Bipolar Disorder

 Bipolar disorder, formerly called manic depression is a brain disorder that causes unusually extreme mood swings that range from emotional highs (mania or hypomania) and lows (depression). When you become depressed, you may feel very sad, hopeless and lose interest or pleasure in most activities. When your mood shifts to the other direction, you are in high spirits, may feel energized and euphoric. Mood shifts may sometimes occur only a few times in a year or as often as several times a week.

Although bipolar disorder is an alarming, long-term condition, you can keep your moods in control by following an appropriate treatment plan. In most patients, bipolar disorder can be controlled using medications and psychological counseling (psychotherapy).

There are different types of bipolar and related disorders and for each type, the symptoms of bipolar disorder differs from one person to another. Bipolar I and bipolar II disorders have additional specific features that can be added to the diagnosis based on your particular signs and symptoms. 

Diagnostic criteria for bipolar disorders 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists a criteria for the diagnosis of bipolar and related disorders. This manual is referred by mental health providers to diagnose mental disorders. Diagnostic criteria for bipolar and related disorders are based on the specific type of disorder:

 Bipolar I disorder

 You have had at least one manic episode. This manic episode may either be preceded or followed by hypomanic or major depressive episodes. The symptoms of mania may lead to significant impairment in your life and require hospitalization or may even trigger a break from reality (psychosis).

 Bipolar II disorder

  You have had at least one major depressive episode for at least 2 weeks and at least one hypomanic episode,which lasted for at least 4 days, but you have never had a manic episode. Major depressive episodes or the unpredictable changes in mood and behavior results in severe distress or difficulty in areas of your life. 

 Cyclothymic disorder

You have had at least two years — or one year in children and teenagers — of several periods of hypomania symptoms (less severe than a hypomanic episode) and periods of depressive symptoms (less severe than a major depressive episode). During these periods, symptoms occur for almost half of the time and last for more than two months. Symptoms may cause significant distress in various aspects of your life. 

Other types

These include, for example, bipolar and related disorder resulting from another medical condition, such as Cushing's disease, multiple sclerosis or stroke. There is yet another type, which is called substance and medication-induced bipolar and related disorder. 

 Bipolar II disorder is not just a milder form of bipolar I disorder, but an entirely different diagnosis. The manic episodes of bipolar I disorder may be severe and dangerous, whereas people with bipolar II disorder remain depressed for longer periods that causes significant impairment. 

Criteria for a manic or hypomanic episode 

The DSM-5 has listed specific criteria for the diagnosis of manic and hypomanic episodes: 

  A manic episode: It is a distinct period in which abnormal and persistently elevated, expansive or irritable mood lasts for at least one week (or less than a week if hospitalization is necessary). This episode involves persistently increased goal-directed activity or energy. 

  A hypomanic episode: It is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts for at least four consecutive days. For both a manic and a hypomanic episode, during the period of disturbed mood and increased energy, three or more of the below mentioned symptoms (four if the mood is only irritable) must be present and should represent a noticeable change from your normal behavior: 

     Increased self-esteem or grandiosity 

     Decreased need for sleep (for example, you feel rested after only three hours of sleep) 

     Being unusually talkative

     Speeding thoughts 

     Distractibility

     Increased goal-directed activity (either socially, at work or school, or sexually) or agitation 

     Doing things that are abnormal and that have a high potential for resulting in painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments 

To be considered a manic episode: 

  The mood disturbance should be so severe that it causes observable difficulty at workplace, school or in social activities or relationships, or requires hospitalization to avoid harming yourself or others, or to trigger a break from reality (psychosis). Symptoms are not because of the direct effects of other factors, such as alcohol or drug abuse, a medication, or a medical condition. 

To be considered a hypomanic episode: 

  The episode is a distinct change in mood and functioning that is not characteristic of you when the symptoms are not present, and enough of a change that other people notice. The episode isn't severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn't require hospitalization or trigger a break from reality. Symptoms are not due to the direct effects of something else, such as alcohol or drug use, a medication, or a medical condition. 

Criteria for a major depressive episode 

The DSM-5 also lists criteria for the diagnosis of a major depressive episode: 

   Five or more of the symptoms listed below over a period of two-weeks that shows a change from previous mood and functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure. Signs and symptoms include

    Depressed mood throughout the day, almost every day, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood may be expressed as irritability)

    Markedly decreased interest or feeling of no pleasure in all activities most of the day, nearly every day 

    Significant weight loss even when not dieting or weight gain, either decrease or increase in appetite nearly every day (in children, failure to gain weight as expected is a sign of depression)

    Either insomnia or excessive sleeping nearly every day 

    Either restlessness or slowed behavior that is noticed by others

    Fatigue or loss of energy nearly every day 

    Feeling of worthlessness or excessive or inappropriate guilt, such as believing false things, nearly every day 

    Reduced ability to think or concentrate, or indecisiveness, nearly every day 

    Recurrent suicidal thoughts or suicide planning or an attempt 

To be considered a major depressive episode: 

   Symptoms must be severe enough to cause marked difficulty in routine activities, such as work, school, social activities or relationships 

   Symptoms are not due to the direct effects of alcohol or drug use, a medication or a medical condition

   Symptoms are not due to grief, such as after the loss of a loved one

 Other signs and symptoms of bipolar disorder 

Signs and symptoms of bipolar I and bipolar II disorders include additional features such as

   Anxious distress — symptoms of anxiety, such as feeling keyed up, tense or restless, having difficulty in concentrating due to worry, fearing something awful may happen, or feeling that you may not be able to control yourself 

   Mixed features — meeting the criteria of a manic or hypomanic episode, but having some or all symptoms of major depressive episode at the same time 

   Melancholic features — losing interest and pleasure in all or most activities and not feeling good even when something great happens 

   Atypical features — experiencing symptoms that are not typical of a major depressive episode, such as having a significantly improved mood when something good happens

  Catatonia — not reacting to your environment in a proper way, holding your body in an unusual position, not speaking, or mimicking another person's speech or movement 

  Peripartum onset — bipolar disorder symptoms that occur during pregnancy or in the initial four weeks after delivery 

  Seasonal pattern — a lifelong pattern of manic, hypomanic or major depressive episodes that changes according to the seasons 

  Rapid cycling — having four or more mood swing episodes in a year, with full or partial remission of symptoms in between manic, hypomanic or major depressive episodes 

  Psychosis — severe episodes of either mania or depression (but not hypomania) that results in detachment from reality, and includes symptoms of false but strongly held beliefs (delusions) and hearing or seeing things that are actually not there (hallucinations) 

Symptoms in children and teens 

The DSM-5 criteria, which is used to diagnose bipolar disorder in adults is also used in children and teenagers. Children and teens may have distinct major depressive, manic or hypomanic episodes, between which they return to their normal behavior, but this is not always the case. Mood rapidly shifts during acute episodes. Symptoms of bipolar disorder can be difficult to identify in children. It is often hard to differentiate whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. The most prominent signs of bipolar disorder in children and teenagers are severe mood swings that are different from their usual mood swings. 

When to see a doctor 

If you have any symptoms of depression or mania, consult your doctor or mental health provider. Bipolar disorder does not resolve on its own. Getting treatment from a mental health provider with experience in bipolar disorder can help you get your symptoms under control.  

When to get emergency help 

Suicidal thoughts are common among people with bipolar disorder. If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately. Also consider these options: 

  Ask help from a close friend or loved one. 

  Contact a minister, spiritual leader or someone in your faith community. 

  Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor. Use that same number and press 1 to reach the Veterans Crisis Line.

  If you have a loved one who is in danger of committing suicide or has made a suicide attempt, ensure someone stays with that person. Call 911 or your local emergency number immediately. Or else, if you think you can do so safely, take the person to the nearest hospital emergency room.

The definite cause of bipolar disorder is obscure, but there are several factors involved such as: 

   Biological differences: An individual with bipolar disorder may have physical changes in the brain structure. The importance of this changes is uncertain but may eventually help in pinpointing the cause. 

   Neurotransmitters: An imbalance in the levels of naturally occurring brain chemicals called neurotransmitters seem to have an important role in causing bipolar disorder and other mood disorders.

   Genes or inherited traits: Bipolar disorder is found more commonly in people with a first-degree relative, such as a sibling or a parent having the condition. Researchers are trying to find out the genes that are involved in causing bipolar disorder.

Making a diagnosis of bipolar disorder is done by several tests.

You may consult your primary care doctor at first or may choose to see a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist). 

What you can do 

Make a list of the following in advance: 

   The symptoms you have had, including those that seem unrelated to the reason for the appointment 

   Key personal information, including any major stresses or recent life changes

   All medications, vitamins or other supplements that you are taking, and their dose 

Questions to ask your doctor

 Ask a family member or friend to come along, if possible. That person can provide you more information or remember something that you missed or forgot. Some basic questions to ask your doctor include:

• Do I have bipolar disorder? 
• Are there any other causes for my symptoms? 
• What kind of tests will be needed?
• What treatments are available for my condition? 
• Which one do you recommend for me? 
• What side effects may be expected with that treatment? 
• Are there any alternatives to the primary approach that you have suggested? 
• How can I best manage my other health problems together?
• Is there a generic alternative to the medicine you have prescribed? 

 What to expect from your doctor

   Your doctor may ask you a number of questions such as:

• When did you or your loved ones first start noticing your symptoms of depression, mania or hypomania?
• How frequently do you experience mood swings? 
• Do you get suicidal thoughts when you are feeling depressed?
• Do your symptoms intervene with your daily routine or relationships? 
• Do you have any blood relatives with similar symptoms or depression? 
• What other mental or physical health problems do you have? 
• Do you drink alcohol, smoke cigarettes or use street drugs?
• Do you get adequate sleep at night? 
• Do you go through periods when you take risks that you would not normally take, such as unsafe sex or making unwise, spontaneous financial decisions?
• Is there anything that seems to improve or worsen your symptoms? 

 When your doctor suspects a bipolar disorder, a number of tests and exams may be performed. These tests rule out other problems, pinpoint a diagnosis, and also check for related complications. These may include: 

    Physical examination: A physical exam and laboratory testing may be done to identify the medical problems that could be causing your symptoms. 

    Psychological evaluation: Your doctor or mental health provider will discuss about your thoughts, feelings, and behavioral patterns. You may be asked to complete a psychological self-assessment or questionnaire. With your permission, your family members or close friends may be asked to give information about your symptoms and possible episodes of mania or depression. 

    Mood charting: In order to identify what exactly is going on, your doctor may suggest you maintain a daily record of your moods, sleep patterns or other factors that could be helpful for diagnosis and appropriate treatment. 

Signs and symptoms

Your doctor or mental health professional will compare your symptoms with the criteria for bipolar and related disorders presented in the Diagnostic and Statistical Manual of Mental Disorders to determine a diagnosis. 

Diagnosis in children 

Although bipolar disorder may also occur in young children, typically it is diagnosed only in the teenage years or early 20's. It is often difficult to distinguish whether a child's emotional ups and downs are normal for his/her age, or a result of stress or trauma, or a sign of a mental health problem other than bipolar disorder. Bipolar disorder symptoms in children and teens often have different patterns than in adults and may not fit accurately into the categories used for diagnosis. Children with bipolar disorder are also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavioral problems. Your pediatrician may explain to you in detail the symptoms of bipolar disorder and how they differ from normal behavior related to your child's developmental age, the situation, and appropriate cultural behavior.

A psychiatrist trained in handling bipolar and related disorders is the best person to guide you through your treatment. An effective treatment plan includes a combination of medications and psychotherapy. You may have a health care team that also includes a psychologist, social worker, and a psychiatric nurse. Based on your needs, treatment plan may include:

    Initial treatment: Often, you will need to start taking medications to stabilize your moods right away. Once your symptoms are brought under control, you will have to work with your doctor to find the most suitable long-term treatment. 

   Continued treatment: Bipolar disorder is a chronic illness and requires lifelong treatment, even during the periods in between the episodes when you feel better. Maintenance treatment is needed to manage bipolar disorder on a long-term basis. People who do not take maintenance treatment are at higher risk of getting a relapse of symptoms or minor mood changes that quickly turn into a full-blown episode of mania or depression.

   Day treatment programs: Your doctor may recommend a day treatment program, which provides the much needed support and counseling while you are getting symptoms under your control. 

   Substance abuse treatment: This will be needed if you have problems with alcohol or drugs, as otherwise, it can be very difficult to manage bipolar disorder.

   Hospitalization: Your doctor may recommend hospitalization if your behavior turns harmful, you feel suicidal or you become detached from reality (psychotic). Psychiatric treatment at a hospital can keep you calm and safe until you stabilize your mood, whether you are having a manic or major depressive episode.

Medications

 There are several medications to treat bipolar disorder. The types and dosage regimen of medications prescribed depend on your symptoms. Medications may include:

   Mood stabilizers: In both bipolar I or II disorder, you will need mood-stabilizing medications to control the manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others), and lamotrigine (Lamictal).

   Antipsychotics: If there are persistent symptoms of depression or mania in spite of treatment with other medications, an antipsychotic medication such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may help. Your doctor may prescribe these medications alone or in combination with a mood stabilizer. 

   Antidepressants: Your doctor may prescribe an antidepressant to manage your depression. As an antidepressant may trigger a manic episode, it is usually prescribed along with a mood stabilizer or an antipsychotic.

   Antidepressant-antipsychotic: The medication Symbyax is a combination of the antidepressant fluoxetine and the antipsychotic olanzapine. It works both as an antidepressant and a mood stabilizer. Symbyax has been approved by the Food and Drug Administration specifically for the treatment of depressive episodes associated with bipolar I disorder.

   Anti-anxiety medications: Benzodiazepines may help in relieving anxiety and improves disturbed sleep, but only on a short-term basis.

Side effects 

 Discuss with your doctor about side effects. If side effects seem to be very intolerable, you may become tempted to discontinue your medication or to reduce your dose on your own. Avoid doing so as you may experience withdrawal effects or your symptoms may relapse. Side effects often improves once you find the right medication and dose that works for you, and as your body gets adjusted to the medications. 

Finding the right medication

  Finding the right medication or medications is like some trial and error. If one is not working well for you, there are several others to try. This process is tedious and requires  lot of patience, as some medications take a few weeks to months to show full effect. Usually, only one medication is changed at a time so that your doctor can check which medication relieves your symptoms causing least bothersome side effects. Medications may also be adjusted as your symptoms change. 

    Medications and pregnancy

       Several medications used to treat bipolar disorder may be associated with birth defects. Talk about these issues with your doctor: 

        Alternative birth control options, as oral contraceptive pills may lose its effectiveness when taken along with certain bipolar disorder medications 

        Treatment options if you are planning to concieve

        Breast-feeding, as certain bipolar medications can pass through breast milk to your infant

 Psychotherapy 

   Psychotherapy is a vital part of bipolar disorder treatment and is provided in individual, family or group settings. There are several types of therapies, which include:

    Cognitive behavioral therapy: The goal of cognitive behavioral therapy is to identify unhealthy, negative beliefs, and behaviors and trying to replace them with healthy and positive ones. It can also help to identify the triggers of your bipolar episodes. Effective strategies of stress management and coping with upsetting situations are learnt. 

    Psychoeducation: Counseling to make you aware about bipolar disorder (psychoeducation) can help you and your loved ones understand bipolar disorder better. Knowing about what is going on helps you get the best support and treatment, and help you and your loved ones easily identify warning signs of mood swings. 

    Interpersonal and social rhythm therapy (IPSRT): The focus of IPSRT is on the stabilization of daily rhythms such as sleep, wakefulness, and mealtimes. A consistent routine allows better mood management. People with bipolar disorder derive benefit from maintaining a daily routine for sleep, diet and exercise. 

    Other therapies: Other therapies have been studied but have only little evidence of success. Ask your doctor if there are any other options appropriate for you. 

      Other treatment options

      Depending on your needs, other treatments may be added to your depression therapy, such as:

     Electroconvulsive therapy (ECT): In ECT, electrical currents are passed through your brain. This procedure may affect the neurotransmitter levels in your brain and typically gives immediate relief from severe depression even when other treatments are ineffective. This therapy is usually used in people who do not find relief with medications, cannot take antidepressants due to other health reasons or are at high risk of suicide. ECT may be an option if you have mania or severe depression during your pregnancy, when regular medications cannot be taken. 

    Transcranial magnetic stimulation (TMS): TMS is an option for people who have not responded to antidepressants. During TMS, you will be seated on a reclining chair with a treatment coil fitted against your scalp. This coil sends brief magnetic pulses that stimulate the nerve cells in your brain that are involved in mood regulation and depression. Typically, there will be five treatments a week for a total period of six weeks. 

Treatment in children and teenagers  

   Treatment for children and teenagers is decided based on their symptoms, medication side effects, and other factors. 

     Medications: Children and teens are often prescribed the same types of medications as those in adults. There is less research conducted on the safety and effectiveness of medications treating bipolar disorders in children than in adults, so treatment decisions are made based on adult research.

    Psychotherapy: Most children diagnosed with bipolar disorder need counseling as a part of initial treatment and to prevent symptoms from returning. Psychotherapy helps children in development of thier coping skills, addressing learning difficulties, resolving social problems, and also helps to strengthen family bonds and communication. 

    Support: Working with teachers, school counselors, and encouraging support from family and friends can help identify services and encourage success.

There is no method that can prevent bipolar disorder for sure. However, seeking treatment as early as possible, when an initial sign of mental health disorder develops, can help prevent bipolar disorder or other mental health conditions from worsening. If you have been diagnosed with bipolar disorder, taking some precautions help in preventing minor symptoms from developing into full-blown episodes of mania or depression: 

     Pay attention to warning signs: Learn to identify your warning signs and address these symptoms at the earliest to avoid episodes from getting worse. You and your caregivers may have recognized a pattern occurring during your bipolar episodes and the triggering factor. Call your doctor if you feel you are falling into an episode of depression or mania. 

    Involve a family member or friend in watching for your warning signs. 

    Avoid drugs and alcohol: Drinking alcohol or use of street drugs may worsen your symptoms and make them more likely to recur. 

    Take your medications as directed by your doctor: You may be feel tempted to stop treatment once your symptoms improve — but do not do so. This may result in immediate consequences — feeling very depressed or you may even go into a manic or hypomanic episode. If you think you need to make a change in your medicine, call your doctor. Check with your doctor before taking other medications. Call the doctor who is treating your bipolar disorder before you take medications prescribed by another doctor or any over-the-counter supplements or medications. Other medications can trigger episodes of bipolar disorder or interfere with medications you are already taking as part of treatment for bipolar disorder.

A few alternative remedies are used for bipolar disorder.

Alternative medicine is the use of a nonconventional approach instead of conventional medicine, whereas complementary medicine is a nonconventional approach used along with conventional medicine. There has been no significant research on alternative medicine used in the treatment of bipolar disorder. Most studies conducted on alternative or complementary medicine are related to treatment of major depression, so it is unclear how well most of these medicines work for bipolar disorder. 

   Omega-3 fatty acids: These oils can improve depression associated with bipolar disorder. For this reason, bipolar disorder appears to be less common in parts of the world where people regularly consume fish, which is rich in omega-3s. Omega-3s have several health benefits, but more research is needed to determine how helpful these are with bipolar disorder. 

   Magnesium: Although several small studies have established that magnesium supplements help lessen mania and the rapid cycling of bipolar symptoms, further  research is required to confirm these results. 

   St. John's wort: This is a herb that is helpful in managing depression. However, it may interact with antidepressants and other medications, and act as a trigger to develop mania in some people.

   S-adenosyl-L-methionine (SAMe): This is a amino acid supplement that helps in brain function related to depression. It is not sure whether it is helpful in people with bipolar disorder. As with St. John's wort, SAMe can induce mania in some people. 

  Herbal supplements: Herbal remedies that combine different herbs, such as those used in traditional Chinese medicine, have not been studied thoroughly, and moreover the composition may vary among products. Risks and benefits of herbal remedies are still not clear. 

  Acupuncture: This is an ancient Chinese practice of inserting fine needles into specific points in the skin. This may relieve depression, but more studies are required to confirm its benefits. However, acupuncture is considered to be safe and may be done with other bipolar disorder treatments. If you want to go for complementary medicine in addition to your physician-recommended treatment, take some precautions first: 

    Do not discontinue your prescribed medications or skip therapy sessions. Alternative medicine is never a substitute for your regular medical care when it comes to treatment of bipolar disorder. 

    Be honest to your doctors and mental health providers. Inform the exact complementary treatment you are using or would like to try. 

    Be aware of potential risks. Only because it is natural, it does not mean it is safe. Therefore, it is important to find out the risks including the potential interactions with other medications before using alternative or complementary medicine.

Certain lifestyle modifications can be followed to stop cycles of behavior that make your bipolar disorder worse. Here are some steps you can take: 

   Avoid drinking or illegal drugs: Negative consequences of drug or alcohol abuse are a great concern for people with bipolar disorder. Get professional help if you find it difficult to quit on your own.

   Be in a healthy environment and avoid unhealthy realtionships: Surround yourself with people with a positive influence and who do not encourage unhealthy behavior or attitudes that may worsen your bipolar disorder. 

   Be physical active and exercise regularly: Moderate, regular physical exercises can stabilize your mood. Work outs release brain chemicals (endorphins) that make you feel good and sleep better. Talk to your doctor before taking up any exercise program, specially if you are taking lithium, to ensure that exercise does not interfere with your medications. 

   Get good amount of sleep: Avoid staying up all the night. Get plenty of sleep because adequate sleep is an important factor that manages your mood. If you have trouble sleeping, find a solution by talking to your doctor or mental health provider about what you can do.

Coping with bipolar disorder can be very challenging. Following strategies may be of help:

   Awareness about your disorder: Knowledge about your condition can empower you and motivate you to adhere to your treatment plan. Help in spreading awareness among your family and friends about what you are going through. 

   Concentrate on your goals: Recovery from bipolar disorder may take some time. Stay motivated until you reach your recovery goals, and remind yourself that you have work towrads setting right damaged relationships and other problems resulting from your mood swings. 

   Consider joining a support group: Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences. 

   Find healthy outlets: Explore healthy ways to utilize your energy, such as pursuing favorite hobbies, exercise and other recreational activities.

   Learn methods of relaxation and stress management: Yoga, tai chi, therapeutic massage, meditation or other relaxation techniques may be helpful in managing your stress.

Risk factors that may increase your chances of developing bipolar disorder or may act as a trigger for the first episode include:

• Family history: Bipolar disorder runs in families. Having a first-degree relative, for instance, a parent or sibling with bipolar disorder makes yourself more susceptible to the illness.
• High levels of stress
• Drug or alcohol abuse 
• Major changes in life such as the death of a loved one or any other traumatic experience

Conditions that commonly occur associated with bipolar disorder

 Along with bipolar disorder, there may be other health condition that may be diagnosed before or after the diagnosis of bipolar disorder. Such conditions should be diagnosed and treated as these may worsen the existing bipolar disorder or make its treatment unuccessful. The conditions include:

    Anxiety disorders such as social anxiety disorder and generalized anxiety disorder. 

    Post-traumatic stress disorder (PTSD): Some people with PTSD, a trauma- and stressor-related disorder may also have bipolar disorder. 

    Attention-deficit/hyperactivity disorder (ADHD): ADHD have similar symptoms as that of bipolar disorder. That is why bipolar disorder is often difficult to differentiate from ADHD, and may be mistaken for the other. In few cases, a person may be diagnosed with both disorders. 

    Physical health problems: People with bipolar disorder are more likely to have certain other health problems such as heart disease, thyroid problems or obesity.

    Drug addiction or substance abuse: Most people with bipolar disorder may also have alcohol, tobacco or drug problems. Intake of drugs or alcohol may seem to ease away your symptoms, but they actually trigger, prolong or even worsen your depression or mania. 

If bipolar disorder is negelected and left untreated, it can lead to very serious problems that affect almost every aspect of your life. These may include: 

• Problems related to drug and alcohol use 
• Suicide or suicidal attempts 
• Legal problems
• Financial problems
• Trouble in maintaining relationships
• Feeling of isolation or loneliness
• Poor performance at work or school 
• Frequent absences from work or school