Prof. Dr. Fisun Akdeniz, Psyc. Dr. Müge Alkan
Aegean University Medical School, Psychiatry Discipline, Affective Sicknesses Unit


Everybody has emotional ups and downs in their daily lives. Our emotions fluctuate between anger, happiness, sadness, grief, discomfort and apprehension. However, in the case of bipolar disorder, long-lasting and intense changes related to our emotional status occur fully or partially independent of the course of life. These changes influence thoughts, emotions, physical health, behavior, one's life and his/her functions. In other words, bipolar disorder is a treatable disorder that causes extreme distortions on emotions, thoughts, energy and behavior. Bipolar disorder does not occur due to a personal mistake or weakness. It is a medical, treatable disorder.


What is Mania/Hypomania?

The main symptoms are extreme cheerfulness, occasionally anger and enthusiastic state of emotion; acceleration in thinking, speaking, movements and a swelling of the ego. The symptoms persist 4-7 full days and it causes damage to personal relationships and functions. This situation is sometimes not perceived as a sickness but "the formation of real personality". In more serious cases, mental delusions like hearing/seeing voices/objects that do not exist in reality and cultivation of mistaken beliefs and thoughts (skepticism, a predominant conception of self and thinking of being followed by someone etc.) that do not have any connection with reality are also observable.

Hypomania is a lighter form of mania. In the hypomanic period, the person is usually more cheerful, feels better than usual and is more productive. The symptoms can be realised by the people around the patient; nevertheless, they do not influence the daily life as much as in mania. The person is usually happy with this situation and he can even prefer to stop taking medicat. Mania or depression may develop abruptly after this period.

What is the Depressive Period?

Fundamental symptoms are a deeply-sad and collapsed emotional state, deceleration in thinking, speaking and movement, as well as feelings worthlessness, powerlessness, pessimism and unwillingness. The symptoms should persist at least for 2 weeks, continue pretty much every single day, and influence the relations and functions of an individual negatively. On an emotional level, collapse, sadness, nervousness, desire to sleep, decrease in social interaction, loss of self-confidence, worthlessness, guilt, failure to get pleasure, continuous fatigue, and tiredness also occur. On a cognitive level, pessimism, susceptibility, indecisiveness, aprosexia, thoughts and practices of self-destruction take place. Apart from these, on a behavioral level, problems like sleeping disorders, low energy, hardships in completing daily tasks, drifting apart from the surroundings and increasing amount of timidity can also be observed.

What is the Mixed Period?

It is the simultaneous occurrence of daily symptoms related to mania and depression. While some patients experience all of these periods from time to time, some patients may only face one of these states (mania, hypermania and depression) at a particular time.

When does Bipolar Disorder start?

It can be seen at any age but most frequently at the beginning of the 20s.

What is the frequency of Bipolar Disorder?

It is possible to encounter it in 1-2 people out of every 100 people. The same frequency is observed in other countries as well. There is no difference between genders in terms of frequency.

How does the sickness progress?

The first period of sickness might be a manic or depression period. There might be a "quiet period" of 3-10 years in between the first sickness period and the second one. The recurrence happens in 90% of cases. The duration of the periods, levels of intensity and frequency are contingent and differ from patient to patient. Irregular consumption of medic also affects the course of sickness. In fact, especially the abrupt cessation of protective medication like Lithium increases the risk of reoccurrence.

What is the reason of Bipolar Disorder?

One single reason stands out in particular. The issues related to the balance and transmission of brain chemicals called neurotransmitters are detected as general problems following the scientific research in field. Although the exact reason for the disorder is still unknown, it is widely accepted that it occurs due to genetic, biochemical and environmental circumstances. It can appear in any gender at any age and it is not related to the person's psychological construals and social situations. Stress and events in daily life may pull the trigger for the sickness.

Is Bipolar Disorder genetic?

While the probability of its occurrence in people whose have no relatives diagnosed with the sickness is around %1-2, this probability is higher (%7-8) for people whose first degree relatives (mother, father and siblings) have suffered from bipolar disorder,

The possibility of bipolar disorder identification in both of monozygotic twins is % 45-60, thus, inheritance is not sufficient to explain this phenomenon.

What is the treatment of Bipolar Disorder?

Stages of Treatment: Acute treatment (in times of initial symptoms) and Protective treatment (prevention from reoccurrence of the sickness).

Content of Treatment: Medication, Education and Psychotherapy.

The most important treatment is the medical treatment. There are two main treatment strategies: Firstly, the existing sickness period (mania or depression) needs to be treated and together with this, the planning of the protective treatment which is supposed to prevent the reoccurrence of the sickness should be planned. The treatment of sickness periods is not enough just by itself because bipolar disorder is a repetitive disorder. The main purpose of the bipolar disorder treatment is to warrant the consumption of relevant drugs and the re-arrangement of life conditions in a way that would reduce periods of sickness. Medication used for the treatment of bipolar disorder are:

Medication for the treatment of Mania: 1.Lithium (Lithuril); 2.Valproic Acid (Depakin, Convulex); 3. Carbamazepine (Tegretol, Trileptal); 4. Antipsychotics (drugs like Zyprexa, Rexapin, Oferta, Seroquel, Cedrina, Risperdal, Abilify, Zeldox, Norodol, Largactil and Clopixol); 5. Drugs with green prescription (Ativan, Rivotril, İmovane)

These drugs are used to reduce the insomnia and psychological/physical (hyperactivity, aggressive behaviours etc.) discomfort. The vaccine forms of these drugs can also be used in peak times of the mania period and/or in case of patient's rejection of the treatment.

Medication used in the treatment of Depression: Antidepressant medication is used together with emotional-state stabilizer drugs like lithium and lamotrigine. However, the sole usage of antidepressant medication may lead to the development of hypomania or mania within bipolar disorder. Antidepressant drugs show their effects in few weeks thus it requires patience. Until the time that it actually shows its impact, your doctor may prefer to add sedative drugs in order to avoid insomnia, dismay and discomfort. Your doctor would guide you to stop taking your medication when you are out of the depressive period. Antipsychotic drugs are also used from time to time.  

Drugs with protective purposes: Emotional stabilizers is the most important type of medication in controlling the symptoms of bipolar disorder. There is also lithium, valproic acid, carbamazepine, lamotrigine and antipsychotics.

Which medication requires blood levels be checked, and why? The blood levels of patients on lithium, valproic acide and carbamazepine need to be checked (maximum every 2-3 months for lithium and maximum 6 months for valproic acid and carbamazepine) at regular intervals. This is because these drugs are only effective within a certain range of blood levels. For lithium, the blood level should be 0.6-0.8 (0.8-1.2 in times of sickness), for valproic acid it should be 50-150 and for carbamazepine it should be 6-12. While they are not influential in low blood levels, they may also lead to unwanted consequences in case of high blood levels.

Guidelines for checking the blood level: Make sure the prescribed dosage of medication is taken otherwise the measured blood level might be misleading. The blood sample should be given 12 hours after the time when the last drug was used and on an empty stomach. In a contrary situation, your blood level would not be reliable and would mislead your doctor. Your doctor will check the functions of your kidney and thyroid from your blood. Female patients should avoid pregnancy in times of medication treatment. These drugs may especially have negative consequences on baby especially when they are consumed during the first three months of the pregnancy. Patients who are planning to have a child should definitely consult with their doctors beforehand.

Lithium's daily dose will be determined by your doctor in accordance with your blood level. Make sure that you do not change the dose by yourself. Lthium is usually used two or three times per day. Most people prefer to take the drug together with their meals. In order to prevent nausea, we do recommend you to use the drug after the meal.

The intake of water and salt is extremely important in people who use lithium. Due to its side-effects, lithium leads people to urinate frequently, and this leads to the feeling of thirst. If you reduce the amount of water intake in order reduce the frequency of bathroom visits, the lithium blood level will rise and the ascent of lithium from the kidneys will be slower. This might be dangerous for your health. Regarding the salt, if you really reduce the salt consumption then the outflow of lithium from the kidneys will be slower and the lithium blood level will rise. This may eventually lead to intoxication symptoms.

What are the side-effects of Lithium? It is possible to observe an increase in acnes, thirstiness, constant need to go to the bathroom, nausea, feeling sleepy (especially in high blood levels), muscular powerlessness, putting on weight and a metallic taste in the mouth. Since lithium leaves the body with the aid of the kidneys, kidney tests should be conducted every 6 months. Furthermore, since thyroid gland disorders are more common in female patients, thyroid hormones in blood need to be checked for once in every 6 months.

Symptoms of Lithium Intoxication: When the lithium blood level rises excessively (due to overdose, limitations on salt and water or combination of various drugs) severe diarrhea (more than 3-4 times per day), nausea, vomiting, intense vibration in hands and legs, muscle cramps, vision problems, sleepiness and loss of balance may occur. Make sure to immediately contact your doctor if you observe these symptoms.

Medication that increases the lithium blood level: Pain killers (nonsteroid anti-inflammatory), anti-hypertensive (excretion removers and ACE inhibitors) and some antibiotics. Make sure that you crosscheck (drug interaction) with your doctor when other doctors prescribe different medication. Your doctor will control your hemogram and the functions of your liver before you start to use carbamazepine or valproic acid. Female patients should avoid pregnancy in times of treatment with medication. These drugs may especially have negative consequences on babies especially when they are consumed in first three months of the pregnancy. Similar to lithium, the drugs should be used in doses recommended by doctors and the dose should not be changed.

Certain antipsychotics (Zyprexa, Risperdal, Leponex and Seroquel)  may lead to an increase in weight. Therefore, you should start to control your weight when you gain 1-2 kg during treatment. An increase in weight is particularly important since it is a threat for diabetes and cardiologic maladies. The blood sugar and fat level (cholesterol and triglyceride) should be measured 3 months after the start of treatment. These controls should continue on an annual basis.

Do not use any drugs other than the ones recommended by your doctor. Make sure that you do not change the dose by yourself. Contact your doctor in case of unwanted effects.

Why do side-effects occur?

Every drug definitely has at least one side-effect. These side-effects depend on the type and dose of your drug, body chemistry, age, other drugs that you consume and your other sicknesses. Consuming higher the prescribed dose and combination of multiple drugs may increase the side effects in times of acute treatment. A change in medication might be possible in case of serious side effects in a patient. If these side-effects create problems for you then your doctor may come up with the following recommendations: reduction in your doses, changing your medication, taking the drug at night and adding another drug which may lower the impact of side-effects.

Do not forget: Changing the dose by yourself may have severe consequences!!

What is the duration of medication?

When you stop taking your medication, the sickness might not show the symptoms immediately; however, it will definitely repeat itself. Although it is not going to be life-long, your treatment will be considerably long. Studies show that even patients who have used protective treatment for 5 years without any case of reoccurrence showed the symptoms of reoccurrence right after they stopped using their drugs. This was the case for an important portion of patients.

Both you and your family should be well-informed about the sickness and treatment processes for a successful treatment of bipolar disorder. You may sometimes want to quit your medication:

  1. You may feel good and believe that there is no need for the drug anymore,
  2. You may miss the days that you were enthusiastic and feeling so good,
  3. You may be unhappy with the side-effects of the drugs
  4. By thinking that this is solely related to the stress level of your life you may think that you can actually solve this sickness by staying away from the sources of stress or by creating alternative solutions.

What should be the ideal frequency of meeting with the doctor?

Before your registration at the hospital, you should at least meet once per week to discuss the determined symptoms from the treatment of mania and depression. If needed, you should communicate with your doctor every day. In case of an improvement in the overall situation, you may prefer to meet once every few months.

If you fit to one of the cases mentioned below, then you should call your doctor even if you do not have an appointment:

  • When there are thoughts of suicide or a feeling of violence,
  • When there is a change in your emotional-state, sleeping order and energy;
  • When there is a change in the side-effects,
  • When you need to use other drugs,
  • In case of an emergency operation or a dental operation.

Is there anything else other than medication in the treatment of bipolar disorder?

Treatment with medication creates positive outcomes on bipolar disorders. However, in some cases, medication by itself is insufficient to meet all needs. For this reason, especially in the last years, social and psychological problems are also taken into consideration. The purpose of this psychological treatment is to increase the life quality of the patient and help him/her live independently. The most important psychological treatment is to inform the patient and the parents about the sickness. One should note that psychotherapy does not replace medication but is a complementary application. Psychotherapy is used in improved periods of the patient.

Is there anything that the patient can do in order to avoid periods of sickness? For sure there is. The most important thing is gathering the right information about the sickness. Nevertheless, being informed is not enough by itself. Please give yourself and your relatives some time to adjust to the sickness. Using your drug in the way recommended by your doctor and your sleeping order are other things that you need to consider. We can list the risks that may restart the sickness periods and protective measures as follows:

1. Don't stop the medication: The most important risk factor. You must take your medication as suggested by your doctor. Always talk to your doctor in case of questions about medication.

2. Be careful about your sleep in spite of stressful daily events: It is quite indispensable for everyone to face stressful life events. The most important thing that bipolar disorder patients should take into consideration is the order of their daily life (mainly the sleeping order).

 3. Stay away from alcohol and substance consumption : Even drinking more than a small glass of alcohol may harm your sleeping and daily order and may even involve in interactions with some other medication that you use. Stay away from alcohol and narcotic substances.

4. Do not change your sleeping order: One of the topics that patients of bipolar disorder should pay most of their attention is their order of life and sleep. Disorders in daily life such as working within a shift-system and sleeping and waking up at different times may increase the risk.

5. Arrange your daily life: Having a settled daily schedule for going out, eating, sleeping around at the same time are few of the other protective factors.  

6. Try to solve family or friendship problems: It is beneficial to not to use anger and criticism expressions while discussing family, marriage and friendship issues. Try to solve your problems and expectations by expressing your emotions and expectations.  

7. Observe your emotional state: Recording how you feel on a daily basis is an extremely beneficial tool both for you and your doctor in order to observe the progress of your sickness. You may find the exclusive emotional state diary developed for this purpose in the attachment.

8. Activate your social supports: The presence of acquaintances who you can share your problems with, know how to act in periods of sickness and give you the required support is an important protective factor. Therefore, we can recommend you to strengthen your existing relationships while also developing new and intimate relationships..

9. Prepare an emergency plan: Making your family members aware of who needs to do what in times of sickness and discussing these with your doctor beforehand may actually help you and your acquaintaces. It might be really hard to bring the patients to the hospital in times of sickness since they do not accept their sickness in these periods and the relatives may have to use physical force. When the patient is in a rather good state, an approval should be taken in terms of bringing him to the doctor even he rejects to go to the hospital. The topic of who should help to get the patient to the hospital should be discussed with the patient beforehand. Considering the fact that, in the manic period the patients show a tendency to develop conflicts with the people they are really close with, this person might be a well-respected old family figure. Especially in the manic period, our patients may show behaviors like excessive shopping, driving with high speed, getting involved in relationships due to their increased sexual interests that they otherwise would not. In order to prevent these, it might be good to give the related permissions and approvals to your relatives about your credict cards, car keys, and your hospitalization before the time of sickness. Otherwise, both our patients and family members feel discomfort because of an unwanted scene of hospitalization and this may lead to conflicts in relationships. It should not be forgotten that our purpose for this period is the protection of the patient.


I have not been sick since a long time, what would happen if I stop taking my medication?

One of the biggest problems in the treatment of bipolar disorder is the patient's decision of stopping medication and/or changing the doses which were prescribed by the doctor. Your medication does not just cure your sickness but also protects you from reoccurrence. Therefore, even if you have not been sick for a long time, you need to keep taking your medication. If the idea of stopping medication comes to your mind, please discuss this with your doctor but do not stop it by yourself. The reasons of our patients for stopping medication are very diverse. Some of our patients do this in order to escape from the tagging of society towards people who consume psychiatric medication, others do this due to diffiulties accepting their own situation.

Although the symptoms of bipolar disorder are quite similar, each patient is quite different for the treatment crew, and their perspectives toward medication may differ. As a biologically-rooted phenomenon, bipolar disorder is not a disorder that one can avoid with his self-will. Some of our patients stop taking their medication by themselves thinking that their doctor will not allow them to do so. Stopping to take medication is the prime reason for the start of sickness periods. Researches show that stopping medication is the main factor for %75 of reoccurrences. Therefore, talk to your doctor if the idea of stoppping medication comes to your mind.

Would society isolate me because of my psychiatric disorder?

Our patients complain that they are discriminated and even isolated by the society from time to time. Unfortunately, just like any other country, there are also people in our country who tag patients with psychiatric sicknesses; however, most of our patients state that their relations with their social surroundings persist without any additional influence. Tagging people with psychological disorders is a problem observed and tackled not just in our country but all around the world.

In recent years, in addition to tagging by society, intrapersonal tagging is another topic which has been focused on. In our clinic, in addition to observing society tagging our patients, we also see that our patients tag themselves, try to escape from social mediums, and express concerns about isolation. This concern may lead to emotions of being distant from the society and loneliness with time.

In order to both tackle social tagging and intrapersonal tagging, we recommend our patients to share their sicknesses not with everybody but with people whom they trust.

End note

Bipolar disorder is a long term, repetitive and periodic phenomenon which may negatively influence the daily life of the individual. Nevertheless, in cases of full cooperation between patient, patient's relatives and the treatment crew, it is possible to obtain positive outcomes and return the patient back to his/her daily life. Gathering information about the sickness, staying with medication, sustaining daily routine and being surrounded by supportive close-ones are some of the protective measures against this disorder. It should not be forgotten that there are many workers, housewives, teachers, businessmen, doctors, poets and painters who managed to sustain their lives together with this sickness.

Recommendations for Acquaintances of Bipolar Disorder Patients

Just as our bipolar disorder patients, their close acquaintances may also suffer from this situation. It may take time for them to get use to this sickness. The first step of coping with this disorder is the acquisition of right information. First of all, familiarize yourself with this sickness. Have information about the causes, symptoms and treatment of the sickness. Talk to your doctor and ask him the resources that you can use in order to answer the questions that may come to your mind. Instead of trying to learn everything about this sickness in one day, give yourself some time to digest the information.

Hearing the diagnosis regarding a sickness is neither easy for the patient nor for his close ones. In the period of adjustment, the individual may reject the existence of a syndrome as such and feel sad/angry about it. Give yourself and your patient some time to adjust to this disorder.

It might be difficult to support and help the patient especially in times of sickness. Spare some time for yourself. Get support from your close-ones and feel free to receive help from a doctor in case you need it.

Some close acquaintances (especially parents and spouses) may blame themselves or get blamed due to the appearance of the sickness. Bipolar disorder is a disorder with biological fundamentals. Although environmental factors also play a role in the occurrence of the disorder, childhood events and/or a bad marriage do not lead to bipolar disorder. Parents and/or spouses do not have any guilt in the occurrence of bipolar disorder.

We are lucky because of the closeness of family and friendship in our society. Family members and friends protect and support their patients; nevertheless, one should abstain from being extremely protective. For example, hiding certain stuff with the concern that they might sadden the patient, or accomplishing responsibilities that the patient can actually do by himself, may reduce the patient's self confidence. Do not help with things that the patient can do by himself.

The cooperation between the patient, close-ones, and the treatment crew makes things easier for everyone. The close acquaintances of the patient are the most important helpers for both the treatment crew and the patient.


What are the aspects that we need to pay attention during the period of sickness?

As always, it is extremely important for patients to maintain the order in their medication in the manic period as well. Since patients may reject the existence and treatment of the disorder in this period, relatives may have to audit the intake of medication. It might be beneficial to define certain limits against the symptoms (excessive expenditures, increase in sexual interests, dangerous behaviors) of this period in order to protect the patient and the family.

Patients might struggle and talk rather harshly with close-ones within the manic period. Being aware of the fact that this is a symptom of the sickness may help close acquaintances to not take this behavior personally. Moreover, not being provocative and reduction of surrounding stimulates are also necessary.

The most important topic within the depression period is the risk of suicide. In the depression period, one needs to be awake and serious in case of suicide-related thoughts of the patient and should immediately communicate these with the doctor. A patient with depression needs support and a boost from his surroundings. The long term period of the sickness creates difficulties for the relatives of the patient as well as the patient by himself. Those relatives who feel like having difficulties coping with this situation should receive help and spare time for themselves.

The periods of sickness are not good times for serious decisions to be taken and important matters to be discussed. Instead, these should be postponed to the wellness state.

What are the things that we need to be careful about while the patient is getting better?

Every patient will eventually get back to his own tempo after the period of sickness. The expectations from the patient should not be high or low. Patients should not be forced to immediately get back to his pre-sickness life. On the other hand, one should not be over protective either. He should do the things that the patient needs to do together with the patient and not for him/her. Our main purpose is to make our patients independently stand on their own feet in times of wellness. It is necessary to motivate them about this subject matter.

It is necessary to behave normally towards the patient after the patient gets better; however, one should also be mindful of warning signs. The relative of the patient may realise the reoccurrence before the patient himself. One may have to draw attention to the symptoms of the sickness and suggest to meet with doctor when it is needed.

Indetifying every single moment of sadness or happiness as a symptom would make both you and the patient more concerned. Try to understand the differences between daily happiness and hypomania and a bad day with depression. Just as anyone else, there are positive and negative moods of bipolar disorder patients as well and they do not necessarily have to be at the level of sickness.


What are things to pay attention to during the wellness period?

Certain behavior that your patient shows prior to the sickness period are actually warning signs of the sickness. As it is mentioned before, make sure that you plan who will do what in case of sickness beforehand, together with your patient. For example, discuss and define certain limits against the symptoms (excessive expenditures, increase in sexual interests, dangerous behaviors) and exchange ideas about which actions you are going to take with the patient. Decide upon people who should help with hospitalization of the patient if the patient refuses to do so.

Monitor medication. Talk to your doctor when you notice deviations in medication routine, together with your patient. Sometimes, close acquaintances of the patients may complain about social tagging. In order to cope with this problem, do not feel like you have to discuss your patient's sickness with everyone. However, do so with people you are close to and trust.


If the patient is a parent, no matter where the patient is located, an understandable explanation should be made by a parent that the child trusts. It should be made clear that neither children nor the patient are guilty of this disorder.