Bipolar Disorder: The Paradox of Diagnosis and Treatment

According to the National Institute of Mental Health, roughly 5.7 million American adults have bipolar disorder, a specific type of mood disorder. Mental disorders classified as mood disorders affect approximately 20.9 million Americans over the age of 18 every year. Approximately 11 people per 100,000 die by suicide in the United States, and more than 90 percent of these people have a diagnosable mental disorder (“The Numbers Count: Mental Disorders in America”). There is no cure for mood disorders, and having bipolar disorder means one must comply with daily, long-term medication routines. Even when medication works, people still feel the uncomfortable side-effects from medication plans. Bipolar disorder is difficult to treat and diagnose, and it is a paradox because even when treatment works, one still may not feel well and may not want to comply with, or be able to afford ongoing treatment plans.

 Bipolar diagnosis and treatment are a paradox because the disorder by definition has symptoms and behavioral changes that impede an individual’s ability to remain on treatment regimens. The inherent nature of bipolar disorder impedes the successful treatment of it because a change in one’s mood potentially causes changes in routines and treatment schedules. The National Institute of Mental Health website says that with bipolar disorder, the mood shifts anywhere from severely depressed (in a depressive episode) to overly happy or irritable (in a manic episode); or can be mixed, which is where behavioral changes indicate the presence of both manic and depressed mood (in a mixed episode). There may also be psychotic symptoms that occur with a severe major depressive episode or a manic episode (“Bipolar Disorder”). When one’s mood changes, they might change how they feel about their medication and whether they should continue with medication therapy. This happens even with bipolar people that are stable. Medications also cause side-effects that would make any “normal” person unhappy. Crazy Meds, a popular website on bipolar disorder says, “There are many reasons why we don’t want to be med compliant. The meds suck!” (“12 Steps to Stay On Drugs”). The author has bipolar disorder and says, “We have to fight with the side effects, we have to fight with the addiction to mania and we have the battle of the budget to pay for the damn things” (“12 Steps to Stay On Drugs”). He also says that people with the disorder more often remember the “fun-fun-fun manias,” and they don’t want to take medication because they want to be their “euphoric manic selves” (“12 Steps to Stay On Drugs”). For some people it is enjoyable to be manic, which makes treatment a paradox, because according to the manic person, there is nothing wrong with them.

The struggle is to find the best medication for each individual with all things considered, including cost. There are positive reviews of medications, but many people have to try several different medications before they find the right combination. Some people love their mood stabilizers. One Anonymous user on a Drugs.com discussion forum said, “Seen the best results in mood and energy level upon adding this drug two years ago. A huge relief after 10 years of struggling to find a medication regime that worked long-term with minimal side-effects” (“Reviews for Lamictal to Treat Bipolar Disorder”). This person finally found relief after struggling with medications for 10 years. Another reviewer, Louhead, wrote about how one medication finally worked, but he, too, had to try many other medications before he found one that worked. This person also addresses the issue of cost, stating that even when the right medication is found, it may be too expensive to stay on it. Louhead wrote:

I have been on Lamictal for almost 2 years. I've tried various anti-depressants to help stabilize my mood disorder, but those always seemed to make my depressive episodes worse. Lamictal gave me back my personality. I've recently lost my insurance, and cannot afford my Lamictal, and I've rapidly noticed my moods changing once again. It's a horrible feeling once I've discovered what it was like to not have constant mood changes.. Lamictal is a wonderful mood stabilizer! (“Reviews for Lamictal to Treat Bipolar Disorder”)

Although Louhead found a medication that worked, this drug is expensive without insurance covering it. Yet another Anonymous user posts how Risperdal finally worked, but it took years of trial and error to find the right one. This person wrote:

This medicine is the best thing that ever happened to me. I had tried several medicines over the years and nothing helped what I thought was stress and anxiety. After I had my baby at 27 I thought I was worse than ever and assumed I had Postpartum Depression. I was surprised to be diagnosed as bi-polar. The medicine worked right away and I have never been happier. I am a better person, mother and wife now. (“Reviews for Risperdal to treat Bipolar Disorder”)

There are many online reviews of medications that report positive aspects of bipolar medications but because no single pill is right for everyone, many people must try several different medications, often feel worse before they feel better, and they may not be able to afford long-term medication therapy.

Not only is bipolar disorder difficult to treat, it is also difficult to diagnose because there are many classifications of the disorder. The National Institute of Mental Health says there are different classifications of bipolar disorder depending on the severity of symptoms, the presence of manic episodes, and the length of time each mood persists. The Diagnostic and Statistical Manual of Mental Disorders (DSM) states the four classifications of the disorder are: Bipolar I, Bipolar II, Bipolar Disorder Not Otherwise Specified (BP-NOS), and Cyclothymic Disorder (Cyclothymia) (“Bipolar Disorder”). There are diagnostic criteria and characteristic symptoms that determine the type of bipolar disorder one has. People who have Bipolar I will have a manic or mixed episode that lasts at least seven days or a manic episode that requires hospitalization. With Bipolar I, depression also occurs for at least two weeks at a time during a major depressive episode. Additionally, manic or depressive episodes can have psychotic features. There must also be periods of time when behavior is considered normal (“Bipolar Disorder”). Bipolar II Disorder is similar to Bipolar I, except there are no full-blown manic episodes. There can be hypomanic episodes in Bipolar II where symptoms such as increased energy and activity level occur, but the episode lasts less than a week, the symptoms are less severe than symptoms of mania, and one does not require hospitalization (“Bipolar Disorder”). Bipolar Disorder Not Otherwise Specified (BP-NOS) is indicated when all criteria for Bipolar I and Bipolar II cannot be met due to severity of the symptoms, but mood changes occur nonetheless (“Bipolar Disorder”). Cyclothymic Disorder is mild and one will only receive this diagnosis if there are hypomanic episodes and mild depressive episodes that last at least two years, but no episode meets the requirements for diagnosing another type of bipolar disorder (“Bipolar Disorder”). Accurate diagnosis is important because the diagnostic criteria indicate the severity of the disorder and can be a good indication of how effective treatment will be (Long).

Because there are behavioral changes during each episode, in between episodes, and during times of wellness, making the initial diagnosis is difficult. Additionally, when a person feels well, they may not seek treatment or believe that their diagnosis is real. Feeling well during a hypomanic episode or symptom free period also causes breaks in treatment. The disorder works against itself, convincing the person that medication is not needed even when it is needed to prevent a full-blown manic episode or future episodes.

Bipolar disorder is also difficult to diagnose because the disorder changes over the course of one’s life and the symptoms may initially present as another disorder, such as major depression, attention deficit disorder (ADD), hyperactivity, or oppositional defiant disorder (ODD) (Griswold). In women, most often the first mood episode is a major depressive episode (Griswold). In pediatric cases, bipolar disorder may look more like ADD, hyperactivity, or ODD because younger people display more irritability, aggression and inability to sit still than classic manic-depressive symptoms (“Pediatric Bipolar Disorder”). In adolescents, the disorder also looks different and the symptoms could be a little more similar to adults, but it is still difficult to be certain at first (Griswold). Adults have more characteristic manic-depressive episodes that are separated by times of wellness (Griswold). The changing appearance of the disorder further complicates accurate diagnosis among different age groups.

 My experience with diagnosis and treatment of my own bipolar disorder is similar to what other people describe because after initial diagnosis it took about 3 years for me to feel somewhat stable.  I suffered through many side-effects of medications, and when I finally felt stable, I thought I no longer needed medication.  I was diagnosed with Bipolar I disorder in 2003, but I had a few major depressive episodes starting in 1999.  I was 24 years old and pregnant with my second child when I was diagnosed with bipolar disorder.  During diagnosis, I was experiencing a mixed episode:  I felt irritable, angry, sad, fatigued, withdrawn yet talkative, peaceful yet uncomfortable, and my mind was always overactive.  Mood changes occurred suddenly and drastically in one day.  For years before diagnosis, I experienced severe depression.  Later, even while on medication, I had manic episodes, depressive episodes, and mixed episodes.  One episode was severe enough to require hospitalization. 

            Medication was the best way to stabilize me even during my pregnancy, but doctors first had to determine that the benefits of medication treatment outweighed the risks of potential harm the medication may cause my baby.  My personal experience with medications is a good example of how many times medications need to be adjusted or changed before finding medication that works.  After my first major depressive episode, I tried Zoloft.  Zoloft caused a hypomanic episode, which is common when people do not yet have a bipolar diagnosis, but I did not recognize it as a hypomanic episode until many years later.  After the first few doses of Zoloft, I had difficulty sleeping, became more moody and irritable, became hypersexual, and started spending too much money.  I also had flu-like symptoms from the medication, but giving the medication a three week trial period was the only way to know if it was going to work.  I eventually realized that I was not feeling terribly sad, but I was not well either.  This medication did not work for me. 

            Over the next two years, I experienced more depressive episodes, and I also began experiencing hypomanic episodes.  I have tried Serzone, Paxil, Prozac, Wellbutrin, and Effexor as anti-depressants, and all of them caused hypomanic or manic episodes.  I tried them in various combinations and doses as my psychiatrist prescribed them.  In 2003, my psychiatrist put me on a mood stabilizer.  The first mood stabilizer I tried was Lithium, but it made me gain a significant amount of weight, and I felt foggy-headed all day.  I then tried Topamax, Lamictal, Abilify, and Risperdal for mood stabilization, later adding atypical antipsychotics to the medication cocktail, and that was what finally worked the best for me.  Other medications I tried are Seroquel, Buspar, and Clonzapam.  I am currently on Buspar, Risperdal, Lamictal, and Clonzapam.  All of these medications have wide-spread side-effects including possible worsening of depression, suicidal ideation, constipation, body aches, flu-like symptoms, headaches, dizziness, urinary problems, and sexual side-effects.  Some side-effects would eventually subside, but sometimes they never went away, and I had to decide whether I wanted to live with them.  Weeks could pass before any change occurred.  I also became less tolerant of medication changes when my symptoms were severe or when I was feeling euphoric from a manic episode.

            The various options to treat bipolar disorder make treatment options confusing and may lead to irregularities in treatment, which will further aggravate the disorder.  The most effective treatment option for Bipolar Disorder is “lifelong therapy with a mood-stabilizer (either lithium, carbamazepine, or divalproex / valproic acid,)” but there are other treatments including psychotherapy, environmental changes, natural supplements, and diet and exercise that can also help (Long).  In fact, research shows “the most effective treatment is a combination of supportive psychotherapy, psychoeducation, and the use of a mood-stabilizer (often combined with an antipsychotic medication” but psychotherapy alone does not work (Long).  These other approaches really need to be add-on or “adjunct” therapies rather than standalone therapies.  Medication is the most effective treatment because people with Bipolar Disorder have changes in their brain.  Studies suggest “the involvement of structural abnormalities in the amygdala, basal ganglia and prefrontal cortex” might cause bipolar disorder (Long).  Other studies indicate the disorder “is associated with abnormal brain levels of serotonin, norepinephrine, and dopamine” (Long).  Psychotherapy may also be effective but it does not treat the underlying physiological cause of the disorder.  Changes in environment, such as adopting a healthier lifestyle, will improve some symptoms of the disorder but not treat it completely (Long).  Alternative treatments are helpful when used in combination with traditional treatments (Bloom).  Diet and exercise are very effective in relieving stress and managing unwanted weight gain during drug therapy, but sticking to a diet and exercise routine is difficult for most people without bipolar disorder.  Because mood effects whether or not one chooses to exercise or diet, it is not always effective in treating bipolar disorder.  Religious or spiritual healing may assist in relieving stress as well (Bloom), but religion alone has not been proven to cure bipolar disorder (Long). 

Medications are absolutely necessary, but the disorder is puzzling because it entails emotional, mental, and physical instability.  At times, a person will feel great and think they no longer need medication.  According to Poore, the problem is that going off medication has severe physical side-effects and will likely cause a new episode, and going back on medication causes the worst initial side-effects to re-emerge as the body readjusts to it (“How to Stop Taking Crazy Meds Safely”).  This could make any logical person want to stop taking medication entirely.  It is logical to want to change medication if it makes you feel bad, and it is more likely that a person with bipolar disorder will not comply with medication treatment plans for this reason.  Additionally, Poore says the initial stage of a manic episode feels incredible:  there is an increased sense of well-being, heightened creativity and sensitivity, a feeling of empowerment, and an overall euphoric feeling that can be addicting (“12 Steps to Stay On Drugs”).  What sensible person would want to stop a euphoric feeling?  This is dangerous because with bipolar disorder, euphoria quickly changes to irritability and violent outbursts or criminal activity.  If the person does not receive medication quickly, there could be severe consequences.  The paradox is that medication dulls the senses, causes mental fogginess, and potentially makes one less productive overall so during a manic episode people are less likely to take medication (Poore).

            Medication itself causes a paradox for one diagnosed with bipolar disorder because it is meant to help, but according to the one who has the disorder, medication appears harmful.  Anti-depressants can cause manic behavior, but depression is unbearable to live with while mood stabilizers dull the senses.  Even stability itself feels like a trap to someone who is used to feeling high occasionally, and one hopes that someone with bipolar disorder has close friends or family to watch over them.  Other therapies help relieve the symptoms of bipolar disorder, but medication is the most effective treatment, allowing those with bipolar disorder to expect periods of time when no symptoms are present.  Luckily, despite having bipolar disorder and needing long-term medication treatment, one can still lead a successful life.

Works Cited

“Bipolar Disorder” National Institute of Mental Health. 16 October 2009. 28 April 2010. <http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml>

Bloom, Allie. Bipolar World. 1998-2009. 6 May 2010. <http://www.bipolarworld.net/Treatments/Alternatives/alt2.htm>

Griswold, Kim. “Management of Bipolar Disorder.” American Family Physician. 2000. 29 April 2010. <http://www.aafp.org/afp/20000915/1343.html>

Long, Phillip. “Bipolar I Disorder.” Internet Mental Health. 1995-2005. 28 April 2010. <http://www.mentalhealth.com/dis/p20-md02.html>

Parens, Erik. "Paper by Center Researchers Examines Broad Application of Bipolar Diagnosis in Children". The Hastings Center. 10 March 2010. 29 April 2010. <http://www.thehastingscenter.org/News/Detail.aspx?id=4567>

“Pediatric Bipolar Disorder” National Resource Center on ADIHD: A Program of CHADD. n.d. 6 May 2010. <http://www.help4adhd.org/treatment/coexisting/pedbipolar>

Poore, Jerod. Crazy Meds. 25 October 2003. 28 Apr 2010. <http://www.crazymeds.us/>

“Reviews for Lamictal to treat Bipolar Disorder” Drugs.com. 2000-2010. 6 May 2010. <http://www.drugs.com/comments/lamotrigine/lamictal-for-bipolar-disorder.html>

“Reviews for Risperdal to treat Bipolar Disorder” Drugs.com. 2000-2010. 6 May 2010. <http://www.drugs.com/comments/risperidone/risperdal-for-bipolar-disorder.html>

“The Numbers Count: Mental Disorders in America” National Institute of Mental Health. 16 October 2009. 29 Apr 2010. <http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml>