression. However, no studies have been done with this medication in children with BP.

All the mood stabilizers work slowly and require several weeks to begin to help.  Also, some of them require certain minimum blood levels to work. As with any other medications, to different degrees and depending on their dosages, all mood stabilizers may produce side effects in some people including tiredness, sleepiness, tremors, changes in appetite and weight, changes in some laboratory tests, and be toxic at high blood levels. Some of the medications have more specific side effects. For example, lithium may produce increased urination, thirstiness and hypothyroidism. Lamotrigine and carbamazepine can induce a skin rash, carbamazepine can lower the blood white cells and valproate can produce liver, pancreas and perhaps ovarian problems.

7.4.2 Pharmacotherapy: Antipsychotics

There are two types of antipsychotics that have been used for the treatment of children with BP, the neuroleptics or typical antipsychotics ( e.g., haloperidol, chlorpromazine) and the new generation or atypical antipsychotics ( e.g., risperidone, quetiapine, aripiprazol, olanzapine). These medications were initially produced to control psychotic symptoms in patients with schizophrenia, but they are also helpful to treat the acute symptoms of mania, psychosis, and agitation in patients with BP. Also, in adults with BP some of the atypicals have been found to be effective for the acute treatment of depression and some studies suggest that these medications may be used to help to prevent both mania and depression.  Due to their potential side effects, the neuroleptics are not often used in children with BP. Moreover, most of the studies in children with BP have been done with the atypicals.  These studies have found that olanzepine, risperidone, quetiapine, and aripiprazol are useful for the acute treatment of manic and mixed episodes in children with BP.
These medications work faster than the mood stabilizers and can be used as the sole treatment.. Depending on which medication is chosen and the dose used, the atypical antipsychotics produce several side effects including rapid and significant increase in appetite and weight, tiredness, sleepiness, and sometimes increase in glucose and cholesterol in blood. Although, with much less frequency than the neuroleptics, the atypicals may also induce abnormal movements (tremor, muscle stiffness, and sudden muscular contractions). Rarely, especially when the older typical antipsychotics are used for long periods of time and at high dosages they may result in a potentially irreversible movement problem called ‘tardive dyskinisia”

7.4.3 Pharmacotherapy: Antidepressants

The use of antidepressants such as the Selective Serotonin Reuptake Inhibitors (SSRIs) for the treatment of depression in children with BP have not been studied.  In adults it appears that these and other antidepressants are not very effective for the acute or maintenance treatment of depression, but they can be useful in certain situations after the mood has been stabilized with the atypicals or mood stabilizers.  Importantly, sometimes the antidepressants may trigger or aggravate the existing symptoms of mania.
The SSRIs are very useful for the acute treatment of anxiety disorders in children. However, their use for children with BP and anxiety disorders has not been investigated.

7.4.4 Pharmacotherapy: Other Medications

The benzodiazepines such as lorazepan may be temporarily used to reduce the agitation and the insomnia of children with acute symptoms of BP until the mood stabilizers begin to work.  However, some children may get more agitated and confused with these medications. Other specific medications for concurrent disorders like the stimulants for attention deficit hyperactive disorder (ADHD) are also indicated for children with BP and ADHD. However, stabilizing the mood with the medications described above is recommended as a first step; otherwise, the mood symptoms, particularly mania and mixed states, may get worse with the stimulants.

7.5 Summary

Given that the symptoms of BP in children are very diverse (e.g., mania, hypomania, mixed, depression), that in children symptoms tend to change rapidly, that treatments are needed to treat acute episodes as well as prevent the symptoms of BP , and that BP usually comes accompanied with other psychiatric disorders, the treatment of children with BP may be complicated. Thus, there is a need for a thorough evaluation of the child at the beginning of and during the treatment and clinicians need a very good knowledge of the current pharmacological and psychosocial treatments and associated side effects. Finally, parents and children need to be well educated about these treatments and become active partners in the treatment of this chronic illness.             

  • The treatment of BP is divided into acute and maintenance (preventative) phases.
  • The treatment should address or target the patients’ current mood stage including mania, hypomania, mixed, rapid cycling, and depression. Also, treatment may be chosen to target specific symptoms such as psychosis, insomnia, and agitation.
  • The goal of the treatment is not only to reduce current symptoms, but  prevent their recurrence.
  • The treatment of BP is usually for long-term.
  • Existing tools to treat children with BP include education, psychopharmacological and psychosocial treatments.
  • The mood stabilizers and the atypicals alone or combined are the first choice to treat the acute symptoms of mania, mixed and rapid cycling symptoms. These medications also seem to be useful for the treatment of depression in children with BP.
  • The mood stabilizers and perhaps the atypicals and lamotrigine are useful to prevent further recurrences in children with BP.
  • Potential psychological and physical side effects of all medications need to be carefully evaluated throughout the treatment
  • Psychosocial treatments are also useful for the acute and maintenance treatment of BP symptoms, particularly depression and disorders that frequently accompany BP in children.
  • All psychosocial treatments should include education, supportive management, coping strategies to manage stress and help the child and his/her parents to make changes in the child’s lifestyle and avoid factors that may trigger or worsen the illness, such as abuse of alcohol and drugs and not following the treatment
  • Careful attention and prompt action need to be taken if the youth has suicidal ideas or behaviours and ideas of hurting others.
  • Children, adolescents, and their parents need to be acquainted with the symptoms of this illness, the importance of taking treatments as prescribed, and become partners with the clinicians.

8.1 A Double-Edged Sword: Part 1

Mental illnesses like Bipolar Disorder often strike with a double-edged sword. On one edge are the illness’s symptoms and the distress it causes; on the other is the stigma that robs people of rightful opportunities, work, relationships, and healthcare. Internalizing this stigma can further affect a person's recovery and achievement of life goals.

Stigma marks an individual as being unacceptably different from ‘normal’ people with whom s/he interacts. (Goffman 1963). It is a process that builds on and reinforces existing negative views and beliefs about a group, and significantly discredits a person in the eyes of others. External stigma happens when society avoids, rejects, judges, abuses, or victimizes people with a mental illness, and endorses stigmatising attitudes, or stereotypes. Internal stigma can be the patients own exclusion, withdrawal, low self-esteem, over-compensation, and fear of disclosure.

People with mental illness are satirized on "Seinfeld," stereotyped in movies like "Psycho" and "Halloween", and ridiculed in George Carlin's comedy routines. “Donna has a mental illness. Donna is to be feared.” Such begins the stigma of having a chronic illness. In our society the myths surrounding mental illnesses alienate those who suffer from them. “People with Bipolar Disorder are dangerous”, “People with mental illness are to blame for their illness”, “People with Bipolar Disorder can't meet the demands of daily living”. Unfortunately, the reality is that Bipolar Disorder is often stigmatized, and many people don’t seek help for fear of being labeled as ‘crazy’, ‘dangerous’, and unreliable..
Mockery, discrimination, and stigma persist despite scientific research that shows mental illnesses like Bipolar Disorder are as real, as serious and as treatable as any other illness like Cancer, Diabetes or heart Disease. People often say hurtful things to people with Bipolar Disorder often because they are uninformed, get caught up in the social stigma of mental illness, even because they think they are giving good advice.

A South African research study, done in 2005, identified barriers against effective treatment among South African’s with Bipolar Disorder. The study, conducted by Linda Trump of the Johannesburg Bipolar Association, found that for the majority of Bipolar respondents the condition is treated as if it is an elephant in the room. Everyone knows it is there, but they are too embarrassed, reluctant, fearful or awkward to discuss it with the person who is affected. Thus, the sufferer does not get the attention and support he would get with a more visible form of disability like a broken leg.
"Mental illnesses are brain diseases just like a stroke or a brain tumour," said Steven Hyman, of the National Institute of Mental Health. "Based on biomedical research, there is absolutely no justification for separating out mental disorders from other serious brain disorders.” But the world's view of mental illness has been one of fear, misunderstanding, and superstition about mental illnesses. Sadly, a lot of this hasn’t changed and there’s still a lot of misunderstanding.

“I have had Bipolar Disorder for many years and, due to fear and shame – and unemployment, have never sought treatment. Four months ago I finally got the courage to try the state system.  I have been very impressed by the thoroughness. I’m on medication, and even though I'm still not 100% stable, the peaks and dips are less and I feel better.  I know there's a long road ahead but for the first time in over 10 years I feel like I might actually have a chance of a normal life sometime in the future”, says Michael of Johannesburg.

8.2 A Double-Edged Sword: Part 2

About 50% of people believe that mental illnesses are problems of character and self-discipline. We are told that our minds are infinitely powerful and because we can do so much with our minds, some people believe that we should be able to do everything – like control our mania or depression, or will-away our mental illness.

Unfortunately willpower doesn't work. It’s just not that simple.

"People think for some reason you have control over it and could make it go away if you wanted to," says Rebecca, a 42-year-old who has Bipolar Disorder. "You don’t. Without medication and therapy, you do not." Rebecca had her first psychotic episode over 25 years ago and says that for years she blamed herself. "I felt like such a failure and so weird that I was doing crazy things. Why couldn't I just stop?" she says. "In the beginning, some doctors even told me that this was my way to get what I wanted from my family." Even now, years later, some of the self-blame persists.

It is sometimes easy to forget that our brain, like all our organs, is vulnerable to disease. People with mental illnesses show many different behaviours, from extreme sadness to excessive happiness, irritability, hostility, social withdrawal, tearfulness, even hallucinations and delusions. Instead of receiving compassion and acceptance, people with mental illnesses may experience hostility, stigma, and indifference.

Shirley, a sales manager, has a son with Bipolar Disorder. He has a history of drug abuse and as a result, many people write off his mental illness and blame it on the drugs, she says. But Shirley says she thinks her son turned to drugs in an attempt to self-medicate his illness. "There's not a person in the world who would say, "I want to be mentally ill," she says. “No-one chooses this and if people could control it with willpower, they would.”

8.3 A Double-Edged Sword: Part 3

One of the most devastating consequences of stigma is when people internalize the stigma they see and hear in society and start to believe the myths and stereotypes. People with self-stigma agree with society’s biased stereotype and apply it to themselves: example, "All people with mental illness are to blame for their illness, so I must be responsible for my symptoms and disabilities." If someone is convinced that he or she is inept and unworthy, this person will not try to get a good job, rent a nice apartment, or obtain satisfactory healthcare. This results in a "Why try?" effect: "Why should I even try to get a job? A person like me is neither worthy of such a position nor able to take advantage of it." Ironically, the "Why try?" effect also undermines individuals' participation in the very treatments that can help them manage their lives.

People's reactions to mental illnesses may be inappropriate because such illnesses, especially Bipolar Disorder and Schizophrenia, are hard to grasp. “Many of us fear what we don’t understand, we fear losing control or going to extremes, and people with mental illnesses point these things out to us”, says psychiatrist Frans Korb. Some people make a career of what they don’t understand, research and investigate it, or avoid it, laugh at it, demean it, and let yourself believe that ‘those people’ are so very different from you.

South African Bipolar sufferer, Rahla Xenopolous, has written a book about her experiences with Bipolar Disorder after years of misdiagnosis and emotional swings. Her book, A Memoir of Love and Madness, sends a powerful message that a diagnosis of Bipolar Disorder doesn’t mean giving up a full and meaningful life, and attempts to destigmatise the illness. “Writing the book helped me help to understand the rhythm in the confusion of this condition”, says Rahla.

"Mental illnesses? Oh they’re just an emotional problem." Often the media is responsible for many of the misconceptions which persist about people with mental illnesses.  Newspapers often stress a history of mental illness in the backgrounds of people who commit crimes of violence. Television frequently sensationalizes crimes where people with mental illnesses are involved.  Ironically, the media probably offers the key to eradicating stigma because of its power to educate and influence public opinion.

Stigma isolates and divides communities - people lose jobs, families and communities reject people, children are denied schooling, treatment is refused. It results in isolation and fear, causes people to socially withdraw, and puts people with mental illnesses beyond the reach of support services. Only 60% of the Bipolar respondents perceived their friends to be concerned and supportive, while a high 57% lost friends during the course of their illness. Four out of ten people with Bipolar became unemployed as a result of their illness, according to the South African research study. Some people would almost rather die than admit needing help - let alone actually getting it.

8.4 How Can You Combat Stigma

So how can you combat stigma? Education is key to address the roots of stigma – fear and ignorance. Share your experience with mental illness - your story can convey to others that having a mental illness is nothing to be embarrassed about. Work with communities to shift values and beliefs. Work with media, religious groups, school, and businesses – everyone – to affect change and help people with mental illness re-enter society by supporting their efforts to obtain jobs. Always respond to false statements about mental illness or people with mental illnesses. Many people have the wrong ideas on the subject of mental illness, ideas and perceptions that are damaging and inaccurate. By challenging negative views openly, and providing accurate facts and information, people’s ideas and actions may be changed.

As Rahla says: “It’s like having Diabetes. It’s a disease. You get sick. You take medication. Can people please try to understand that?”

Common Myths and Misconceptions about People
with Mental Illness

Myth: "People who need psychiatric cares should be locked away in institutions"

Fact: Today, most people can lead productive lives within their communities thanks to a variety of supports, programmes, and/or medications

Myth: "A person who has had a mental illness can never be normal"

Fact: People with mental illness can recover and resume normal activities. For example, Mike Wallace of "60 Minutes," who has clinical depression, has received treatment and today lives and enriched and accomplished life.

Myth: "Mentally ill persons are dangerous"

Fact: The vast majority of people with mental illness are not violent. In the cases when violence does occur, the incidence typically results from the same reasons as with the general public, such as feeling threatened or excessive use of alcohol and/or drugs.

Myth: "People with mental illnesses can work low-level jobs but aren't suited for really important or responsible positions"

Fact: People with mental illnesses, like everyone else, have the potential to work at any level depending on their own abilities, experience and motivation.