Manic depression is a mood disorder that causes people to have extremely high and low moods. People with this disorder experience certain periods of happiness or sadness or both. Because of the frequent mood swings between extreme happiness and extreme sadness, the condition is also referred to as “bipolar disorder”. The hallmarks of manic depression comprise sudden episodes of depression or mania or both. Although it cannot be completely cured, it can be easily managed with therapy and medication.
What Is Manic Depression?
Manic depression, also known as Bipolar disorder, is a mood disorder characterized by periods of depression followed by periods of abnormal mood elevation for a period of time. It causes severe mood swings with periods of intense emotional highs or elevated moods, known as mania or hypomania, and periods of low moods or depression. A 2018 study 1 elaborates “Bipolar affective disorder (bipolar) is a multicomponent illness involving episodes of severe mood disturbance, neuropsychological deficits, immunological and physiological changes, and disturbances in functioning.”
The depressive phases feature depression, while the elevated moods swing between severe “mania” and less-severe “hypomania”. These episodes are separated by periods of ‘uncategorized’ symptoms that fail to meet diagnostic criteria.
Read More About Bipolar Disorder Here
Understanding Manic Depression
Manic depression or bipolar disorder is essentially spectrum disorders occuring on continuum. These have been associated with serious medical and psychiatric comorbidity, early mortality, high levels of functional disability, and compromised quality of life. These are also related to a range of mental health issues, such as anxiety disorders, personality disorders, eating disorders, substance abuse disorders, self-harm, and suicide ideation and attempt.
Research suggests that this chronic disorder is experienced first in early adulthood, but onsets can occur in childhood or in older age. The typical onset is between 18 and 44, with higher rates between 18 and 34 than 35 and 54. Findings in a 2006 study 2 suggest that bipolar I disorder starts on average at 18 years and bipolar II disorder at 22 years.
Studies situate the epidemiology of this mood disorder to a lifetime prevalence of around 1% for bipolar type I in the general population. A large cross-sectional survey 3 of 11 countries found the overall lifetime prevalence of bipolar spectrum disorders was 2.4%, with a prevalence of 0.6% for bipolar type I and 0.4% for bipolar type II. Studies 4 alarmingly show that more than 6% of the afflicted die through suicide in the two decades after diagnosis.
Read More About Eating Disorders Here
Types Of Manic Depression
Bipolar disorders can be primarily categorized into two subtypes which are mentioned below:
1. Bipolar I Disorder (BD-I)
The first type in the bipolar spectrum disorder, BD-I, is characterized by the occurrence of at least a singular manic episode—with or without psychotic features or mixed symptoms. It also conforms to the classic construct of manic-depressive illness involving depressive episodes, psychosis, and manic stages (from hypomania to full-blown mania) in different patients.
2. Bipolar II Disorder (BD-II)
The second type in the bipolar spectrum disorder, BD-II, is characterized by the occurrence of at least a singular episode of hypomania accompanied by one episode of major depression.
A third subtype of bipolar disorder, cyclothymia, is listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and the International Classification of Diseases (ICD-11). Patients with cyclothymia experience hypomanic episodes with periods of depression. However, neither the experienced hypomania nor depression meet the criteria of severity that characterize BD-I and BD-II.
Read More About DSM 5 Here
Bipolar I Disorder vs Bipolar II Disorder
Clinical convenience 5 differentiates between BD-I and BD-II. The necessary feature of bipolar I disorder involves the occurrence of at least one lifetime full-blown manic episode, with or without a history of major depressive episodes. In contrast, bipolar II disorder requires at least one hypomanic and one major depressive episode.
Both manic and depressive symptoms are defining features of bipolar spectrum disorders. The episodes featuring both are enduring, disabling, and frequent over a patient’s lifetime. Clinical convenience emphasizes the frequency and duration of manic episodes in BD-I. In BD-II, the frequency and duration of depressive episodes are considered more important. In fact, depressive episodes typically exceed manic/hypomanic episodes in duration and frequency in both bipolar I and II disorders. Yet, there is a scarcity of evidence to suggest that depressive symptoms and severity of both subtypes differ. However, in psychiatry, it is believed that the chronicity of illness is typically greater in BD-II than BD-I.
Symptoms Of Manic Depression
The generalized symptoms in bipolar disorders get reflected in phases experienced by the afflicted.
1. Phases Of Occurence
In manic depression, both manic and depressive symptoms are defining features. The episodes featuring both are enduring, disabling, and frequent over a patient’s lifetime. Patients may also display mixed episodes as well as episodes with comorbid conditions. According to one study, 6, “rapid cycling” in manic depression is defined as having at least 4 or more mood episodes in a 12-month period. These mood episodes can be manic, hypomanic, or depressive, but they must meet all of the diagnostic and duration criteria.
1. Manic episodes
Manic episodes involve mental and behavioral disorders characterized by altered energy levels, moods, and patterns. A person with bipolar disorder, during a manic episode, displays overactive and aggressive behavior, thought and speech disturbances, unrealistic expansiveness of mood, and vegetative symptoms. A full-blown manic episode usually includes experiences associated with acute and delirious mania and lasts for weeks or (3–6) months.
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2. Hypomanic episodes
Hypomania is the mildest form of mania, with symptoms such as insomnia, irritability, poor judgment, and euphoria. It is associated with increased productivity and creativity. Hypomanic episodes are common in patients with BD-II and cyclothymia.
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2. Depressive episodes
Considered to be the earliest symptom upon onset, depressive episodes in bipolar disorders are characterized by persistent feelings of sadness, anger, irritability, loss of concentration, erratic sleep schedules, fatigue, suicide ideation, etc. Manic or hypomanic episodes often last two weeks longer than depressive episodes.
3. Mixed affective episodes
Mixed affective episodes in bipolar disorder comprise symptoms of simultaneous episodes of both mania and depression. Such episodes are further influenced by anxiety disorders, eating disorders, substance abuse, and suicidal instincts.
Read More About Anxiety Here
4. Comorbid conditions
Coexisting psychiatric conditions and physical ailments add to the chronicity and impair the prognosis in cases of bipolar disorders. These conditions include, but are not restricted to, phobias, menstrual disorders, anxiety disorders, eating disorders, substance-use disorders, substance-use disorders, etc.
2. Presentation Of Symptoms
Manic depression manifests in a large number of physical and behavioral ways:
1. General appearance
People afflicted with bipolar spectrum disorders are erratic and hyperkinetic or hypokinetic. They dispositionally display irritability, negligence of social propriety, garish attires, and unnatural bouts of euphoria or depressive behavior.
2. Mood and affect
In manic episodes, they appear unusually elated or unhappy (in depressive episodes). In the former, the impact is heightened, extreme, and intense lability expressed in hyperkinesis. In the latter, hypokinesis is prevalent, accompanied by a congruent affect.
The afflicted display restlessness and irritability in speaking skills. During experiencing a manic episode, the patient displays rapid, incessant, and disjointed production of speech. In a depressive episode, speech and reciprocity are both soft and slow.
Mood-congruent and mood-incongruent behaviors (comprising delusions, hallucinations, negative emotions, etc.) are present in both depressive and manic episodes.
5. Thought process and content
The patient, in the manic phase, displays illogical condensations, flight of ideas, easy distractibility, delusions of grandeur, lack of concentration, etc. Depressive episodes come with negative ruminations, particularly suicidal thoughts in severe cases.
6. Sensorium and cognition
These factors vary in orientation, especially in reference to time, person, place, and the chronicity of the illness. Manic patients may display intact memory, with impaired orientation and memory only occurring during full-blown manic episodes. Depressed patients mostly show signs of neurological degeneration and serious impairment in memory and cognition.
7. Judgment and insight
Impaired judgment and narrow insights are distinctive features of people afflicted with bipolar disorders.
People with bipolar disorders, due to impaired memory and cognition, are considered unreliable as sources of information or reference. They display obsession over selective remembered aspects and overemphasize facts, processes, events, etc.
9. Impulse control
Impulse control is weak in both manic and depressive phases. In both phases, the patients display avolition, abulia, aggression, and threatening assaultive tendencies. There is a significant lapse in attentional and executive capabilities. Suicide ideation and execution form parcels of patients with chronic manic depression. Circadian rhythm desynchronization associated with bipolar disorder causes volatile physiological changes in the afflicted.
Causes Of Manic Depression
Bipolar disorder is a multifactorial illness with uncertain etiology. A 2006 study states “There is not a single hypothesis that unifies genetic, biochemical, pharmacological, anatomical, and sleep data on bipolar disorder.” Roughly, the causes for the bipolar disorder spectrum can be attributed to the following:
1. Biological Factors
A number of biological factors lay the setting for bipolar disorders, some which are mentioned below:
1. Genetic factors
Bipolar disorders have the highest genetic link to all psychological disorders. Behavioral genetic studies suggest that many chromosomal regions and candidate genes are related to bipolar disorder susceptibility. A 2009 study 7 testifies that the risk of bipolar disorder is almost ten-fold higher in first-degree relatives of those with bipolar disorder than in the general population.
Multiple family studies involving monozygotic twins have confirmed the genetic factor in bipolar disorders, citing the concordance rates at 70-90% in monozygotic twins. Other studies show that the risk of bipolar disorder is 10-25% when one parent has a mood disorder. A 2017 research 8 found that genetic influences accounted for 73–93% of the risk of developing the disorder, indicating a strong hereditary component. The overall heritability of the bipolar spectrum has been estimated at 0.71.
Read More About Genetics Here
Research 9 reveals that the prefrontal cortex, anterior cingulate cortex, hippocampus, and amygdala are considered important areas for emotion regulation, conditioning of responses, and behavior response to stimuli. A 2018 meta-analyses of structural MRI studies showed that, in people with bipolar disorders, certain brain regions (the left rostral anterior cingulate cortex, fronto-insular cortex, ventral prefrontal cortex, and claustrum) are smaller, whereas other regions (lateral ventricles, globus pallidus, subgenual anterior cingulate, and the amygdala) are larger.
3. Structural and functional changes in the brain
A 2018 study 10 found that people with bipolar disorder have higher rates of deep white matter hyperintensities. Studies into abnormal hyperintensities in the subcortical regions in bipolar disorders indicate recurrent episodes and show neurodegeneration. Patients with severe depression or a family history of mood disorder show increased glucose metabolism in the limbic region, with decreased metabolism of the anterior cerebral cortex.
4. Biogenic amines
Research implicates dysregulation of neurotransmitters (dopamine, serotonin, and norepinephrine) responsible for mood cycling to be inherent in bipolar disorders. For instance, decreased levels of serotonin-byproducts are present in the cerebrospinal fluid of patients during both the depressed and manic phases. Due to the tendency of dopamine agonists to trigger mania in persons with bipolar disorder, increased dopaminergic activity has been theorized in manic episodes.
5. Second messengers
Research implicates dysfunctioning of nucleoproteins and second messengers regulating neuronal membrane channels to be inherent in bipolar disorders.
6. Hormone regulation imbalance
Studies show that adrenocortical hyperactivity and a number of other hormonal disorders are associated with the setting of BD. Chronic stress reduces neurokinin brain-derived neurotrophic factor (BDNF), impairing neurogenesis and neuroplasticity. Growth hormone is released in response to dopamine and norepinephrine stimulation. Its release is inhibited by somatostatin. Increased CSF somatostatin levels and adrenocortical hyperactivity are observed during manic episodes in BD.
7. Immunological factors
Research finds that chronic elevation of cytokines and interleukins are associated with clinical severity in bipolar disorders.
2. Neurological Factors
Bipolar disorders may occur as a result of or in association with a neurological condition or injury, such as traumatic brain injury, HIV infection, stroke, multiple sclerosis, porphyria, and temporal lobe epilepsy.
3. Psychosocial/Environmental Factors
Psychosocial factors are significant players in the development and course of bipolar disorder. Relationships, disabilities, stressful life events, harsh ‘living’ environments, irregular schedules, substance abuse, experiences of abuse and trauma, etc. make individuals vulnerable to bipolar disorders. A 2021 study states, “A significant life stressor can lead to neuronal changes such as neurotransmitter levels, synaptic signaling alterations, as well as neuronal loss. This is involved in both the initial episode of the mood disorder and the recurrence of subsequent episodes.” It has also been discovered that people who have comorbid psychiatric disorders (such as histrionic, obsessive-compulsive, or borderline personality traits, for example) are more prone to the onset of BD.
In acute management, the first step toward the preliminary diagnosis of BD is a meticulous differential screening of its symptoms. This should define the patient’s physical and emotional state, treatment history and response, inclination towards treatment, comorbidities, cognitive impairments and suicide risks, and chronicity of the BD. Case-finding tools comprise the Mood Disorder Questionnaire (MDQ) and the Composite International Diagnostic Interview (CIDI), My Mood Monitor (M3), etc. Laboratory tests on a case-by-case basis (such as head imaging and other imagings, urine or blood toxicology, a complete blood count (CBC), serum chemistries, electroencephalograms (EEGs), etc.) should be employed to confirm the biophysical markers in the symptomatology of BD.
Post diagnostic evaluation, steps should be taken to ensure the safety of the patient and the people at close proximity, as well as achieve clinical and functional stabilization. In the most severe cases, referrals for hospitalization and/or institutionalization should be administered.
Treatment methods in the bipolar disorder spectrum involve pharmacological and psychological techniques that aid the effective management of the long-term course of what is deemed an incurable mood disorder.
The patients suffering from manic depression should avail the benefits of psychotherapy to manage it in the long term. Therapy 11 has been found most effective in the treatment of BD, 12 when punctually adhered to for a long tenure and accompanied by pharmacological treatment. This is known as combination therapy. Some of the common therapies used for treatment of manic depression include:
1. Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy (CBT) 13 is a psycho-social intervention aimed towards the symptomatic reduction of mental health disorders. It focuses on the challenging and changing cognitive distortions and behaviors, the improvement of emotional regulation, and the development of personal coping strategies that target solving current problems.
Read More About Cognitive Behavioral Therapy (CBT) Here
2. Family-focused therapy
Family-focused therapy 14 involves psychotherapy carried out for people in intimate and/or familial relationships. Such therapy aims at personal development and seeks to change the terms and dynamics of interaction amongst the counselee participants.
3. Interpersonal and social rhythm therapy
Interpersonal and social rhythm therapy (IPSRT) 15 is an intervention for people with bipolar disorders. It focuses on stabilizing the circadian rhythm disruptions, thereby increasing quality of life, reducing mood symptoms, and helping prevent relapse into manic depression. It is drawn from the principles of interpersonal psychotherapy.
4. Group psychotherapy/support groups
Group psychotherapy or group therapy 16 is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The logic of group therapy involves the helping processes that take place in a group, including support groups, skills training groups, and psychoeducation groups.
5. Jungian therapy
Jungian therapy 17 involves therapeutic practices aimed at exploring the unconscious mind of the patient and the emotions of acute sadness rooted in it. Such practices often involve an exploration of dreams, symbols, and myths that the patient is acquainted with.
6. Self-help therapeutic techniques
Self-help techniques 18 in bipolar disorders have shown great promise. These include –
- Educating oneself about the fundamentals of the bipolar disorders
- Monitoring one’s moods and their changes
- Developing a healthy lifestyle
- Developing a well-being plan and a suicide-support plan
- Adhering to therapy and medication
- Developing a strong support group and becoming more involved socially
- Abstaining from intoxicants and other frequently abused substances
- Managing stress
- Adhering to exercise programs, yoga, etc.
- Developing a new hobby and indulging in walks, journaling, art, etc.
7. Electroconvulsive therapy
Electroconvulsive therapy (ECT) 19 is a psychiatric treatment in which a generalized seizure is electrically induced to manage refractory mental disorders. A usual course of ECT involves multiple administrations, typically given two or three times per week, and the suffering symptoms disappear.
Studies show that acute pharmacologic treatment results in greater symptom control and symptom reduction in manic depression. Alongside psychosocial approaches, concurrent medication treatment is selected based on the characteristics of the mood episode and on the patient’s general physical and mental health statuses. A lack of response or an adverse effect to a medication prompts a change in dose or a switch to another medication class. A 2014 study 20 shows that approximately 1 in 5 bipolar patients requires 4 or more concomitant pharmacologic medications to control their symptoms. High rates of co-medication use are particularly common in patients with a high burden of depressive symptoms and at elevated risk for suicidality.
Pharmacological treatment in bipolar disorders involve a number of medications:
1. Mood stabilizers
The most common mood stabilizer in BD involves lithium salts that impact regulation of gene expression for growth factors and neuronal plasticity, inhibition of inositol monophosphatase, and modulation of G proteins. Lithium is also associated with reduced occurrence of suicide. A 2014 study reveals that lithium facilitates a moderate improvement in symptoms in 40%–80% of patients after 2 to 3 weeks of treatment for acute mania. Prolonged use of lithium 21, however, has proven to be harmful and should depend on doctor’s recommendations.
For mood stabilization, a number of anticonvulsant drugs are used, namely, valproic acid, carbamazepine, lamotrigine, and zonisamide. Other anticonvulsants currently being researched include phenytoin, levetiracetam, pregabalin and valnoctamide.
3. Atypical antipsychotic drugs
Antipsychotics are the most effective during manic episodes in bipolar disorder. Second-generation or atypical antipsychotics have emerged as effective mood stabilizers that can be used both as single-agent and adjunctive treatments. The conventional atypical antipsychotic drugs include aripiprazole, olanzapine, quetiapine, paliperidone, risperidone, and ziprasidone.
4. New treatments
Newer mood stabilizers 22 have been employed to treat manic depression, such as benzodiazepines, calcium channel blockers, L-methylfolate, and thyroid hormone. As for supplements to medication, agents such as omega-3 fatty acids, ketosis, and cannabis, etc. are used for the treatment of BD.
Antidepressants have been used as combination drugs with mood stabilizers to treat manic depression. A 2014 study revealed that quetiapine monotherapy, olanzapine in combination with fluoxetine, and lurasidone monotherapy or in combination with lithium or Valproate is the only medication approved by the US Food and Drug Administration (FDA) for bipolar I depression, while only quetiapine is approved for bipolar II depression.
6. NMDA-receptor antagonists
Research 23 shows that administration of an N-methyl-d-aspartate–receptor antagonist or ketamine to BD helps reduce symptoms of hypomania and suicidal inclination.
7. Dopamine agonists
The dopamine D3 receptor agonist pramipexole is found to be highly effective in the treatment of manic depression.
Read More About Dopamine Here
3. Research, Psychoeducation, And Awareness
Like any other mental disorder, the long-term management of bipolar disorder involves heavy familial and community involvement and psychoeducation. The patient should acquaint himself with the fundamentals about BD from readily available information pamphlets in government, non-government, and health organizations. The patient and his family and friends should seek information about utilization and value of mental health services. Exhaustive multidisciplinary research should also be conducted into the diagnosis, maintenance therapy, long-term monitoring, and medication of patients with manic depression.
Manic depression is a complex psychiatric disorder to manage, even for psychiatrists, because of its many episodes and comorbid disorders and nonadherence to treatment. Misdiagnosis leads to exorbitant costs and mistreatment. It is incurable, but it can be managed in the long-run. Symptomatic recovery rates and relapse rates are difficult to garner. However, more pharmacologic options are now available, and psychoeducation, self-help, and psychotherapy (individual, couple, and family) interventions are frequently utilized to treat BD.
Manic Depression At A Glance
- Manic depression, often known as bipolar disorder, is a group of mood disorders that cannot be cured but can be effectively treated over time.
- Manic depression progresses in stages, with episodes of mania, hypomania, depression, mixed symptoms, or coexisting conditions.
- It is associated with a number of physical and mental disorders and comorbidities.
- It also causes high levels of functional disability and compromised quality of life.
- It stems from a number of causes, namely, biological, neurological, and psychosocial.
- It can be effectively managed by therapy or medication or a combination of both and psychoeducation and self-help strategies.
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