Bipolar disorder always requires medication

Bipolar disorder (manic-depressive)

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In bipolar disorder, depressive and manic phases alternate. The exact causes are so far unclear. Bipolar disorder usually has to be treated with medication. In addition, psychotherapy and other procedures can be useful.

Sometimes sad, sometimes happy, sometimes listless, sometimes full of energy: everyone's emotional state fluctuates. This is completely normal.

However, people with bipolar disorder experience mood swings that go far beyond normal levels: their mood is overly depressed or exaggerated for no external reason - from manic to depressed. During depression, people are depressed and lack interest and drive. In mania the mood is reversed. Euphoria, thirst for action and limitless overconfidence are then typical symptoms.

What is Bipolar Disorder?

With a bipolar disorder (also: bipolar affective disorder, earlier: manic-depressive illness) the mood fluctuates again and again between two extremes: between high spirits (mania) and depression. These fluctuations can vary in strength, but they always go far beyond an appropriate level. Between mania and depression there are periods in which the mood is in a healthy frame.

During one manic phase those affected are full of enthusiasm: They dare to do almost anything, feel exaggeratedly self-confident and could literally uproot trees. Often they hardly sleep because they want to put their flood of ideas into action immediately. You behave unusually reckless, risk-taking and unrestrained.

The exact opposite is that depression. Instead of high spirits, there is now a deep depression and listlessness. What used to be fun has suddenly become meaningless.

Symptoms of mania and depression can occur in bipolar disorder as well at the same time occur or arise in rapid succession alternate.

How common is bipolar disorder?

Around 1 in 100 people will develop bipolar disorder with depressive and manic episodes at some point in their life. A weakened form (bipolar II disorder) is somewhat more common: it is estimated that around 4 out of 100 people develop it. Men and women are equally affected.

Bipolar disorder: forms

Doctors differentiate between two forms of bipolar disorder:

  • The guy Bipolar I. (Bipolar I disorder) stands for the typical course with pronounced depressive and manic phases.
  • People with a so-called Bipolar II disorder experience however depressive and hypomanic phases. This means: the high spirits are less developed than in a real mania - depressive episodes, on the other hand, can be just as difficult as with type bipolar I.

The individual phases of the illness can last for different lengths of time. In most cases, it takes two to three years to complete a full manic-depressive cycle. The cycles can also be significantly shorter:

  • Rapid cycling: With a so-called rapid cycling, the patient experiences at least four (hypo-) manic or depressive phases per year. It is estimated that rapid cycling occurs in up to 2 in 10 people with bipolar disorder.
  • Ultra rapid cycling: The phases change weekly or more frequently.

Once the respective phase of the illness has subsided, a symptom-free phase usually follows (so-called Remission). In some cases, however, the symptom-free phase does not occur and depression and mania alternate immediately.

Cyclothymia: Slight, persistent mood swings

A long-lasting (chronic), but rather mild form of mood lability is the so-called Cyclothymia: The mood fluctuates again and again over the years. However, it is less pronounced in one direction. Rather, patients repeatedly experience phases of a slightly elevated mood (Hypomania) dealing with a mild depression alternate. Pronounced manic or depressive episodes do not occur. Cyclothymia often develops in early adulthood.

Read more on the topic:Cyclothymia

Bipolar disorder: symptoms

The symptoms of bipolar disorder can vary greatly depending on whether mania or depression is prevalent. Not only the mood, but also thinking, acting and feeling are considerably impaired during an acute phase of illness.

Overview: Typical Symptoms of Mania and Depression

Symptoms during a maniaSymptoms During Depression
Inappropriately high spirits up to euphoria, but also irritabilitydepressed mood, restlessness, fears
excessive activity, constant switching between different activitiesdecreased drive; slowed movements, but also psychomotor arousal
always new, quickly changing ideas ("flight of ideas")Joylessness and lack of interest
lack of need for sleepsleep disorders
Jumps in thought, rapidly changing thoughts ("racing thoughts"); Distractibilityslowed thinking; Difficulty concentrating
Urge to talkslowed down speech
Overconfidencelow self-esteem, feelings of inferiority
strong need for contact, risky or reckless behaviorsocial withdrawal
increased sexual need,decreased sexual need
psychotic symptoms such as megalomaniapsychotic symptoms, e.g. delusional impoverishment

Symptoms of mania

A manic phase usually arises very suddenly. People going through a manic episode believe they are invulnerable. You are in absolute High spirits and feel overconfident. You tend to overestimate yourself. Some react noticeably irritable, restless or aggressive and are very suspicious of others.

Manics are inappropriately enterprising, sociable, and energetic. They are just overflowing with ideas that they want to put into practice as soon as possible. Most of the time, however, their thoughts are so erratic that they fail to complete a project. They think, speak and act quickly, but are very distracted. Often they lose all inhibitions towards others and behave very freely sexually, for example.

During a mania, those affected are hardly or not at all able to lead a regular everyday life. In addition, they hardly come to rest because sleep seems rather annoying to them.

A manic phase can be accompanied by psychotic symptoms. That means: the connection to reality is temporarily lost. Manics often develop a megalomania: they overestimate themselves immeasurably and believe that they can cope with any task, no matter how risky or difficult - although this is unrealistic from an objective point of view. Hallucinations or paranoia can also occur during mania.

Manicists keep getting into trouble and recklessly jeopardizing their health, relationships, job, or finances. They behave in a way that is not normally their nature. Some examples:

  • They spend all their money on an actually hopeless project and get into debt.
  • You quit your job and go on an ad hoc trip around the world without thinking about it beforehand.
  • You bet all your money on one number in roulette.
  • They rush into sexual adventures and endanger their relationship in the process.

Hypomania: Mania's little sister

A weakened form of mania is hypomania. In hypomania, the mood is significantly increased - but not so strong that one could speak of mania. In contrast to people with mania, people with hypomania are able to lead a regular everyday life. Hypomania usually only lasts a few days.

Other signs of hypomania are

  • decreased need for sleep,
  • increased need to talk, need to be sociable,
  • Concentration problems,
  • Restlessness,
  • increased sexual need as well
  • Tendency to be careless / irresponsible.

Symptoms of depression

In a sense, the symptoms of depression represent the opposite of mania. Depressive phases are usually more common than manic and last longer.

To the Main symptoms of depression counting

  • a depressed mood
  • Joylessness and lack of interest as well
  • decreased drive.

Depression can be accompanied by thoughts of suicide. If you have thoughts like this or notice that someone around you may be suicidal: Don't be afraid to seek help. If you have thoughts of suicide, contact the nearest psychiatric clinic or call the emergency number on 112.

Another point of contact can be the telephone counseling. You can reach them anonymously and free of charge at the following numbers:

  • +49 (0)800 1110111
  • +49 (0)800 111 0 222

Depressed people no longer enjoy doing things that they previously enjoyed. You feel a deep sadness or an inner emptiness. Some have the impression that they are no longer capable of any emotions. During depression, those affected are pessimistic about the future and do not trust themselves to be confident. They no longer have as much drive as they did before, which often makes activities difficult for them. You have trouble making small decisions on your own. Often they withdraw from friends and acquaintances.

Depression can manifest itself in very different forms: For some, physical symptoms are in the foreground, while others suffer primarily from emotional complaints. Possible physical symptoms include stomach pain or headache. Others especially suffer from the feeling of being worthless. Movement and speaking can be slowed down (so-called psychomotor inhibition). But restlessness and a strong urge to move (so-called psychomotor agitation) are more common. Mentally, depression is often noticeable in that those affected have the feeling that they are not worth anything.

In a depressive phase it can happen that the connection to reality is temporarily lost (psychotic symptoms). For example, the depressed person then has the delusion of being impoverished and going into debt.

Mixed states

Symptoms of mania and depression can be at the same time or in rapid succession occur. Doctors then speak of one mixed episode. Up to 60 out of 100 sufferers experience such mixed states.

An example of a mixed state: a person feels down and depressed. At the same time, however, she is very restless, active and feels driven.

Bipolar disorder: causes

The causes of bipolar disorder are not yet known in detail. One thing is certain that several factors interact are involved in the development of a manic-depressive illness. Above all, these include:

  • genetic components: A genetic predisposition seems to play a major role in bipolar diseases, but it is not the only cause. People with a first-degree bipolar relative (e.g. mother, father) are 10 times more likely to develop bipolar disorder than people without a hereditary predisposition. If one of the parents is ill, the risk of illness is 10 to 20%. If both parents are sick, the risk increases to up to 60%.
  • Character traits: People with certain character traits are at increased risk of developing bipolar disorder. Above all, this includes people who are by nature rather extroverted and exaggeratedly exuberant (hypothymic).
  • external influences: Serious life events (e.g. separation of parents, death of a relative) or trauma (e.g. due to abuse) can trigger an acute manic or depressive episode if the person is predisposed to it.

Bipolar disorder: diagnosis

It can take time for a doctor to diagnose bipolar disorder. (Hypo-) manic phases in particular are often overlooked for a long time. The reason: Many of those affected do not feel at all affected by the high spirits. On the contrary - they are happy to be in a better mood again after a depressive phase. They do not realize that their mood is beyond a healthy level and can sometimes react aggressively when directed to do so by family members. The doctor may initially assume that it was pure depression.

The following applies: Only when the doctor has identified at least one (hypo-) manic and one depressive episode can he diagnose a bipolar disorder (manic-depressive illness).

Not every bad mood is a depression. And not every high mood has to mean that it is a mania. In order to find out whether his patient is actually going through a manic or depressive phase, the doctor will take certain steps Diagnostic criteria orientate. For example, to speak of a depressive episode, the mood must be depressed for at least two weeks. At least four out of ten typical symptoms must occur - including at least two of the three main symptoms (depressed mood, loss of interest, reduced drive).

That's what the doctor does

The first signs of bipolar disorder often emerge from the Conversation between doctor and patient. The doctor asks the patient, among other things, about his life story, about mental illnesses within the family and about the type and duration of the complaints.

Related partiesEscorts their descriptions help the doctor to get a first impression.

The following exams and procedures are helpful in diagnosing bipolar disorder:

  • psychological tests and procedures for personality diagnostics, e.g .:
    • structured interviews with the patient
    • Questionnaires for self-assessment (e.g. mania self-assessment scale, MSS; Beck Depression Inventory II, BDI II)
    • Assessment sheets that help the doctor assess the patient's condition (e.g. the Clinical Global Impression Scale, CGI)
  • a physical exam
  • Laboratory values ​​and, if necessary, further diagnostic procedures

Rule out other causes

Certain medical conditions or medications can cause symptoms that are similar to those of bipolar disorder. These include, for example

It is important that the doctor see such diseases excludes. If necessary, he will therefore initiate further examinations. This includes imaging procedures such as MRI or CT, an EEG or the determination of hormone levels.

Treatment for bipolar disorder belongs in the hands of one Specialist. If the family doctor suspects that his patient has bipolar disorder, he will refer him to a specialist in psychiatry and psychotherapy or neurology.

Bipolar disorder: therapy

Therapy for bipolar disorder consists of the

  • Acute treatment with the aim of alleviating acute (hypo-) manic or depressive episodes and the
  • Phase prophylaxis with the aim of preventing or alleviating renewed episodes.

They are usually getting used to treating bipolar disorder Medication required. Psychotherapy can also be useful. If the usual treatment methods do not work or do not work sufficiently, the doctor can suggest other treatment options.


  • non-drug treatments like
    • Electroconvulsive therapy,
    • Light therapy,
    • Sleep deprivation and
    • Methods of brain stimulation, e.g. vagus nerve stimulation.

There is also the option of supplementing the therapy with occupational therapy, art, music or dance therapy or body work.

Psychoeducation: educate patients and relatives

The more precisely a manic-depressed person and their loved ones know about bipolar disorder, the better. At the beginning of treatment, it is therefore important that the patient and their relatives are informed about the disease, its causes and possible forms of therapy and that they learn how best to avoid relapses. You can learn the most important basics in an appropriate course. Such an explanation by an expert is called Psychoeducation. Psychotherapy can follow after psychoeducation.

In an acute manic phase in particular, those affected often do not feel sick and discontinue drug therapy. At this point it is particularly important that relatives, psychiatrists and / or psychologists are on hand to provide support. Sometimes it is necessary for the person concerned to be treated temporarily in a clinic - possibly against his will, if he would otherwise harm himself or others.

Bipolar Disorder: Medication

There are three main groups of active ingredients that are particularly suitable for treating bipolar disorder:

  • Mood stabilizers,
  • Antipsychotics and
  • Antidepressants

Mood stabilizers: equalize moods

Mood stabilizers play a central role in drug therapy for bipolar disorder. They compensate for the strong manic-depressive mood swings. They are suitable both in acute phases of the illness and to prevent new episodes. Frequently used active ingredients include

Which active ingredient the doctor chooses depends on various factors, for example,

  • whether the patient is going through an acute depressive or manic phase,
  • whether or how well he tolerates the drug and
  • which complaints are in the foreground.

Especially in symptom-free phases and for the treatment of mania lithium proven. In many cases, lithium prevents new phases of the disease from occurring - or it significantly reduces the symptoms. In the case of lithium therapy, however, it is particularly important that the patient takes the drug regularly and adheres to the prescribed dose.

Possible Side effects of lithium include weight gain, tremors, nausea, an underactive thyroid or disorders of the parathyroid glands.

Antipsychotics and antidepressants

Antipsychotics (neuroleptics) have a dampening and calming effect. Among other things, they can relieve psychotic symptoms such as delusions.

Antipsychotics prescribed for bipolar disorder include atypical antipsychotics such as

Antidepressants such as fluoxetine or sertraline have a mood-enhancing and drive-enhancing effect. They are especially useful during a depressive episode. The side effects of antipsychotics and antidepressants vary depending on the active ingredient.

Know more: which drug in which phase?

acute depressive episodeDuring a moderate or severe depressive phasethe antipsychotic quetiapine is the first drug of choice. If this is unsuccessful, the doctor can use mood stabilizers or, alternatively, antidepressants from the group of selective serotonin reuptake inhibitors (SSRIs). Mild depressive episodes do not necessarily have to be treated with medication.
acute manic episodeIn the case of mania, the doctor will first use a mood stabilizer (e.g. lithium, carbamazepine, valproate). If this does not work sufficiently, he can alternatively prescribe an antipsychotic (e.g. aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone). The doctor can combine mood stabilizers and antipsychotics if necessary.
symptom-free phaseIn a symptom-free phase, the doctor will prescribe lithium if possible. Alternatively, he may give other mood stabilizers (carbamazepine, valproate, or lamotrigine) or an antipsychotic (aripiprazole, olanzapine, or risperidone) if necessary.

Bipolar disorder: psychotherapy

Psychotherapy is one useful addition to drug treatment. The therapy helps to prevent new phases of the disease and to remain symptom-free for as long as possible. As a rule, however, psychotherapy cannot replace the administration of medication.

In psychotherapy, for example, the patient learns

  • recognize and influence possible triggers for acute phases of illness in good time,
  • how drugs work and why he needs them,
  • to recognize the first signs of a manic / depressive phase and to counteract them,
  • Coping with problems in everyday life, e.g. social exclusion due to the diseases,
  • To reduce fears of the future / relapse and
  • Create a regular, structured daily routine (e.g. pay attention to regular bedtime).

The content of the therapy depends, among other things, on whether the person is currently experiencing an acute phase of illness or whether they are symptom-free. Avoiding too many stimuli is important during a manic episode. During depression, on the other hand, therapy can be aimed at making the patient more active.

Various therapy methods have proven effective in treating bipolar disorder:

  • Cognitive behavioral therapy: Among other things, the patient learns to recognize the first signs of an acute phase, to minimize stress and to deal with manic / depressive symptoms.
  • Family-focused therapy (FFT): The therapist involves the relatives in the treatment. Together with the sick, they learn to lead a regular everyday life, prevent relapses and resolve conflicts.
  • Interpersonal and social rhythm therapy (IPSR): On the one hand, the patient learns to find solutions to interpersonal problems. On the other hand, a regular daily routine and a balanced sleep-wake rhythm should prevent mood swings.

Bipolar Disorder: Other Non-Drug Treatment Options

In certain cases, other treatment options may be considered. Two examples are electroconvulsive therapy and waking therapy.

Electroconvulsive therapy

In very severe acute manic or depressive phases, the doctor may consider electroconvulsive therapy (ECT).

An ECT is performed under general anesthesia. The brain receives a weak electric shock. This solves you Seizure out. The attack lasts about 20 to 40 seconds. The patient cannot remember the seizure after waking up.

In most cases, the ECT stabilizes the mood - it is still unclear why this is exactly the case.

The doctor only considers the ECG if the patient feels very bad despite medication and psychotherapy or if he cannot tolerate the medication.

Waking therapy

During severe depression, waking therapy, in addition to medication, can provide relief for a short period of time. Waking therapy means sleep deprivation: the patient remains awake for a certain period of time (maximum 40 hours). The antidepressant effect only lasts for a short time, but signals to the patient that he can overcome the depressive phase.

For people who experience manic and depressive symptoms at the same time (so-called. mixed episode), is the Guard therapy not suitable.

Complementary therapy methods

In addition, other therapy methods can be helpful:

Bipolar disorder: history

Every bipolar disorder is different: some experience very long periods between manic and depressive episodes in which the mood is stable. With others, the mood changes more frequently (so-called rapid cycling). Manic and depressive symptoms can occur simultaneously or alternate immediately.

Although there is no cure for bipolar disorder, it can be managed well with medication. With appropriate therapy, up to 7 out of 10 patients have no acute phases or are very mild.

What are the consequences of bipolar disorder?

Bipolar disorder can be very distressing and seriously affect the person's life. The acute manic and depressive phases in particular can lead to problems. However, some sufferers have difficulty leading a normal life even in symptom-free phases.

Possible consequences of bipolar disorder include:

  • Problems in the workplace up to and including job loss
  • Debt in a manic phase
  • social isolation, for example because friends or acquaintances cannot understand the symptoms or because the person concerned withdraws out of shame
  • Conflicts in the partnership due to constant changes of mood
  • Suicidal thoughts and attempts.

The risk of suicide is particularly increased during a depressive or mixed episode.

Bipolar disorder is often associated with other mental illnesses, such as with

Certain physical illnesses are more common in people with bipolar disorder. These include diabetes mellitus, obesity, migraines and cardiovascular diseases.

ICD-10 Diagnostic Key:

You can find the appropriate ICD-10 code for "Bipolar Disorder" here:

Onmeda reading tips:

Link tips:

German Society for Bipolar Disorders e.V.

Self-help group search on the website of the German Society for Bipolar Disorders


Online information from the German Society for Bipolar Disorders e.V .: (accessed: 9.8.2018)

Bipolar diseases. Online information from neurologists and psychiatrists on the Internet: (access date: 8/9/2018)

Payk, T., Brüne, M .: Checklist psychiatry and psychotherapy. Thieme, Stuttgart 2017

Bipolar Affective Disorder. Online information from the Pschyrembel: (as of April 2016)

Möller, H., et al .: Dual Series Psychiatry, Psychosomatics and Psychotherapy. Thieme, Stuttgart 2015

German Society for Bipolar Disorders (DGBS): S3 guidelines for the diagnosis and therapy of bipolar disorders. AWMF guidelines register No. 038/019 (as of September 2012)

Schäfer, U., et al .: Mania and Depression - Bipolar Disorder. Advice for those affected and their relatives. Online publication of the German Society for Bipolar Disorders e.V .: (status: 2011)

Last content check:14.08.2018
Last change: 07.09.2020