By Janice A. Youngwith

To address the alarmingly high rates of misdiagnosis and under-diagnosis of bipolar disorder, the National Mental Health Association (NMHA) is shifting the spotlight to help more Americans recognize the illness and urging those experiencing symptoms to seek help.

The need is highlighted in a new NMHA survey revealing that while more than 60 percent of people can identify bipolar disorder as a mental illness, more than two-thirds of those surveyed said they have little or no knowledge of it, pointing to gaps in public awareness and understanding.

Although there is no known cure for bipolar disorder, recently updated American Psychiatric Association (APA) guidelines stress that treatment can significantly decrease symptoms and the death rate often associated with the illness.

Bipolar Disorder:  Do You Know It?

Bipolar disorder, also known as manic depression, affects an estimated 2.5 million Americans.  It’s a chronic illness characterized by mood swings ranging from elation to despair, and the diagnosis can be challenging, according to Joseph Kut, M.D., chairing the psychiatry department at Northwest Community Healthcare, Arlington Heights.

“There’s no blood test, x-ray or physical test we can administer to make the diagnosis,” the assistant professor of psychiatry at Rush-Presbyterian-St. Luke’s Medical Center, says. “Because the mental illness involves a continuum of mood swings ranging from excessive highs and/or irritability to sadness and hopelessness with periods of normalcy in between, it can be difficult to diagnose.”

In fact, according to the NMHA, as many as 80 percent of individuals go undiagnosed or misdiagnosed for up to 10 years.  On average, patients receive 3.5 misdiagnoses and consult four physicians before receiving an accurate diagnosis.

If ignored, bipolar disorder can have serious, life-altering consequences that range from loss of employment and difficulty regaining it to drug and alcohol abuse and suicide.  Bipolar disorder has one of the highest mortality rates of all mental illness.

According to Dr. Kut, whose private practice includes offices in both Arlington Heights and Palos Heights, signs and symptoms vary and include:

Mania Symptoms

• Severe changes in mood – either extremely irritable or euphoric and elated
• Overly-inflated self-esteem and grandiosity
• Increased energy
• Decreased need for sleep – able to go with very little or no sleep for days without tiring
• Increased talking – talks too much, too fast or changes topics too quickly, cannot be interrupted
• Distractibility – attention moves constantly from one thing to the next
• Hypersexuality – increased sexual thoughts, feelings or behaviors, use of explicit sexual language
• Increased goal-directed activity or physical agitation
• Disregard of risk, excessive involvement in risky behaviors or activities.

Depressive Symptoms:

• Persistent sad or irritable mood
• Loss of interest in activities once enjoyed
• Significant change in appetite or body weight
• Difficulty sleeping or oversleeping
• Physical agitation or slowing
• Loss of energy
• Feelings of worthlessness or inappropriate guilt
• Difficulty concentrating
• Recurrent thoughts of death or suicide.

Although a specific genetic link to bipolar disorder has not been found, studies show that 80 to 90 percent of those who suffer from bipolar disorder have relatives with some form of depression.  NMHA experts say it also is possible that some people may inherit a tendency to develop the illness, which then can be triggered by environmental factors such as distressing life events. 

The presence of bipolar disorder indicates a biochemical imbalance, which alters a person’s moods. The imbalance is thought to be caused by irregular hormone production or a problem with certain chemicals in the brain called neurotransmitters that act as messengers to nerve cells.

Treatment focusing on combating symptoms of depression, mania and a combination of both is critical for recovery, according to Mark Lerman, M.D., director of clinical research at Alexian Brothers Behavioral Health Hospital, Hoffman Estates.

While antidepressants and mood stabilizing medications are used to battle biological factors, experts say psychotherapies designed to help patients and families better understand and manage the disorder and support from family, friends and peers are important.

“Current treatments all offer hope,” the clinical associate professor of psychiatry at Loyola University Medical Center, states. “But thanks to research and many new mood stabilizing and antipsychotic medications limiting unpleasant side effects, quality of life is even better.”

Dr. Lerman, who has been in practice for 15 years and focused on research for six years, says cognitive slowing, hair and memory loss, weight gain and sedation have all been reported by patients using traditional antipsychotic medications.

Lithium, effective in controlling mania in 60 percent of all individuals with bipolar disorder, is one of those medications with long-term repercussions.

“While effective in short-term usage, some mood stabilizing medications like lithium can have adverse effects over time, resulting in nasty tremors, an unsteady gait, gastrointestinal upset, weight gain and both thyroid and kidney problems,” he states. 

Newer antipsychotic medications currently being prescribed and including Risperdal, Zyprexa and Abilify, can be used with fewer side effects and promise to serve as a basis for ongoing pharmacologic development.

“Studies show all three of these antipsychotics effective, user-friendly and easier to take,” Dr. Lerman notes. “Atypical neuroleptics like Zyprexa (olanzapine) also are being studied in relation to bipolar disorder. We continue to evaluate newer formulations of anticonvulsant seizure medications like Depakote (divalproex sodium) and Tegretol (carbamazapine) as biochemical and psychopharmacological research evolves.”

On The Not-So-Distant Horizon

Research thrusts put the spotlight on other promising atypical neuroleptics like Seroquel and Abilify or anticonvulsants like Lamictal and Topamax in line for FDA evaluation and approval. Calcium channel blockers and other medications seeking to modulate the endocrine system may offer hope for those suffering bipolar disorder.

“It’s a lifelong process,” admits Dr. Kut. “Moods can be stabilized and treatment can help reduce the extremes of mania and depressive episodes. However, it’s not always a simple process.” 

Dr. Kut adds that a diagnosis of bipolar disorder doesn’t necessarily mean isolationism and an inability to function.

“Throughout history, some of our most famous political leaders, artists and philosophers like Thomas Jefferson, Winston Churchill, Abraham Lincoln and Vincent Van Gogh also suffered from the disorder.”

Not Just An Adult Issue

Once thought to typically emerge in late adolescence or early adulthood, new studies indicate manic-depressive illness can begin in childhood.

“Depression and bipolar disorder are being seen in younger adolescents, and even children whose moods include a rollercoaster of emotions,” notes Kenneth Phillips, M.D., psychiatrist currently serving director of the adolescent day program at Central DuPage Hospital, Winfield. “Primarily a disorder of mood presenting with more discreet episodes in older teens and adults, children with the disorder tend to experience a more rapid series of continuous ups and downs, ranging from erratic happiness in the morning to depressed sullenness, irritability and less stable depressing later in the day.”

Experts say some 2.5 million American adults, or about one percent of the population in any given year, have bipolar disorder. Numbers vary on predictions involving children and teens.

“Many experts believe the diagnosis can be made in preschool and even among toddlers and infants," Dr. Phillips cautions. “It’s much more common to see a diagnosis made in the early elementary school years.”

According to Dr. Phillips, who has been in practice in Wheaton for 17 years, bipolar disorder is a serious mental illness characterized by recurrent episodes of depression, mania and mixed symptom states. The manic-depressive illness causes extreme shifts in mood, energy and functioning.  Overly energized, disruptive, and reckless periods typically alternate with periods of sadness, withdrawal, hopelessness and other depressive symptoms.

“Unlike normal states of happiness and sadness, bipolar symptoms of manic-depression can interfere with school performance, family relationships, peer interactions and other day-to-day activities,” he states. “Research findings, clinical experience and family accounts provide evidence that bipolar disorder can occur in both children and adolescents, with earlier onsets typically more depressive.”

Difficult to recognize and diagnose in young patients, bipolar disorder doesn’t follow the same clear-cut lines for diagnosis as it does for adults. Symptoms often are masked by or closely resemble other common childhood-onset mental health disorders, or symptoms can be mistaken for the normal and sometimes volatile emotions of children and teens.

According to Phillips, the largely biological illness needs to be treated aggressively, especially among its youngest sufferers.

“If any family history of the disorder is involved, parents should be especially vigilant not to miss signs in their kids,” Dr. Phillips states. “So much can be done in terms of addressing symptoms.  Bipolar disorder does progress and if left untreated or improperly treated, symptoms will become worse. The good news is that the intense and disabling symptoms of bipolar disorder often can be relieved through treatment involving combinations of psychotherapy and with medication.”

Mood stabilizers such as valproate and lithium, anti-anxiety medications including non-addictive tranquilizers such as Risperdal and low-dose anti-depressants such as Zoloft and Lexapro, often used individually and in combination, are considered frontline medications for treating children and teens with bipolar disorder.

“Education also is a huge piece of the puzzle,” Dr. Phillips cautions. “It’s important for parents to better understand the disorder, learn not to take things so personally and develop strategies for structure and setting clear guidelines, expectations and consequences. Accommodations can be made at school through 504 and individual education plans. And, both teens and children can benefit from group and individual therapies designed to enhance self-esteem, friendship and acceptance.” 

Experts caution that symptoms of mania and depression in children and teens may manifest themselves through a variety of different behaviors. When manic, teens as compared to adults, may be more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. When depressed, teen complaints may include headaches and muscle aches, tiredness, frequent school absence, poor performance, running away from home, irritability, unexplained crying, social isolation, poor communication and extreme sensitivity to rejection and failure.

“Other manifestations could include alcohol or substance abuse and conduct problems,” Dr. Phillips adds. 

NIMH experts caution that existing evidence indicates bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of mental illness than older adolescent and adult-onset bipolar disorder. When the illness begins before or soon after puberty, it often is characterized by continuous, rapid cycling, irritable and mixed symptom state, often co-occurring with disruptive behaviors, like attention deficit/hyperactivity disorder (ADHD) or conduct disorder.

In contrast, later adolescent-onset bipolar disorder tends to begin suddenly, often with a classic manic episode, and forms a more episodic pattern with relatively stable periods between episodes. 

“Any child or teen who appears depressed and exhibits ADHD-like symptoms that are very severe, with excessive temper outbursts and mood changes should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder, especially if there is a family history of the illness,” Dr. Phillips explains. 

“Despite treatment advances and ongoing research, the stigma of mental illness isn’t something which will disappear in the near future,” says Jan Holcomb, executive director, Mental Health Association in Illinois. “Mental illness can affect people of any age. Including young children, teens, adults and the elderly. There is a national search for answers and a long-term commitment to national basic behavioral research which we hope will point to a practical payoff and ultimately to recognition, treatment, cure and acceptance.”