Bipolar Info: Defining (and Treating) Mania

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Depression is one of the worst states the human mind can endure.  Anyone who's been depressed will easily recognize the symptoms:  low mood, lack of enjoyment in things they once loved, tiredness/exhaustion, slowed thinking, feelings of emptiness, worthlessness, despair & hopelessness.  But what about depression's flipside:  mania?  Mania is a unique state that only occurs in bipolar disorder & can be harder to recognize, often being mischaracterized as other things.  Worse, doctors often miss it because patients rarely come to them for help when they're manic or in a neutral state, and the term "mania" itself can be misleading.  It's not always a euphoric state where you're having million brilliant ideas or running around at 2x speed like characters in a silent film. 

At its core, mania is when your mind is going too fast.  This can manifest as racing thoughts, anxiety, insomnia, irritability, rage, hypersexuality/high libido, poor decision-making, distractibility & trouble focusing, impulsivity/risk-taking or restlessness, aka a need to "go go go" and "spend spend spend."  Notice I said "or," not "and".  That's because it need not include ALL of these symptoms to be considered a manic episode.  One person's mania can look very different from another person's.  While everyone experiences some of these symptoms some of the time, the thing that sets them apart in bipolar disorder is the severity:  they must be severe enough to interfere with your daily functioning, health, finances, relationships, emotional well-being or some other aspect of your life to qualify as a disorder.

In small doses ("hypomania") or for short periods, this can sometimes be positive in terms of mood & productivity, but true mania left unchecked is often disastrous to your life & health.  This is because the mind and body eventually grow weary from the constant state of motion, of "going" and "doing".  Your brain is saying you're fine even as your immune system, heart & other muscles say they can't go on.  That's to say nothing of your bank account or the people who care about you.  In people with Bipolar I (the most severe type), mania may occasionally spiral into psychosis, or hallucinations & complete loss of touch with reality.  For others on the bipolar spectrum* it may manifest as a mixed state, or a combination between mania and depression as one state transitions into the other.  Mixed states are one of the most dangerous states in psychology in terms of suicide risk.  They're especially dangerous because, unlike in unipolar depression, patients in a mixed state actually have the energy to follow through with their suicidal plans and are often impulsive enough to do so.  

Adding to the overall risk, bipolar disorder affects not only mood but perception of reality, decision-making & judgment.  Because it's cyclic (i.e. the symptoms come in waves or cycles), these things will not always be impaired but when they are, you may not realize it.  50% of people with bipolar disorder and schizophrenia have what's called "anosognosia," a fancy word for "lack of insight into their condition".  In other words, they don't perceive or believe they're ill.  This isn't denial but a true inability to see a problem despite others persistently bringing it up.  It's why so many bipolar people refuse medication or quit taking it after they "feel better".  This can be unimaginably frustrating for loved ones, police, social workers & others, but equally so for the patient who legitimately doesn't perceive a problem within themselves.

Clear as mud?




*Slow Down. What IS Bipolar Disorder?

The 3 (Currently Accepted) Types of Bipolar Spectrum Disorder

BP Disorder is a spectrum of mood disorders that includes Bipolar I, Bipolar II and Cyclothymia in descending order of severity.  However most people don't fit neatly into these little boxes as the human brain is way more complex than that.  Many psychiatrists believe the bipolar spectrum goes way further, including types I-IV as well as Seasonal Affective Disorder (aka "Seasonal Depression") and PMDD or Premenstrual Dysphoric Disorder, a severe form of PMS.  The important takeaway is that it includes some degree of mania + depression at different times & is generally more influenced by external factors than is unipolar depression.  Mania doesn't occur in other disorders or as a standalone condition in psychiatry; it only exists in people on the bipolar spectrum which is important for diagnostic purposes.  That means it can't be induced with drugs or other triggers in a person who does not carry the bipolar gene(s).  

By contrast, unipolar depression is clinical depression with an absence of mania or hypomania.  It tends to exist in the families of bipolar patients & likely rides on the same genes, but it's generally easier to treat & carries a lower overall risk of suicide & accidental self-injury due to the lack of mania and all its attendant risks.  There are multiple types of unipolar depression as well:  major depression, atypical depression, dysthymia, post-partum depression, double depression & minor depressive disorder to name a few.  

Bipolar disorder is largely genetic & not a sign of weakness, "craziness" or some other character flaw.  The onset is typically later than in unipolar depression, often with a first episode occurring in the 20's or early 30's as opposed to adolescence or the early teen years.  It shares many characteristics with epilepsy & migraines in that changes of any kind, be they hormonal, changes in daylight/season, sleep habits, stress levels, drug/alcohol intake or other daily habits can trigger an episode.  Even positive changes like slowing down after a stressful/busy week can throw a bipolar brain into chaos.  And it's treated with many of the same anti-epileptic medications as these other 2 disorders.  




What Can Worsen Mania, If Anything?

Knowing the symptoms & triggers is half the battle.

Just as certain triggers can make depression worse, some activities and substances can aggravate mania in bipolar people.  SSRI antidepressants like Prozac, Zoloft, Paxil and Lexapro as well as SNRI's like Cymbalta & Effexor can worsen bipolar mania when taken without a mood stabiling agent.  Other drugs that may cause or worsen mania include amphetamines (Adderall, Ritalin, Phentermine) & cocaine; corticosteroids (Prednisone, Flonase); benzodiazepines (Xanax, Valium, Klonopin), anabolic steroids and some Parkinson's drugs.  Bright lights/loud noises, sleep deprivation, high levels of stress and events like loss of a loved one or divorce, seasonal changes, hormonal shifts like pregnancy/menopause & other big changes can trigger mania in some bipolar people.

In general, it's best to keep as regular a sleep/wake schedule as possible & get regular sunlight exposure (with sunscreen, of course) if you have this condition.  Regular cardio exercise, a healthy balanced diet, reducing stressors whenever possible & making time each evening before bed to unwind by avoiding blue light & loud noise so you can sleep is even more important for bipolar people than the general population for reasons you're about to see. 

Most episodes of postpartum psychosis "manifestations of bipolar disorder".

Because they're more sensitive to hormonal shifts, bipolar women tend to have worse PMS, PMDD, menopausal symptoms & post-partum depression (PPD), and they're also at elevated risk for a dangerous condition called Post Partum Psychosis (PPP).  Nearly all the mothers who kill their newborn infants are later diagnosed with this affliction, and many or most women with PPP are bipolar. 

This does NOT mean all bipolar women will harm their babies or develop the condition, but it is something to be aware of.  Symptoms of PPP include:  paranoia, visual or auditory hallucinations, severe confusion about things like the day or year, obsessive thoughts about your baby or hurting your baby, mania/depression or delusions (thoughts that are unlikely to be true).  This is why it's so vital to get on an effective medication combo right after giving birth & to reach out for help with the baby as much as necessary.

If you experience symptoms of PPD or PPP, seek help immediately.  These should be considered a medical emergency.




How Is Bipolar Disorder Treated?

Health effects of untreated bipolar disorder.

In addition to talk therapy & general health measures like those mentioned in the previous section, medication is vital for managing both mania and depression in bipolar disorder.  Meds used to prevent & manage mania include mood stabilizers like lithium, Depakene & Depakote; anti-epileptics like Lamictal, Tegretol, Topamax & Gabapentin & antipsychotics like Abilify, Rexulti, Vraylar, Latuda, Seroquel & Risperdal.  All of these are used with great success these days.  The vast majority of these meds can be taken with your antidepressant, though they shouldn't be combined with alcohol. 

Ask your prescribing doctor which one might be best for your particular situation & start with the lowest possible dose unless you're in a crisis situation.  Tell them if there are any side effects that especially concern you (i.e. - weight loss/gain; dry mouth, nausea) so they can choose the best fit.  Generally these drugs need to be taken long-term like your antidepressant.  While symptoms and episodes in bipolar disorder are cyclic, the disease itself is not considered "curable" and must be treated for the lifespan to avoid relapse.  Thankfully most of the meds mentioned above are very affordable as generics.

Physical illness rates in bipolar vs. unipolar vs. "normal" people.

Because medications affect everyone differently & may have unwanted side effects, it often takes some experimentation to find the right medication and/or dose for you, but doing so is vital for managing your condition in both the long and short term.  And treating bipolar disorder IS important not only for your mental health but your long-term survival.  In addition to an increased risk of suicide and substance abuse/addiction, untreated bipolar people are at elevated risk of heart disease, Type II diabetes, sarcopenia (bone disease), asthma, urinary tract infections, gastrointestinal disorders & dying on average 10 years earlier than the general population.  Among other awful things.  

Some of this could be due to genetic factors but it's also likely worsened by oxidative stress caused by the lifestyle habits of the disorder itself, such as lack of sleep, overworking, substance abuse, homelessness or the direct effects of things like anxiety or anger, which directly affect blood pressure & other bodily processes.  Indeed, people with more severe bipolar disorder almost always have indicators of more severe oxidative stress in the brain, which means it's likely a two-way street in terms of cause & effect.  Put simply:  the longer the condition is left untreated, the more severe it can become because you're doing physical damage to your brain cells (and heart & other organs) by not treating it.

This is Depressing.  Are There Any Upsides to Being Bipolar?

Yes, provided the condition is properly managed.  Bipolar people are often considered unique & creative and sometimes have higher than normal IQs, particularly in the area of verbal IQ and abstract reasoning.  The disorder is almost 10x more common in people in artistic fields than in the general population.  Some bipolar people can have an abundance of energy and motivation for projects, which can be useful in a work or academic environment provided they don't lose interest partway through.  These patients often find it easier to empathize with and help others because of their own sensitivity and struggles, and may have more strength or tenacity to deal with hard times due to past tribulations.  

Most importantly, bipolar disorder has a very high success rate in treatment which is not the case with all mental health disorders.  Around 80% of patients who consistently seek treatment are considered "well" or functional & can lead long and healthy lives.   💚

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***Antidepressants & Bipolar Meds That Can Be Safely Used During Pregnancy***

The information below is from LactMed, the largest & best-researched database on lactation & medication use on the web:

Safest Bipolar meds while nursing:  Risperdal, Zyprexa, Seroquel & Haldol.  These can be taken WITH your antidepressant.  Unlike antidepressants, these drugs don't have to build up in your system for weeks to feel effects.  However these 4 drugs can cause unwanted side effects in the mother such as weight gain, movement issues & sedation so they probably wouldn't be something you'd want to take beyond the post-partum period when symptoms were at their worst.  But take whatever you have to during that difficult time just to make it through & you can quit or switch later.  These meds are EXCELLENT for sleep--I know, I took Risperdal.  Tell your doc you want the absolute lowest dose available if side effects are a concern.

Here's what LactMed says about some other bipolar medications:

Abilify:  Limited information indicates that maternal doses of aripiprazole (Abilify) up to 15 mg daily produce low levels in milk. Aripiprazole can lower serum prolactin in a dose-related manner. Cases of lactation cessation have occurred, but cases of gynecomastia and galactorrhea have also been reported. Weight loss and poor weight gain have been reported in breastfed infants whose mothers were taking aripiprazole. Until more data become available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant.[1]

Depakote:  Valproic acid (Depakote) levels in breastmilk are low and infant serum levels range from undetectable to low. Breastfeeding during valproic acid monotherapy does not appear to adversely affect infant growth or development; however, and breastfed infants had higher IQs and enhanced verbal abilities than nonbreastfed infants at 6 years of age in one study.[1] A safety scoring system finds valproic acid possible to use during breastfeeding,[2] and a computer model predicted a relatively low infant exposure, consistent with literature reports.[3] If valproic acid is required by the mother, it is not a reason to discontinue breastfeeding.

     No definite adverse reactions to valproic acid in breastfed infants have been reported. Theoretically, breastfed infants are at risk for valproic acid-induced hepatotoxicity, so infants should be monitored for jaundice and other signs of liver damage during maternal therapy. A questionable case of thrombocytopenia has been reported, so monitor the infant for unusual bruising or bleeding. A rare case of infant baldness might have been caused by valproate in milk. Observe the infant for jaundice and unusual bruising or bleeding. Combination therapy with sedating anticonvulsants or psychotropics may result in infant sedation or withdrawal reactions.

Lamictal:  Breastfeeding during lamotrigine (Lamictal) monotherapy does not appear to adversely affect infant growth or development in most infants. Breastfed infants had higher IQs and enhanced verbal abilities than nonbreastfed infants at 6 years of age in one study.[1] Occasional adverse reactions have been reported in infants who receive lamotrigine in milk. Breastfed infants should be carefully monitored for side effects such as apnea, rash, drowsiness or poor sucking, including measurement of serum levels to rule out toxicity if there is a concern. Monitoring of the platelet count and liver function and infant serum concentrations before and after increases in maternal lamotrigine dosage might also be advisable. If an infant rash occurs, breastfeeding should be discontinued until the cause can be established. Infants of mothers taking 150 mg daily or less can undergo less extensive monitoring because they are unlikely to have measurable serum lamotrigine concentrations. If the mother requires lamotrigine, it is not a reason to discontinue breastfeeding. It is important to monitor maternal serum lamotrigine concentration after delivery and adjust the dosage accordingly, because maternal serum levels often increase after delivery.

Latuda:  Lurasidone (Latuda) is more than 99% bound to plasma proteins, so it is unlikely that the drug would be excreted into milk in sufficient amounts to affect a breastfed infant. Data from one mother-infant pair appears to support the poor excretion into milk and lack of effect on the breastfed infant. Until more data are available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant.[1]

Vraylar:  No information is available on the use of cariprazine (Vraylar) during breastfeeding. Until more data become available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant.

Lithium is not considered safe during breastfeeding.

And here are a few antidepressant options:

Zoloft, Paxil & Nortriptyline are considered the safest options when breastfeeding but here are some others:

Cymbalta:  Little published information is available on the use of duloxetine (Cymbalta) during breastfeeding; however, the dose in milk is low and serum levels were low in two breastfed infants. If the mother requires duloxetine, it is not a reason to discontinue breastfeeding. Expert opinion finds duloxetine acceptable to use during breastfeeding,[1] and a safety scoring system finds duloxetine use to be possible to use cautiously during breastfeeding.[2] An alternate drug that has been better studied may be preferred, especially while nursing a newborn or preterm infant. Monitor the infant for drowsiness and adequate feeding, weight gain and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs. Galactorrhea has been reported in women taking duloxetine.
     Infant Levels. An infant whose mother was taking oral extended-release duloxetine 60 mg daily was exclusively breastfed. On day 32 of life, a blood sample was obtained 4 hours after the previous nursing which was 8 hours and 15 minutes after the mother's previous dose. Duloxetine was undetectable (<1 mcg/L) in the infant's plasma.[4]  Cymbalta appears to be safer than its sister drug, Effexor, during breastfeeding.

Luvox:  Limited information indicates that maternal fluvoxamine doses of up to 300 mg daily produce low levels in breastmilk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months. If the mother requires fluvoxamine, it is not a reason to discontinue breastfeeding. A safety scoring system finds fluvoxamine use to be possible during breastfeeding.[1] One infant was reported to have an elevated serum level of fluvoxamine, but most who have been tested have undetectable serum levels. Another infant developed diarrhea, vomiting and stimulation after maternal initiation of fluvoxamine. A limited amount of long-term follow-up on growth and development has found no adverse effects in breastfed infants. Monitor infants exposed to fluvoxamine through breast milk for diarrhea, vomiting, decreased sleep, and agitation.  Luvox appears to be preferable to sister drug Prozac during breastfeeding.

To check a specific medication, visit   ---> THIS LINK <--- and enter the drug name in the "Search This Book" section.  This is a far more reliable site than Reddit or other random forums online.  It contains all kinds of drugs, not just psych meds.  The most important thing during the post-partum period is YOUR mental health and stability.  Most of these medications can be used during breastfeeding so long as you monitor the baby for excess sleepiness.  🩵

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