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Sandya lost half a leg in a bike accident in 1992. Three years later, she moved to the United Arab Emirates to get a sense of self and gain independence. Apart from feeling a little down occasionally, all was well. There were some mood swings, but this was only natural, she thought, after an accident.

Sandya, who did not want to disclose her full name, worked in various capacities, running her own restaurant for a while, and finally working as the brand assistant of a multinational cosmetic company. Her mood swings increased. She would go from an euphoric “saviour-of-the-world" feeling to extreme depression within a span of weeks. People around her couldn’t understand why she was up one day and down the next. She struggled with mood swings for years without understanding what caused them. Financial problems, bad relationships and living on the edge became a way of life.

In 2005, however, the low moods got to a point where death was the only thing on her mind. She realized she needed help and approached a doctor. She was diagnosed with bipolar disorder.

Priya Pothan, a Bangalore-based clinical psychologist, says: “Bipolar disorder is primarily a mood disorder due to a biochemical imbalance. Here, the mood variations, the ‘highs’ or ‘lows’ a person goes through, are markedly more intense and prolonged than our regular mood fluctuations." The “low" mood is the depression phase of the illness whereas the “high" mood is clinically termed mania.

The disorder has a strong genetic correlation, but environmental factors also play a role. Life events and interpersonal relationships can be a trigger. Johnson Pradeep R., assistant professor, department of psychiatry, St John’s Medical College Hospital, Bangalore, says: “The age of onset of the disorder is around the 30s, and generally women are more susceptible than men. The episodes of mania and depression are usually connected with stress." Worldwide incidence ranges from 0.6-2%; in India, it is estimated to be 1-2%, according to Dr Johnson.

There are many types of clinical bipolar disorder with varying symptoms and patterns. J.C. Narayanaswamy, assistant professor, department of psychiatry, Nimhans, Bangalore, says: “In most patients, both manic and depressive phases occur. There may be a subset of patients who have only manic episodes. Also, some patients have many episodes of depression and only very few episodes of mania. So the proportion varies considerably and it is quite difficult to predict a pattern. Generally, in both phases, the person becomes dysfunctional at work and in their personal life."

A study of 439 subjects, conducted by Dr Narayanaswamy and his team at Nimhans, found that the manic phase is more prevalent here; in Western countries, the depressive phase is more prevalent. “Bipolar disorder is affected by various factors which set our biological rhythm, such as sunlight, sleep, regularity of food habits and regularity of routine. Among these, sunlight is a very critical factor," says Dr Narayanaswamy. He believes the prevalence of mania could be related to more sunlight in our regions, as opposed to the cold and temperate climate of Western countries. The study was published online in the journal Medical Hypotheses in June.

Dr Johnson says: “In the manic phase, symptoms can include decreased need for sleep, increased energy, grandiose ideas, increased self-esteem, delusions, irritability, shopping unnecessarily, and increased grooming." People can even get violent—hitting others and harming themselves. In the depression phase, a pervasive low mood affects every aspect of life. Nothing elevates depression, and sufferers feel fatigued.

Sandya says that in the manic phase, she would survive on 4 hours of sleep, shop for things she didn’t really need and go out of her way to help others, thinking she had to “sort out the world". Her brain would be wired up with so many thoughts that it would be hard to filter them out. She could come up with “brilliant business plans" but be unable to execute them. On the other hand, the depression would take her into a deep dark place, and she would hide from the world, lying in bed, unable to do anything for days.

Bipolar disorder often goes undiagnosed because of the variability of symptoms—and the fact that the individual needs to come forward with his/her experiences. Ignorance of symptoms and fear of being stigmatized often lead to a delay in diagnosis.

Diagnosis is based on international guidelines, basically a question and answer format. Treatment includes mood stabilizers and antidepressants. According to Pothan, the characteristic of bipolar disorder is recurring episodes of high and low moods. The “high" periods last typically two weeks to four months while the “low" periods last around six months, with interspersed periods of normality.

Dr Johnson says: “The treatment is done in three phases. First is the acute management, where mood stabilizers and antidepressants are given and the patient is monitored regularly. During the continuation phase, the medications are adjusted according to the symptoms and patterns." The third phase is maintenance, where the patient continues to take medications. Dr Narayanaswamy adds: “Severe and disruptive episodes of mania or severe depressive phases with suicidal thoughts might warrant hospitalization. Psychological interventions and educating the patients regarding the factors that maintain regularity in biological and social rhythms goes without saying."

Sandya says that while her medication kept her moods on an even keel, what really helped her manage her illness was therapy. She has been going to a clinical psychologist for the past two years, initially twice a week, and now once a week. Now, she knows when a manic or depressive phase is coming on, and takes steps to manage it.

Pothan explains, “In psychotherapy, the client learns to understand his/her stressors and stress thresholds as higher stress levels can also precipitate/aggravate their episodes. Strategies are provided for how he/she can cope better with bipolar and overall lower stress levels. Families are taught how to progress with moderation as a family together rather than focus on the person with the mood disorder."

Sandya realized that a certain type of music increased her mania, so she stays away from it. She tries to sleep early, and follows a routine. “I’m more aware of what’s happening to me and I’m confident that I can now take on a job."

The cure for bipolar disorder varies from case to case. Some patients have a good prognosis; some have to be on medication for life.

Pothan says: “We have to understand that bipolar disorder can occur and can be effectively handled with regular supervised medication with a psychiatrist and psychotherapy with a qualified mental health professional. With appropriate treatment and management, an individual can live a fulfilling life."

Watch Out

Signs that may point to a brewing bipolar episode and how to deal with it

Manic phase

Overcheerfulness; high energy levels; increased activity levels; grandiose planning; decreased need for sleep; increased self-esteem; delusions; shopping unnecessarily; increased grooming; easily agitated or irritable; moved to violence —harming others or/and themselves.

Depressive phase

Low self-esteem; craving for carbohydrates; sleep disturbance; lethargy; pessimism; lack of appetite; suicidal.

—Compiled with inputs from Johnson Pradeep R., assistant professor, department of psychiatry, St John’s Medical College Hospital, Bangalore; and J.C. Narayanaswamy, assistant professor, department of psychiatry, Nimhans, Bangalore.

Management

Structured daily routine; adequate nutrition; adequate and regular sleep; regularized working hours; relaxation with Pranayam/yoga; family support.

—Priya Pothan, clinical psychologist, Bangalore.

Write to us at businessoflife@livemint.com

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