Of Cycles and Bipolar Disorder

A guide to utter chaos.

The Frontier Psychiatrists is this very newsletter. Today, how I think about bipolar disorder. I’ve written about my personal experience with this illness more than once. It’s not a secret. I’ve done podcast versions! We (with @Psych Fox and Carlene MacMillan, MD ) have busted myths about it.

Manic-Depressive illness was a well-understood condition, and its rebrand as “bipolar disorder” and, more perniciously, “bipolar II” didn’t do the field of psychiatric care any favors. I’ve written about the role of Depakote in the evolution of the misunderstanding of this illness. I will define some concepts, and I hope they help clarify things!

Bipolar disorder is a mental illness that has profound underlying biology. It lives in your brain and body.

At least once, there will be a manic episode. Mania is a state—in a time-limited period—where someone acts differently. This can range from a little different to “completely bonkers” different. It’s in the direction of “more”—more energy, more volatile mood, more enthusiasm, more grandiosity, more irritability, more sex, more drugs, more rock and roll, more spending, more wakefulness. The only things that we get less of are sleep and good sense.

The “mood” part of this “mood disorder” is conceptually less important than the “episodic” nature of the mood. Someone can be irritable, expansive, grandiose, and have mania or not have mania. It is the time course that will help us differentiate between mania, as a symptom of the brain disorder bipolar disorder, and being a huge *ssh*le, for example.

Most individuals with bipolar disorder don’t spend most of their time manic:

The above graph is from a paper by R. Uher et al.¹, which demonstrates that the range is from “rare to often.”… Most people with bipolar disorder spend only a small amount of time manic. They have symptoms that only last eight weeks, plus or minus. They have some very mild symptoms, some moderate, and some severe. There is a range.

This is in contrast to the experience of episodes—again, time-limited—depression in those with bipolar disorder:

You will note that the lines are more towards the right—more individuals are more depressed more often, even with “bipolar”—it’s depression… plus! Mostly, it’s bad depression…some of the time.

The crucial idea for this article is that “episode” — a period different from other times— is the sin e qua non of bipolar disorder. It’s not about mood alone. Mood, a snapshot of mood, can be anything. It could be narcissism, hypoglycemia, acute intoxication, sleep deprivation, or a bad day. Bipolar disorder has episode(s)—more than one, usually. They will recur. They will have some frequency.

This is hard to predict:

The course of bipolar-I disorder from onset was largely random or chaotic over nearly 6 years from onset.²

A long initial hospitalization is a predictor of cycles being longer, and fewer episodes are predictive of things being shorter, but total cycles didn’t tell us much:

The distribution of cycle length is also very much not a normal distribution, as we can see from research data from Baldessarini’s data:

Bipolar disorder is episodic, and some people slow down, and some speed up in terms of cycles. It is hard to predict what will happen next. This is frustrating for patients and clinicians alike.

The good news? It tends to get a little better over time, with fewer cycles and less lengthy cycles seen on average³:

My takeaway is that people with bipolar disorder tend to suffer on repeat, and it would be awesome if we could fix this. But the suffering ends, even if it will come back:

The median duration of bipolar I mood episodes was 13 weeks. More than 75% of the subjects recovered from their mood episodes within 1 year of onset.⁴

We reliably don’t, with current treatments. We know lithium helps people not die by suicide. It also means less suffering from fewer cycles:

Lithium was more effective than placebo in preventing overall mood episodes (Relative Risk (RR) 0.66, manic episodes(RR 0.52), and, dependent on the type of analyses applied, depressive episodes (RR 0.78)…⁵

The actual role of sleep in the pathophysiology of bipolar disorder is wildly complicated. Still, it is fair to say it’s a problem.⁶. Addressing bad sleep is a good idea.

Bipolar disorder: It’s Episodic.

There are mood symptoms, but it’s about the episodic nature, not the mood alone!

—Owen Muir, M.D.

1. Uher, R., Mantere, O., Suominen, K., & Isometsä, E. (2013). Typology of clinical course in bipolar disorder based on 18-month naturalistic follow-up. Psychological medicine, 43(4), 789-799.

2. Baldessarini, R. J., Salvatore, P., Khalsa, H. M., Imaz-Etxeberria, H., Gonzalez-Pinto, A., & Tohen, M. (2012). Episode cycles with increasing recurrences in first-episode bipolar-I disorder patients. Journal of affective disorders, 136(1-2), 149-154.

3. Subramanian, K., Kattimani, S., Rajkumar, R. P., Bharadwaj, B., & Sarkar, S. (2016). What happens to episode duration and cycle length over the course of bipolar disorder?. Australasian Psychiatry, 24(4), 376-380.

4. Solomon, D. A., Leon, A. C., Coryell, W. H., Endicott, J., Li, C., Fiedorowicz, J. G., ... & Keller, M. B. (2010). Longitudinal course of bipolar I disorder: duration of mood episodes. Archives of general psychiatry, 67(4), 339-347.

5. Hui, T. P., Kandola, A., Shen, L., Lewis, G., Osborn, D. P. J., Geddes, J. R., & Hayes, J. F. (2019). A systematic review and meta‐analysis of clinical predictors of lithium response in bipolar disorder. Acta Psychiatrica Scandinavica, 140(2), 94-115.

6. Gold, A. K., & Sylvia, L. G. (2016). The role of sleep in bipolar disorder. Nature and science of sleep, 207-214.