York and District Mind

Manic depression is characterized by extremes of mood: periods of deep depression, and periods of overactive, excited behaviour known as mania. These severe highs and lows may occur directly after each other, or they may alternate with varying periods of stability. Some people diagnosed with manic depression also experience visual or auditory hallucinations or delusions.

While most people experience highs and lows in daily life, in manic depression these changes are extreme. During the manic or high phase people may feel euphoric, self-important and full of expansive ideas. This could include being extravagant, spending vast amounts of money and building up debts. During these periods they may be unable to sleep and take little time to eat. They may talk so quickly that it is difficult for others to understand what they are saying, and they can be irritable and angry. They may have no awareness of their changed attitude or behaviour. After a manic phase some people are shocked at what they have done and the effect that it has had. However, some of those diagnosed with manic depression find that they are very creative during mania, and argue that it is a very valuable experience.

Although mania may flare up, depression is often the primary consistent symptom. People may experience overwhelming despair, guilt and feelings of unworthiness. They might experience difficulty trying to concentrate or remember things, and feel unable to do the simplest task. They may want to kill themselves.

The most common form of manic depression - bipolar manic depression, also called affective mood disorder - involves both highs and lows. However, it is possible to be diagnosed with the condition and experience the depressive phase without a manic period; this is called unipolar affective disorder.

This is a less severe form of mania. The majority of people experiencing hypomania do not suffer a subsequent major depressive episode. (Mind Information produces a factsheet on hypomania)

About 1 per cent of the general population are diagnosed with manic depression; they are often intelligent and creative people. There seems to be no difference between the number of men and the number of women who are diagnosed. Manic depression generally appears when people are in their 20s or 30s, although some teenagers are affected.

Experiences of manic depression vary a great deal. Some people experience infrequent episodes, with years of stability. Some people only have a couple of episodes in their lifetime. Others may have frequent episodes. Experiencing four or more episodes of mania a year is sometimes referred to as 'rapid cycling'.

There are several theories as to the cause of manic depression. These theories are not necessarily compatible.

It would appear that siblings, parents and children of people with manic depression have a 5 to 15 per cent chance of developing the condition. An identical twin has a 70 per cent chance. However, as yet no particular genes have been identified as responsible for manic depression, and not all experts believe that genes play a part in manic depression. In any event it is generally agreed that genetic make-up alone cannot cause the condition - a 'trigger', often a stressful event, is also needed. (Mind Information produces a factsheet on genetics and mental health that includes a section on manic depression)

Some people link the start of their manic depression to stressors such as relationship breakdown, money problems or career changes. Some psychiatrists believe that these events trigger off a biochemical imbalance in the brain.

Some psychiatrists and psychotherapists believe manic depression can result from severe emotional damage caused in early life, perhaps the result of being overprotected or overcriticized as a child. This can produce in the adult a very fragile sense of self, and difficulties in containing any strong emotion. Those who point to these more developmental causes believe counselling, cognitive therapy or psychotherapy can be beneficial.

Another view is that manic depression is a reaction to what are considered unresolvable problems in everyday life. Mania is perceived as an escape from unbearable feelings of depression. Constantly blaming others for everything and being excessively irritable are seen as ways of avoiding emotional dependence on friends and relatives. Again, talking treatments are thought to be helpful once the condition has stabilized.

Some people believe that their mood swings are affected by the seasons. At present there is no evidence for this.

Services vary enormously from area to area; they are run by the NHS, social services departments and voluntary organizations. It is important to find out as much as you can about local services. Try asking your GP; the social services department, community health council, Citizens Advice Bureau and voluntary organizations such as local Mind. The first step is usually to contact your GP, who may refer you to a psychiatrist. If a treatment does not suit you, say so and ask for other options.

Lithium carbonate is the most common treatment prescribed for manic depression. It is a way to control the condition and not a cure. It should, therefore, be seen as a foundation for a much wider treatment that takes account of an individual's needs. If you are using lithium it is important to have frequent blood tests to ensure that the lithium in your blood does not reach a toxic level. It is also important that you maintain proper salt and water levels.

There are a number of side-effects associated with lithium. Some occur while the body is getting used to the treatment and should disappear. Side-effects such as vomiting or severe nausea, confusion or persistent diarrhoea may suggest that the level of lithium in the blood is reaching a dangerous level and that you should see your doctor. (See Making Sense of Treatments and Drugs: Lithium, and Lithium and Manic Depression, Further reading)

Carbamazepine is prescribed to curb agitation and has a sedative effect. For more information see Carbamazepine and Manic Depression (see Further reading).

Major tranquillizers such as Largactil or haloperidol are sometimes given to people for brief periods when mania is at its height - to control distressing symptoms. These drugs may cause some people considerable discomfort and distress. Prolonged use may cause permanent damage to the central nervous system. Mind Publications' booklet Making Sense of Treatments and Drugs: Major Tranquillizers gives further details of these drugs (Further reading).

This is a controversial treatment which involves passing an electric current through the brain of someone who is under anaesthetic. It is given for severe depression and was used to treat mania before major tranquillizers became available. It is important to bear in mind that ECT can have severe side-effects such as short- or long-term memory loss. It is used less now than it used to be, although some people do still find it helpful. (For further detaiIs see Mind Publications' Making Sense of Treatments and Drugs: ECT; Further reading)

Counselling or psychotherapy can help people understand why they feel as they do, why they behave in certain ways and perhaps to see the world in a different way. This sometimes helps people to overcome the relationship difficulties often associated with manic depression. Manic depressive episodes can be very stressful, and having the opportunity to talk about those experiences can help people to deal with them. However, psychotherapy for people diagnosed with manic depression is very rare under the NHS.

Cognitive behavioural therapy aims to help people to find out what their problems are and overcome emotional difficulties. It is a practical talking treatment with the focus on changing the negative thought patterns which are often associated with depression. (See Useful organizations and Further reading for sources of information about talking treatments.)

These nurses can visit you at home. They may offer practical help, a chance to talk, or they may administer medication.

They may be based in a local social services office, or at a hospital. Social workers can help you to get the most out of local services and welfare benefits. Hospital social workers help people who are leaving hospital and, if appropriate, may be able to find you accommodation.

There are hostels where people in need of support can live for a limited length of time and be helped by staff to gain the confidence to live independently again. Sheltered housing schemes offer less intensive support to a group of residents who can live there as long as they want. (Mind Information has produced a factsheet on housing advice; see Further reading)

These vary widely; some provide services such as therapy groups, counselling, information or advice; some offer a chance to learn new skills, such as cooking or crafts; some organize day trips, or simply the opportunity for a cup of tea and a chat. Some centres require a referral by a social worker or psychiatrist.

Mind Information has produced a factsheet on crisis services (see Further reading).

If you are particularly distressed you may benefit from shelter and protection in an environment that is not too demanding. At present hospital is often the only place that provides this. It will give staff the opportunity to assess your needs and try to find the best way to help you. And, for those close to you, it may provide some relief.

Most admissions are voluntary but, if you are unwilling to go into hospital, you may be admitted compulsorily under the Mental Health Act 1983. Mind Publications has a series of Rights Guides explaining people's rights in relation to compulsory hospital admission, consent to treatment and other issues (see Further reading p.10). You can obtain further advice from the community health council, a law centre or solicitor, Mind's Legal Department, accessed via MindinfoLine.

Unfortunately being in a psychiatric hospital or unit is often a distressing experience. The hospital may be very drab with little privacy. People miss their own possessions and surroundings, and it can be frightening to be with other people who are acting in a way which is difficult to understand. There may be little opportunity to talk to staff. If you stay in hospital a long time you may become so used to the institutional routine that you find it hard to face the demands of the outside world again.

During a manic phase you may have been unaware that your actions were distressing or even harmful to others. If you later find out how they felt you may feel guilty and ashamed. It can be especially difficult if those around you seem afraid or hostile. It can help to provide people with information about manic depression so as to increase their understanding.

After going through a manic depressive episode you may find it difficult to trust others and may want to cut yourself off. These feelings are to be expected after experiencing such difficulties, but it may be far more helpful to talk through your emotions and experiences with friends, family or a counsellor. There are now also many groups of people who have gone through similar problems and have come together to support each other. The Manic Depression Fellowship (see Useful organizations) can provide details of any local groups in your area.

Self-management involves finding out about manic depression and developing the skills needed to recognize and control mood swings. It can be very difficult at first to tell whether a 'high' is really the beginning of a manic episode or whether you are just feeling more confident, creative and socially at ease. It can be a strain to be watching continually for symptoms, particularly when you are first learning about manic depression's effect on your life.

Inside Out, produced by the Manic Depression Fellowship, is a guide to self-managing manic depression (see Further reading). The booklet features checklists and exercises to help you recognize and control mood swings. It includes practical tips for dealing with depression and mania. Self-management is by no means instant, and can take some time to use effectively. However, if you choose this method you may rely less on professionals, and have some control over mood swings. This in turn can lead to greater self-confidence.

It is important to take things gradually and avoid stressful situations. If you have a job you might want to find out if you can return on a part-time basis to start with. For more information on your rights at work, and on employment opportunities, see Mind Information's 'Brief guide to the Disability Discrimination Act', and factsheet on employment (Further reading).

It can be very distressing if you are a relative, partner or friend of someone who has been diagnosed with manic depression, particularly when the person is going through a manic phase. The person may not accept that there is anything unusual about their behaviour and may be hostile to you. However, you can be vital in providing support and in helping to get practical assistance.

It is important for you to have support in coping with your own feelings. The Manic Depression Fellowship and the Carers National Association may be able to help you in this (see Useful organizations). Try to give yourself time away from the person you are caring for, and to ask friends and relatives to help. You may find counselling helpful. Many carers also feel that learning as much as possible about manic depression can help them in caring.

Sometimes people with manic depression experience suicidal feelings. If the person you are caring for has such feelings you might find Mind Publications' booklet ‘How to Help Someone who is Suicidal’ useful (see Further reading).

It is not helpful to argue with someone if you feel that they are experiencing delusions, but it isn't useful to play along either. It sometimes helps to state how you see the situation by saying something like 'I accept that this is how you see things but I don't share that way of looking at it.' It can help to concentrate on how the person is feeling about the way they are seeing the world. It can be useful to the person you are supporting if you empathize with their emotions and encourage them to talk about them.

Someone who has been diagnosed with manic depression may find it hard to be organized. They may require some assistance with practical matters; for example in getting proper nourishment and enough rest. They may require help with financial matters, particularly if they have built up debts during a manic phase.

You could ask the person what support they feel they need and help by finding out what is available. You could help them if they decide to self-manage their manic depression. Respect their wishes regarding care as far as possible. If they are in agreement you can go ahead and approach agencies for help. It is worth remembering that under the Carers (Recognition and Services) Act 1995 carers are entitled to ask for an assessment of their needs from their local social services department.

If all else fails, particularly if the person is a risk to themselves or to other people, it may be necessary to seek admission to hospital. The 'nearest relative' as defined under the Mental Health Act 1983 has the legal right to request a mental health assessment from an approved social worker (ASW) to look at possible options and to decide whether the person should be detained. For more information about the Mental Health Act see Mind's leaflet 'An outline guide to the Mental Health Act'; there is also more information for friends and relatives in the leaflet Understanding Caring.

The Manic Depression Fellowship (MDF)
8-10 High Street, Kingston-upon-Thames, Surrey, KT1 lEY Tel. 0181 9746550, Fax 0181 9746600
A self-help organization for people diagnosed with manic depression, their friends, family and carers. They have many local branches which offer self-help support and produce publications. For more details send an s.a.e.

British Association for Counselling (BAC)
1 Regent Place, Rugby, Warwickshire, CV21 2PJ Tel. 01788578328 (recorded information message), Fax 01788562189
For a list of counsellors in your area write to the above address enclosing an s.a.e.

The Carers National Association (CNA)
20-25 Glasshouse Yard, London, EClA 4J5 Helpline 0345 573369 (lOa.m.-l2noon, 2-4p.m.), Fax 0171 4908824
Offers advice, information and support to carers.

National Debtline
318 Summer Lane, Newtown, Birmingham, B19 3RL Lo-call helpline: 0645 500511 (Mon,Thurs 10am-4pm, Tues, Wed 10am-7pm, Fri 10am-l2noon), Fax 0121 3596357
Offers confidential advice concerning debts.