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Mental Health Information Centre - Southern Africa

Bipolar disorder – 26 May 2015

What is bipolar disorder?

The essential characteristic of bipolar disorder is one or more manic episodes, usually, but not always, with one or more major depressive episodes.

Types of bipolar disorder

Bipolar I disorder: at least one previous manic episode.
Bipolar II disorder: at least one hypomanic episode (a milder form of mania), together with one or more major depressive episodes.

What causes bipolar disorder?

The exact cause of bipolar disorder is unknown, but it may be a combination of biochemical, genetic and psychological factors. Bipolar disorder occurs more frequently in first degree relatives of people with bipolar disorder than in the general public. Approximately 50% of patients with bipolar disorder have at least one parent with a mood disorder. Stressful life events such as childbirth, drug use, periods of sleeplessness, or medications such as anti-depressants or steroids, may trigger a manic episode.

Who gets bipolar disorder?

Men and women are affected equally. It usually starts between the ages of 15-25 years.

Characteristic symptoms

The essential characteristic is one of more manic episodes. Symptoms of a manic episode include:

  • Increased energy, activity and restlessness
  • Excessively high, euphoric mood
  • Extreme irritability
  • Spending sprees
  • Distractibility (cannot concentrate)
  • Little sleep needed
  • Racing thoughts, rapid speech
  • Poor judgment (excessive buying, sexual indiscretions)
  • Inflated self-esteem
  • Increased sociability
  • Binge eating, drinking and/or drug use
  • Denial that anything is wrong

Symptoms of a depressive episode include:

  • Persistent depressed mood, most of the day, almost every day
  • Decreased interest and pleasure in almost all activities
  • Insomnia or hypersomnia
  • Feelings of worthlessness, self-reproach, guilt
  • Tiredness, listlessness, restlessness or irritability
  • Impairment in concentration
  • Recurrent thoughts of death, suicidal ideation
  • Change in appetite and/or weight gain/loss


The first episode with which the patient with bipolar I disorder presents to a doctor is usually mania. Frequently, an episode of mania or major depression is followed by a short episode of the opposite type. There are often two or more episodes within a year. Occasionally, the episodes occur very frequently, with almost no “normal” or symptom-free periods in between. This is known as “rapid cycling”. It is impossible to predict the future course of bipolar disorder. It is important to note that, although the manic episodes are often more dramatic and obvious than the depressive episodes, patients with bipolar illness spend more time in the depressive phase than in the manic phase.


Bipolar disorder requires long-term treatment, since it is a chronic, relapsing illness. The most effective treatment plan includes a combination of medication, psychotherapy, lifestyle changes and social support.

Medication is used to stabilise the extreme mood swings of mania and depression. The mood stabilisers form the backbone of the treatment of bipolar illness. Diagnosis of the disorder can be tricky and medication should be closely monitored by a psychiatrist.

Treatment of the manic phase of bipolar disorder:
The manic patient usually requires hospitalisation, except when the condition is of a very mild degree. Hospitalisation in a psychiatric unit in a general hospital is possible if the patient is willing to undergo treatment. Admission to a psychiatric hospital is, however, usually necessary, and frequently as an involuntary patient (in accordance with the Mental Health Care Act). The duration of hospitalisation can be a few days, but usually it is a few weeks. After discharge, the patient is followed up as an outpatient for ongoing evaluation and adjustment of medication.

Treatment of the depressive phase of bipolar disorder:
Once again, the mood stabilisers form the cornerstone of treatment. Unopposed prescription of anti- depressants (i.e. anti-depressant without a mood stabiliser) must be avoided as it can induce “rapid cycling”.

Bipolar medications are powerful drugs. For this reason, medication should not be stopped without a doctor’s supervision.

When to call the doctor

Over and above the normal consultations, call the doctor when there are:

  • Suicidal feelings or violent behaviour
  • Changes in mood, sleep or energy levels
  • An increase in medication side-effects
  • An acute medical illness, a need for surgery, or an need for other medications

The vast majority of people with bipolar disorder respond well to treatment. The first step is to discuss your symptoms with an experienced professional, like your family practitioner.

Acknowledgement: Textbook of Psychiatry, Emsley, Pienaar & Seedat

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University of Stellenbosch
South African Medical Research Council
University of Cape Town