Bipolar disorder

Diagnosis

Bipolar disorder is very rare in childhood, and getting a diagnosis before you’ve reached puberty is controversial. There are quite a few studies that suggest it might often start in the mid-teens. Bipolar disorder can be difficult to diagnose in young people because it is often only over a period of time that the pattern of your episodes becomes clearer. Milder episodes of hypomania can seem like other problems, or even extremes of normal mood and behaviour.

As a young person, bipolar disorder is only diagnosed if you have experienced an episode of mania, and during this episode you experienced euphoria (elated mood or feeling unusually happy) most of the time for at least seven days, as well as other symptoms of mania.

Your first episodes are often of depression, and so the diagnosis of bipolar disorder only becomes clear later when you experience a definite episode of mania.

There are different types of bipolar disorder, which vary in how severe the symptoms are and how long they last:

• Bipolar 1 is when you have episodes of depression and mania.
• Bipolar 2 is when you have episodes of depression and hypomania. In practice though bipolar 2 is not diagnosed in young people, because the diagnosis of bipolar disorder in young people requires at least one experience of a manic episode.
• Rapid cycling bipolar disorder is when you experience mood changes over hours to days, instead of the weeks to months which are more typical in bipolar disorder.
• Cyclothymia is when you have mood swings which are less severe than in bipolar disorder. This isn’t usually diagnosed in young people.

Co-existing conditions (also known as comorbidities)

Co-existing conditions are common for people with bipolar disorder. If you have a co-existing condition, your treatment for bipolar disorder will need adapting depending on your co-existing condition.

The most common co-existing conditions are:

• ADHD
• anxiety
• conduct disorder
• oppositional defiant disorder
• substance misuse

Other conditions which can also co-exist with bipolar disorder are:

• autism
• borderline personality disorder (in older adolescents)
• learning difficulties

If you have co-existing condition(s), combined treatment is often required for both conditions.

Getting help

If you are experiencing depression or possible mania you should see your GP, who should refer you to child and adolescent mental health services (CAMHS). In some areas you might be able to refer yourself to CAMHS. You might also have contact with other professionals, such as school nurses, who could refer you to CAMHS.

If you are experiencing mania or hypomania it might be other people, often parents or other family members, who notice that there is something wrong. Sometimes you might not agree there is a problem, which could make you feel reluctant to seek help.

If you have symptoms of psychosis and are over 14 you might be referred to an early intervention in psychosis (EIP) Service. These are usually linked to CAMHS, and often work from the same clinic.

You can find more information about mental health referrals here  and more information about local mental health services here.

Treatments for bipolar disorder

In the short term, your treatment for bipolar disorder will be aimed at treating symptoms of your current episode: mania, depression or mixed state. Your longer-term treatment will aim to prevent future episodes.

As with all mental health conditions treatment should follow a bio-psycho-social approach, with treatment for bipolar disorder usually involving:

• Biological factors: Different types of medication are used depending on the type of episode (mania, depression or mixed state) you are experiencing. Medication can also be used to prevent future episodes.
• Psychological factors: Psychological treatments (such as Cognitive Behavioural Therapy) are used to treat episodes of depression, symptoms of psychosis and to help prevent future episodes, and are used in combination with medication.
• Social factors: This involves identifying any social stresses that might trigger your episodes, and helping you manage these, as well as any social supports needed to help you with your recovery.

Overview of treatments for bipolar disorder

This overview briefly summarises the treatments for bipolar disorder which you will usually be offered. Each of the treatments described here is covered in more detail in its own individual treatment section.

Psychoeducation

Psychoeducation involves teaching you and your family more about bipolar disorder and how it can be treated. It is an essential part of any treatment for bipolar disorder. It can involve your family, or you could be offered individual psychoeducation.  

Usually your doctor will give you information about bipolar disorder when you are diagnosed and when you start a new treatment. Your CAMHS worker might also give you information about bipolar disorder during any contacts with them.   

There are different types of psychoeducation that you could be offered. Sometimes people might have a more formal psychoeducation programme which means working through a set number of sessions on different topics related to bipolar disorder.  

Psychoeducation should include information about: 

• mood monitoring 
• recognising and managing stressors 
• developing relapse prevention plans 
• having daily routines 
• stabilising sleep patterns 
• encouraging medication adherence 
• reducing self-stigma 
• avoiding alcohol and drug use 
• encouraging a healthy lifestyle (diet, exercise, and stopping smoking) 

Psychoeducation can be delivered as a group programme and these are often run by voluntary organisations such as Bipolar UK. As bipolar disorder in young people is rare, there may not be enough young people in your area who need psychoeducation at the same time as you to run a group specifically for young people. Some groups for adults will also allow 16 and 17 years old to join if they come with a parent or carer. If you do attend an adult psychoeducation group, it’s important to remember that adults may have different issues they want information and advice on, and some of the treatment strategies are different for adults.   

Treatments for mania

If you’re experiencing mania you are likely to need increased supervision by your parents or carers to help you manage your symptoms and reduce risks. During an episode of mania it is important that you have a calming environment, and reduce levels of stimulation. It is often advised that you don’t make any major decisions during an episode of mania. Your doctor and clinical team should discuss how to manage these things with you and your parents/carers.

Medication may be the first type of treatment you are offered for mania. The most commonly used medications for mania are second generation antipsychotics, which are sometimes also called ‘atypical antipsychotics’. Mood stabilisers such as lithium or sodium valproate might also be suggested to help with episodes of mania.  

If you have manic symptoms and are taking antidepressants, you should talk to your professional as soon as you can. They may advise you to stop taking the medication.  

If you have more severe episodes and/or you are at high risk of harm, you might need to be admitted to hospital. You may also need additional sedative medication (e.g., lorazepam) in the short-term to help reduce your levels of agitation and to help with sleep.   

Treatments for bipolar depression

You should be offered an individual psychological therapy as a first treatment option for bipolar depression. This could be either cognitive behavioural therapy (CBT) or interpersonal therapy (IPT). If these don’t work well for you, you might need a different psychological therapy such as family-based therapy, or a different type of individual therapy.

If your bipolar depression is moderate to severe your doctor should consider prescribing you medication.

Treatment for mixed states

NICE recommend that if you are treated for mixed episodes, the treatments offered to you should follow the recommendations for treatment of mania, but that there should be careful monitoring of whether the episode develops into depression.

Longer term treatments to prevent future episodes

Preventing future episodes involves helping you understand your bipolar disorder. This is sometimes called psychoeducation, and usually involves both you and your family. You should also be offered an individual or family psychological intervention for managing bipolar disorder in the longer term.

If there are any social stressors which have an effect on your mental health, or you or your family need extra support to help manage the impact of your bipolar disorder, your team should make a plan to help you with these.

Medication to help prevent future episodes of bipolar disorder can be prescribed to young people in some circumstances.

What about my parents or carers?

Involving parents and carers in the assessment and treatment of bipolar disorder is important and is usually helpful. Parents and carers will often be more aware of any history of bipolar disorder in your family and are often more able to take a longer-term view of how any symptoms or problems have developed. Family history and a longer-term knowledge of how your symptoms have varied of can be important in making the diagnosis. Parents or carers and other family members might also be good at helping to spot early warning signs. This doesn’t mean that your parents or carers will know everything that happens in your individual sessions. You can find more information about confidentiality and privacy here. 

Bipolar disorder can often result in risky behaviour, and involving parents or carers can also be important in helping you to stay safe. Parents or carers can also be useful in helping you manage your medication.

Depending on your age and whether you have capacity to make decisions about your treatment yourself, your parents might also be involved in making decisions about your treatment, or supporting you to make decisions. You can find more information about how treatment decisions are made here.   

The wellbeing of your parents or carers is important, and your professional should help them to access support and advice. This could include:

• group or individual support designed for parents and carers
• psychological support (e.g. a family therapy)
• Your professional should also help your parents or carers access an assessment to discuss their own needs.

Transition to adult services

Transition from CAMHS to services for adults usually occurs at about age 18. If you are under the care of Early Intervention in Psychosis (EIP) services they can work with you beyond age 18, although there might sometimes be a change of workers from professionals who normally work with young people, to professionals who usually work with adults.

If you do need to change service it is important for professionals in adult services to get to know you before your transition. You should get clear information about what to expect from adult services, and your professional should talk with you about how your family can be involved in planning the transition. 

You may also transition to another CAMHS service (e.g. if you move house). If this happens, your professional should work with you to make sure that your care can continue smoothly, and that your new service has all the information they need.

For more information about transitioning between services, please see Moving on.

Additional bipolar disorder support

The below organisations offer [diagnosis] specific support for children, young people and their families:

• AFC Crisis Messenger: a free, confidential, 24/7 text message support service for anyone who is feeling overwhelmed or is struggling to cope. If you need support, you text AFC to 85258.
• Bipolar UK: charity providing peer support services for people affected by bipolar
• Childline: Childline is there to help anyone under 19 in the UK with any issue they’re going through. Whether it’s something big or small, their trained counsellors are there to support you
• The Mix: support and advice for children and young people under 25

Treatments outlined on these webpages may not be available in every local area. It’s important that you discuss with your GP or mental health professional the treatment options available to you. You can also search for services near you on our Youth Wellbeing Directory and find out more about referral processes here.