Bipolar affective disorder involves episodes at both ends: periods of elevated, accelerated mood, and periods of depression. It is frequently diagnosed late, because people seek help during the depression and not during the elevation, and the elevation is what distinguishes the condition.
Islamic Medical Centre provides psychiatric assessment and treatment for bipolar disorder in Islamabad, including inpatient admission during acute mania, when insight is often absent and risk is at its highest.
Recognising mania and hypomania
During an elevated episode the person usually does not feel unwell. They feel better than usual — energetic, capable, unusually confident — which is exactly why they do not seek help and why they resist the suggestion that anything is wrong. The family sees the problem well before the patient does.
- Sharply reduced need for sleep, without the expected tiredness
- Rapid speech, jumping between topics, difficult to interrupt
- Inflated confidence, or beliefs about ability, wealth or mission that are out of proportion
- Spending far beyond means, or giving money away
- Uncharacteristic risk-taking, including sexual and financial
- Irritability and anger when contradicted, often more prominent than elation
- In severe episodes, psychosis — delusions and hallucinations
The depressive side
Bipolar depression looks much like other depression from the outside, and this is where most patients present. It matters clinically because the treatment differs: an antidepressant given alone to someone with bipolar disorder can trigger a switch into mania or accelerate the cycling between episodes.
This is the principal reason that a full history — including asking specifically about periods of reduced sleep, elevated energy and uncharacteristic behaviour — is taken before starting treatment for what appears to be straightforward depression. Family members are often better informants here than the patient, because the elevated periods were not experienced as illness.
Substance use and bipolar disorder
Substance use is common in bipolar disorder and complicates it in both directions. Stimulants can precipitate or worsen mania and can produce a picture almost identical to it, and alcohol is frequently used during depressive periods.
Distinguishing a manic episode from stimulant intoxication requires knowing what has been taken and observing what persists once it has cleared. Where both a mood disorder and a dependence are present, both are treated together rather than sequentially.
How treatment works
Treatment has two parts that are easy to confuse: settling the acute episode, and preventing the next one. The second is the part patients most often abandon, and it is the part that determines the long-term course.
- Psychiatric assessment including a full history of previous episodes, taken from the family where necessary
- Mood stabilising medication, which is the foundation of both acute and preventive treatment
- Antipsychotic medication during acute mania or where psychosis is present
- Inpatient admission during severe episodes, when judgement and insight are impaired
- Psychoeducation for the patient and family on recognising early warning signs
- Attention to sleep, which is both an early warning sign and a trigger in its own right
- Long-term follow-up, because this is a relapsing condition managed over years
A specific warning about valproate
Sodium valproate is an effective mood stabiliser and it carries a particular risk that must be stated plainly: taken during pregnancy it causes serious birth defects and developmental problems in a substantial proportion of exposed pregnancies. It should not be used in women who could become pregnant unless there is no suitable alternative and effective contraception is in place.
Any woman of childbearing age prescribed this medicine should have been told this explicitly. If you are taking it and were not, raise it at your next appointment rather than stopping it on your own — abrupt cessation of a mood stabiliser carries its own risk of relapse.
Why medication continues after recovery
The commonest cause of relapse is stopping treatment while well. The reasoning is understandable: the person feels normal, dislikes the side effects, and concludes the medicine is no longer needed. Bipolar disorder is a relapsing condition, and the medication is preventing the next episode rather than treating a current one.
Where medication is genuinely causing problems, the answer is to review and adjust it rather than to stop it silently. Families should know that a patient quietly discontinuing treatment frequently precedes a relapse by several weeks, which is enough time to act if anyone notices.
Frequently Asked Questions
- How is bipolar disorder different from depression?
- Bipolar disorder involves episodes of elevated or irritable mood with reduced need for sleep and uncharacteristic behaviour, alongside depressive episodes. Depression alone has no such elevated periods. The distinction matters because treatment differs substantially.
- Why was my relative only diagnosed after years?
- Because people seek help during depression, not during elevation, and the elevated periods are frequently remembered as good times rather than as illness. Diagnosis often depends on a family member describing episodes the patient did not experience as abnormal.
- Can antidepressants make bipolar disorder worse?
- An antidepressant given alone, without a mood stabiliser, can trigger a switch into mania or accelerate cycling between episodes. This is why a full history is taken before treating apparent depression.
- Does mania require admission?
- Severe mania frequently does. Insight is usually absent during an acute episode, judgement is impaired, and the financial, social and physical risks are at their highest. Admission also allows sleep to be restored, which is central to settling the episode.
- Is valproate safe for women?
- Valproate causes serious birth defects and developmental problems when taken in pregnancy and should not be used in women who could become pregnant unless there is no suitable alternative and effective contraception is in place. Discuss it with your psychiatrist rather than stopping it yourself.
- How long does treatment continue?
- Long-term. Mood stabilising medication prevents future episodes rather than treating a current one, so it continues after recovery. Stopping while well is the most common cause of relapse.
- What are the early warning signs of a relapse?
- Reduced need for sleep is usually the earliest and most reliable. Increased talkativeness, new projects begun at pace, increased spending and irritability commonly follow. Recognising the individual pattern early is a core part of treatment.
- Can someone with bipolar disorder and an addiction be treated together?
- Yes, and they should be. Substance use both mimics and worsens mood episodes, and treating either alone tends to fail. Both are addressed in one plan.