Bipolar disorder

Bipolar affective disorder, previously known as manic depression, is a mood disorder characterised by the experience of extreme moods (McIntyre and Calabrese, 2019).

A person living with bipolar disorder will have prolonged periods of elated (high) mood and prolonged periods of depressed (low) mood (National Institute for Health and Care Excellence (NICE), 2023). Although there are manifestations of the disorder where symptoms are less severe, such as in rapid cycling bipolar illness and bipolar II, the disorder is not to be confused with emotional lability – where a person’s mood can vary frequently through the day (NICE, 2O20).

Cyclothymia is similar to bipolar disorder, where people living with cyclothymia experience cycling mood in a similar pattern to that of bipolar, but on a milder scale (highs and lows are less extreme) (Rethink Mental Illness, 2023). Support should be sought for cyclothymia, as it can develop into bipolar disorder.

Psychotic symptoms,

Bipolar disorder should be considered as a possible diagnosis if symptoms of mania and depressed mood have been identified.

Symptoms of mania may manifest as:

• inappropriately elevated mood
• irritability and agitation, which may lead to aggression
• pressured speech
• fast-paced thoughts
• grandiose thoughts (eg overly confident in abilities, skills or talents)
• poor concentration
• poor sleep
• excessive energy
• increased libido
• disinhibition (eg sexual behaviour, spending money, engaging in unusual plans such as going on holiday with a stranger or taking up an activity that they would not normally do)
• psychotic symptoms (eg hearing voices, delusional thoughts, visual experiences) (NICE, 2023; Rethink Mental Illness, 2023)

Hypomania presents similarly to the symptoms described above, but has less of an impact on functioning and less likelihood of psychotic symptoms.

Symptoms of depression may manifest as:

• low mood or persistent sadness
• feelings of hopelessness
• feelings of worthlessness and or inappropriate guilt
• loss of interest
• lack of

There is no specific known cause of bipolar disorder, but it is thought to occur as a result of the interaction between multiple potential factors (NICE, 2023).

It is theorised that the functioning of brain neurotransmitters is altered in those experiencing a bipolar illness, which is why bipolar disorder is often treated pharmacologically (Lee et al, 2022).

Evidence suggests a genetic link, although no specific gene has been identified as causal. However, having family members who have experienced bipolar disorder increases a person’s risk of developing it (Gordovez and McMahon, 2020).

Other risk factors, similar to those of other mental disorders, include:

• childhood trauma
• physical and psychological abuse
• grief
• physical stressors (eg insomnia, pain)
• social stressors (eg financial, housing, employment)
• relationship difficulties including loneliness, divorce, betrayal
• seasonal fluctuations (NICE, 2023)

Diagnosis can be challenging, as bipolar disorder can present similarly to conditions such as personality disorder, anxiety disorder and problem substance use. For example, the emotional lability seen in emotionally unstable personality disorder can lead to a misdiagnosis of bipolar disorder.

The International Classification of Diseases from the World Health Organization (2019) or Diagnostic and Statistical Manual (American Psychiatric Association 2013) are used to diagnose bipolar disorder. Further exploration of their criteria is advised.

Physiological causes must be considered before diagnosis, and blood tests may be taken to rule out issues which cause similar presentations, such hyper- or hypothyroidism (NICE, 2020).

Practitioners should be aware that people will present in one of the two states: mania or depression. Both states should be explored, as it is easy to misdiagnose bipolar disorder as unipolar depression if the person first presents in a low state.

The time in a person’s life in

The mainstays of treatment are pharmacological interventions, psychoeducation (including relapse planning) and talking therapies.

Treatment for bipolar disorder can be challenging, and people are often unable to recover to their previous level of functioning (McIntyre et al, 2022). The challenges occur as a result of the complex effect on all areas of a person’s life: emotional, social and financial (McIntyre and Calabrese, 2019). Appropriate and considered involvement of loved ones and carers can be highly beneficial.

Some elements of bipolar disorder can be perceived as favourable to a person – often the elated mood that is experienced during the manic state – which may enable them to achieve positive outcomes or experiences. This perceived positive association with bipolar disorder adds a level of complexity to treatment and recovery.

Practitioners must consider the individual as a whole person, exploring psychosocial issues (eg loneliness) in addition to the more clinical nature of

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1. Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

1.1 mental health and wellbeing status
1.2 physical health and wellbeing

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington DC: American Psychiatric Association Publishing; 2013

Baldessarini RJ, Vázquez GH, Tondo L. Bipolar depression: a major unsolved challenge. Int J Bipolar Disord. 2020;8(1):1. https://doi.org/10.1186/s40345-019-0160-1    

Dome P, Rihmer Z, Gonda X. Suicide risk in bipolar disorder: a brief review. Medicina (Kaunas). 2019;55(8):403. https://doi.org/10.3390/medicina55080403   

Gordovez FJA, McMahon FJ. The genetics of bipolar disorder. Mol Psychiatry. 2020;25(3):544-559. https://doi.org/10.1038/s41380-019-0634-7  

Lee JG, Woo YS, Park SW et al. Neuromolecular etiology of bipolar disorder: possible therapeutic targets of mood stabilizers. Clin Psychopharmacol Neurosci. 2022;20(2):228-239. https://doi.org/10.9758/cpn.2022.20.2.228  

McIntyre RS, Alda M, Baldessarini RJ et al. The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management. World Psychiatry. 2022;21(3):364-387. https://doi.org/10.1002/wps.20997  

McIntyre RS, Calabrese JR. Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Curr Med Res Opin. 2019;35(11):1993-2005. https://doi.org/10.1080/03007995.2019.1636017

Miklowitz DJ, Efthimiou O, Furukawa TA et al. Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. JAMA Psychiatry. 2021;78(2):141-150.