What bipolar disorder is
Bipolar disorder = a chronic mental illness alternating depressive and manic (or hypomanic) episodes over time. "Bipolar" = two extreme mood poles. Formerly "manic-depressive illness". Neurologically, chronic dysregulation of the brain's mood circuits (frontal lobe, limbic system, dopamine, serotonin, norepinephrine).
Korean data
- Prevalence: 1~2% (~500K)
- Onset: peak 18~25 years, average 25
- Female:Male: 1:1 (unlike unipolar depression)
- Diagnostic delay: average 8 years after first symptom (misdiagnosed as depression)
- Suicide risk: 15× general — highest of psychiatric disorders
- Heritability: 60~80% (first-degree relative = 10× risk)
- Korean trend: ↑ diagnosis rate (doubled in 10 years), ↑ adolescent diagnosis
Subtypes — DSM-5
Bipolar I: at least one manic episode (hospitalization or psychosis). Depression common but not required for diagnosis.
Bipolar II: hypomania (mild mania) + depression. No hospitalization; daily function partly preserved. Often misdiagnosed as depression.
Cyclothymia: mild hypomania + mild depression alternating for 2+ years. Below full criteria.
Other specified: meets only some criteria.
Manic episode — DSM-5
≥1 week (any duration if hospitalized) of abnormally elevated / irritable / expansive mood + 3 of 7 (4 if only elevated):
- Grandiose self-esteem / confidence ("I'm a genius")
- ↓ need for sleep (feels enough after 3 hours)
- More and faster speech than usual
- Racing thoughts
- Distractibility
- ↑ goal-directed activity / psychomotor agitation
- Risky behavior (overspending, sex, drugs, gambling)
+ social / occupational impairment, psychosis, or hospitalization.
Hypomania — Bipolar II
Similar to mania but:
- ≥4 days (vs. ≥7 for mania)
- No or mild social / occupational impairment
- No hospitalization, no psychosis
- Others notice "something's off", but the person feels "great"
Hypomania feels like a "good period" — "creativity, productivity, confidence". Hence resistance to treatment / difficult to diagnose.
Depressive episode (bipolar)
Same symptoms as major depression (2+ weeks depression / loss of interest + 5+):
- Appetite / weight changes
- Sleep changes (insomnia or hypersomnia)
- Psychomotor changes
- Fatigue
- Worthlessness / guilt
- ↓ concentration
- Suicidal thoughts
But bipolar depression vs. unipolar depression:
- More hypersomnia (vs. insomnia)
- ↑ appetite (vs. ↓)
- More fatigue / lethargy
- Mixed state (depression + agitation)
- Risk of "switching" to mania on SSRI
Why 8-year diagnostic delay
① Depression first: 50% of patients start with a depressive episode. Mania emerges years later. First depression → SSRI prescription.
② Hypomania goes "untreated": feels like a "good period" — not reported to doctors.
③ Visits doctor for depression after mania: patients don't seek care during mania, only for depression — leading to a depression diagnosis.
④ Family history not collected: first-degree bipolar info is a diagnostic key.
⑤ SSRI monotherapy risk: SSRI alone in bipolar = 25% switch to mania. But without diagnosis, SSRI is prescribed.
Average 8-year delay in Korea → ↑ suicide / divorce / job loss / financial collapse risk during that window.
Treatment — medication is core
Bipolar requires lifelong medication (similar to diabetes). The core is mood stabilizers:
① Lithium: most evidence-based (since 1949). Clearly ↓ suicide risk. Side effects: tremor, thirst, ↑ weight, thyroid, kidneys (monitor blood levels). Regular blood tests.
② Valproate (Depakote): ↑ efficacy for mania. Side effects: weight, liver, teratogenic. Avoid in pregnancy.
③ Lamotrigine: ↑ depression prevention. Side effects: rash (rare Stevens-Johnson — emergency).
④ Carbamazepine: if lithium fails.
⑤ Antipsychotics: quetiapine, olanzapine, risperidone, aripiprazole — effective for mania / depression / maintenance.
⑥ SSRI: use for depression but only with a mood stabilizer. SSRI alone is risky (mania switch).
Stopping meds → 50% relapse in 1 year, 70% in 2. Lifelong therapy essential.
Treatment — psychotherapy / lifestyle
① Psychotherapy: CBT-BD, IPSRT (Interpersonal and Social Rhythm Therapy), Family-Focused Therapy.
② Sleep schedule: most important in bipolar. Same bedtime / wake time daily. Sleep variability = mania / depression trigger. Jet lag, all-nighters, shift work — risky.
③ Social rhythm: meals, exercise, social activities on a fixed schedule. Irregularity is a trigger.
④ Trigger avoidance: alcohol, drugs, stimulants, severe stress, sleep deprivation.
⑤ Family education: family recognizing mania / depression cues → early medical help.
⑥ Journal: daily mood (0~10), sleep, meds, key events. Share with doctor — ↑ pattern recognition.
Early warning signs — for self / family
Mania-onset signs:
- ↓ sleep need (feels enough on 3~4 hours)
- More / faster speech
- Multiple new projects at once
- Overspending (millions of won+)
- ↑ sexual desire / infidelity
- ↑ alcohol / drugs
- Fast driving
- Family / friends remark "you're acting strange"
- "Everything is possible" feeling
Depression-onset signs:
- 2+ weeks of depression or ↓ interest
- Trouble waking up
- Appetite changes
- Fatigue
- Suicidal thoughts
1~2 signs = psychiatry immediately (outpatient even if not emergency). Med adjustment prevents major episodes.
Real difficulties for Korean bipolar patients
- Average 8-year misdiagnosis: depression diagnosis, SSRI, mania switch
- Med refusal: lifelong meds, stigma
- Hypomania feels "good": "don't want treatment"
- Family burden: ↑ family depression risk
- Divorce / job loss: from mania-driven risky behaviors
- Suicide: many attempts during depression / mixed states
- Health insurance: covers psychiatric visits; copay 10~30% for meds
What family / partner should do
- ① Recognize mania / depression signs — the patient can't see them
- ② Accompany to care — even if patient refuses
- ③ Verify med adherence — journal, pill box
- ④ Maintain sleep / life rhythm — not just for the patient
- ⑤ Prevent risky behavior — credit card limits, driving control (in mania)
- ⑥ Self-care — family is at ↑ mental health risk
Emergency signs — care now
- Suicidal thoughts / plan / attempt
- Mania (no sleep 5+ days, hallucinations, delusions)
- Mixed state (depression + agitation = ↑ suicide risk)
- Sudden med stop (relapse risk)
- Drug side effects (rash, severe tremor, kidney abnormalities)
- Family violence
1577-0199 or ER. Mania / mixed states are psychiatric emergencies — involuntary admission possible (family consent + physician decision). Bipolar is lifelong but treatment enables a normal life. 80% of patients reach stable maintenance with meds + lifestyle. Never refuse treatment.
