Bipolar disorder: highs, lows and staying well
Bipolar disorder is a long-term mood condition in which a person has episodes of depression and episodes of abnormally raised mood called mania or, in a milder form, hypomania. Between episodes many people feel well. It is diagnosed by a psychiatrist from the pattern of episodes over time, often with the family's account. Treatment is usually a mood stabiliser such as lithium or an antipsychotic, psychological support, a regular sleep routine and a written plan for spotting early warning signs. Antidepressants on their own can trigger a high, so they are used with care.
Health writers · Aslam Clinic
Bipolar disorder is a mood condition in which a person has episodes of depression — deep low mood, no energy, no interest in anything — and separate episodes of or , when mood, energy and activity rise far above the person's normal. These are not ordinary good and bad days. Episodes last days to weeks, they change how a person sleeps, thinks and behaves, and between them many people are completely well.
It is a long-term condition, but a very treatable one. Most people who take a , keep a regular sleep routine and have a plan for catching the early signs of an episode go on to work, marry, raise children and live full lives. The old name was manic depression; ICD-10 still lists that as an alternative term.
Mania, hypomania and depression
The three kinds of episode feel very different, and the high ones are often noticed first by the family rather than the person, because being high can feel wonderful from the inside.
| Episode | What it looks like | How long |
|---|---|---|
| Mania | Very high or very irritable mood, little need for sleep without feeling tired, racing thoughts, fast speech, grand plans, reckless spending or driving, sexual or social disinhibition. Severe mania can include false beliefs (delusions) or hearing and seeing things (hallucinations). | At least a week, or any length if hospital care is needed |
| Hypomania | The same kind of changes but milder: more energy, more talkative, more productive, sleeping less. Others notice the change, but the person can usually still work and there is no psychosis. | Usually a few days |
| Depression | Low mood, loss of interest (), tiredness, sleep and appetite changes, guilt, poor concentration, and sometimes thoughts of death or suicide. | Typically two weeks or more, often much longer |
Bipolar I and bipolar II
Doctors separate two main types. In bipolar I, the person has had at least one full manic episode, lasting at least seven days or severe enough to need hospital care; most also have episodes of depression. In bipolar II, there has never been full mania, but there are episodes of hypomania and of depression. Bipolar II is not simply the mild version: the depressions can be long and disabling, and they are often what brings a person to the doctor.
Some people have mixed episodes, with high energy and agitation at the same time as low, hopeless mood. These are especially risky, because the drive to act and the despair arrive together. Four or more episodes in one year is called rapid cycling.
How it is diagnosed
There is no blood test or scan for bipolar disorder. A makes the diagnosis from a careful history: the pattern of past episodes, how the person slept and behaved, what triggered them, and whether relatives have had similar problems. An account from a parent, spouse or sibling is often the most useful piece of evidence, because hypomania is easy to forget or to remember simply as a good patch.
The doctor will also want to rule out things that can mimic a mood episode — thyroid disease, drugs such as steroids or stimulants, cannabis, alcohol and some neurological conditions — so blood tests are usually part of the assessment. It often takes time to be sure, and many people are first diagnosed with ordinary because the lows are what they seek help for.
Treatment: medicines
Medicines are the foundation for most people, both to treat an episode and to prevent the next one. The choice depends on the type of episode, past response, other health problems and, for women, plans for pregnancy.
- Lithium — the longest-established mood stabiliser, good at preventing both highs and lows, and it also lowers the risk of suicide.
- Antipsychotics such as quetiapine, olanzapine, risperidone and haloperidol — used to bring mania under control quickly, and some (quetiapine in particular) also treat bipolar depression.
- Valproate — effective, but it can seriously harm an unborn baby, so it is avoided in girls and women who could become pregnant.
- Lamotrigine — used mainly for the depressive side of the illness.
- Antidepressants — only with an antimanic medicine, and usually for a limited time. UK guidance recommends fluoxetine combined with olanzapine as one option for bipolar depression.
Do not start, stop or change these without your doctor. Stopping suddenly — especially lithium — is one of the commonest causes of relapse. Coming off lithium should be done gradually over weeks to months, under supervision.
Living safely with lithium
Lithium works well, but the gap between a helpful level and a harmful one is narrow, so it needs regular blood tests. UK guidance is to check the lithium level every three months in the first year and then every three to six months, and to check kidney function, calcium and function (lithium can cause ) and weight every six months. Keep your results in one book or folder and take it to every appointment, including when you see a new doctor.
Therapy, sleep and routine
Medicine works better alongside other support. — learning how your own illness behaves — is one of the most useful things a person and family can do. Structured psychological therapy, including , interpersonal and social rhythm therapy (built around keeping daily rhythms steady), and family-focused therapy all have evidence in bipolar disorder, and UK guidance recommends offering a family intervention to people who live with or are close to their family.
Sleep deserves special attention. Losing sleep can trigger a high, and a shrinking need for sleep is often the first sign of one. Regular times for sleeping, waking and meals protect mood. In Pakistan that can mean planning around things that scramble routine: loadshedding nights in summer, weddings that run past 2 am, night-shift work, long travel, and the changed timings of Ramadan. Cannabis, alcohol, and large amounts of tea, coffee or energy drinks all make mood less stable.
An early warning signs plan
Most people's episodes start the same way each time — their personal 'relapse signature'. Writing it down while well, with the family, turns vague worry into a plan everyone has agreed to.
- List your early signs of a high (for example: sleeping four hours and feeling fine, starting many projects, spending, talking fast, irritability) and of a low (withdrawing, not praying or eating with the family, missing work).
- Keep a simple daily mood and sleep chart, on paper or on your phone, and bring it to appointments.
- Agree what you will do at the first signs: protect sleep, cut stimulation, contact your psychiatrist, and any extra medicine your doctor has already agreed.
- Agree what your family will do: who calls the doctor, and whether a trusted person holds bank cards or cheque books during a high.
- Write down your psychiatrist's number, the nearest hospital with a psychiatry department, and Rescue 1122.
The family's role
In many Pakistani homes the family decides about treatment, so the family's understanding matters as much as the patient's. Helpful families notice early changes without constant policing, remind rather than nag about medicine, and do not argue with grand ideas during a high — they calmly steer towards sleep and the doctor. Blaming the person for what they did while unwell ('he just wants attention', 'she is doing it on purpose') makes things worse.
Families sometimes hide the diagnosis because of rishtay and 'log kya kahenge'. That fear is real, but stopping medicine to keep a secret is dangerous, and pregnancy and the weeks after birth are a high-risk time for women with bipolar disorder, including a risk of postpartum psychosis. Prayer, Quran recitation and the support of elders can sit comfortably alongside treatment; they are not a reason to stop it.
What you can do today
- If you suspect bipolar disorder, see a psychiatrist — district (DHQ) and teaching hospitals have psychiatry departments — and bring a relative who has seen your highs and lows.
- If you are already diagnosed, check when your next lithium or thyroid test is due and book it.
- Set a fixed wake-up time and protect it for the next two weeks.
- Write the first version of your early warning signs plan and share it with one person you trust.
Common questions
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