Disease: Bipolar Disorder in Children and Teens: A Parent's Guide

    Introduction

    All parents can relate to the many changes their kids go through as they grow up. But sometimes it's hard to tell if a child is just going through a "phase," or perhaps showing signs of something more serious.

    Recently, doctors have been diagnosing more children with bipolar disorder, sometimes called manic-depressive illness. But what does this illness really mean for a child?

    What is bipolar disorder?

    Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood and energy. It can also make it hard for someone to carry out day-to-day tasks, such as going to school or hanging out with friends. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. They can result in damaged relationships, poor school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

    Bipolar disorder often develops in a person's late teens or early adult years, but some people have their first symptoms during childhood. At least half of all cases start before age 25.

    What are common symptoms of bipolar disorder in children and teens?

    Youth with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

    Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. Symptoms of bipolar disorder are described below.

    Symptoms of mania include: Mood Changes
    • Being in an overly silly or joyful mood that's unusual for your child. It is different from times when he or she might usually get silly and have fun.
    • Having an extremely short temper. This is an irritable mood that is unusual.
    Behavioral Changes
    • Sleeping little but not feeling tired
    • Talking a lot and having racing thoughts
    • Having trouble concentrating, attention jumping from one thing to the next in an unusual way
    • Talking and thinking about sex more often
    • Behaving in risky ways more often, seeking pleasure a lot, and doing more activities than usual.
    Symptoms of depression include: Mood Changes
    • Being in a sad mood that lasts a long time
    • Losing interest in activities they once enjoyed
    • Feeling worthless or guilty.
    Behavioral Changes
    • Complaining about pain more often, such as headaches, stomach aches, and muscle pains
    • Eating a lot more or less and gaining or losing a lot of weight
    • Sleeping or oversleeping when these were not problems before
    • Losing energy
    • Recurring thoughts of death or suicide.

    It's normal for almost every child or teen to have some of these symptoms sometimes. These passing changes should not be confused with bipolar disorder.

    Symptoms of bipolar disorder are not like the normal changes in mood and energy that everyone has now and then. Bipolar symptoms are more extreme and tend to last for most of the day, nearly every day, for at least one week. Also, depressive or manic episodes include moods very different from a child's normal mood, and the behaviors described in the chart above may start at the same time. Sometimes the symptoms of bipolar disorder are so severe that the child needs to be treated in a hospital.

    In addition to mania and depression, bipolar disorder can cause a range of moods, as shown on the scale below. One side of the scale includes severe depression, moderate depression, and mild low mood. Moderate depression may cause less extreme symptoms, and mild low mood is called dysthymia when it is chronic or long-term. In the middle of the scale is normal or balanced mood.

    Range of moods in bipolar disorder

    Sometimes, a child may have more energy and be more active than normal, but not show the severe signs of a full-blown manic episode. When this happens, it is called hypomania, and it generally lasts for at least four days in a row. Hypomania causes noticeable changes in behavior, but does not harm a child's ability to function in the way mania does.

    What affects a child's risk of getting bipolar disorder?

    Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the building blocks of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

    Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, most children with a family history of bipolar disorder will not develop the illness.

    Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:

    • Missed work because of their illness
    • Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
    • Been treated or hospitalized for bipolar disorder.

    The researchers also identifies certain traits that appeared to run in families, including:

    • History of psychiatric hospitalization
    • Co-occurring obsessive-compulsive disorder (OCD)
    • Age at first manic episode
    • Number and frequency of manic episodes.

    Scientists continue to study these traits which may help them someday find the genes that cause bipolar disorder.

    However, genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how theses factors interact to cause bipolar disorder.

    How does bipolar disorder affect children and teens differently than adults?

    Bipolar disorder that starts during childhood or during the teen years is called early-onset bipolar disorder. Early-onset bipolar disorder seems to be more severe than the forms that first appear in older teens and adults. Youth with bipolar disorder are different from adults with bipolar disorder. Young people with the illness appear to have more frequent mood switches, are sick more often, and have more mixed episodes.

    Watch out for any sign of suicidal thinking or behaviors. Take these signs seriously. On average, people with early-onset bipolar disorder have greater risk for attempting suicide than those whose symptoms start in adulthood. One large study on bipolar disorder in children and teens found that more than one-third of study participants made at least one serious suicide attempt. Some suicide attempts are carefully planned and others are not. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that must be treated.

    How is bipolar disorder detected in children and teens?

    No blood tests or brain scans can diagnose bipolar disorder. However, a doctor may use tests like these to help rule out other possible causes for your child's symptoms. For example, the doctor may recommend testing for problems in learning, thinking, or speech and language. A careful medical exam may also detect problems that commonly co-occur with bipolar disorder and need to be treated, such as substance abuse.

    Doctors who have experience with diagnosing early-onset bipolar disorder, such as psychiatrists, psychologists, or other mental health specialists, will ask questions about changes in your child's mood. They will also ask about sleep patterns, activity or energy levels, and if your child has had any other mood or behavioral disorders. The doctor may also ask whether there is a family history of bipolar disorder or other psychiatric illnesses, such as depression or alcoholism.

    Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

    1. Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.
    2. Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.
    3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
    4. Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years (one year for children and adolescents). However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

    When children have manic symptoms that last for less than four days, experts recommend that they be diagnosed with BP-NOS. Some scientific evidence indicates that about one-third of these young people will develop longer episodes within a few years. If so, they meet the criteria for bipolar I or II.

    Also, researchers are working on whether certain symptoms mean a child should be diagnosed with bipolar disorder. For example, scientists are studying children with very severe, chronic irritability and symptoms of ADHD, but no clear episodes of mania. Some experts think these children should be diagnosed with mania. At the same time, there is scientific evidence that suggests these irritable children are different from children with bipolar disorder in the following key areas: the outcome of their illness, family history, and brain function.

    When you talk to your child's doctor or a mental health specialist, be sure to ask questions. Getting answers helps you understand the terms they use to describe your child's symptoms.

    What illnesses often co-exist with bipolar disorder in children and teens?

    Several illnesses may develop in people with bipolar disorder.

    Alcoholism. Adults with bipolar disorder are at very high risk of developing a substance abuse problem. Young people with bipolar disorder may have the same risk.

    ADHD. Many children with bipolar disorder have a history of ADHD. One study showed that ADHD is more common in people whose bipolar disorder started during childhood, compared with people whose bipolar disorder started later in life. Children who have co-occurring ADHD and bipolar disorder may have difficulty concentrating and controlling their activity. This may happen even when they are not manic or depressed.

    Anxiety Disorders. Anxiety disorders, such as separation anxiety and generalized anxiety disorder, also commonly co-occur with bipolar disorder. This may happen in both children and adults. Children who have both types of disorders tend to develop bipolar disorder at a younger age and have more hospital stays related to mental illness.

    Other Mental Disorders. Some mental disorders cause symptoms similar to bipolar disorder. Two examples are major depression (sometimes called unipolar depression) and ADHD. If you look at symptoms only, there is no way to tell the difference between major depression and a depressive episode in bipolar disorder. For this reason, be sure to tell a diagnosing doctor of any past manic symptoms or episodes your child may have had. In contrast, ADHD does not have episodes. ADHD symptoms may resemble mania in some ways, but they tend to be more constant than in a manic episode of bipolar disorder.

    What treatments are available for children and teens with bipolar disorder?

    To date, there is no cure for bipolar disorder. However, treatment with medications, psychotherapy (talk therapy), or both may help people get better.

    It's important for you to know that children sometimes respond differently to psychiatric medications than adults do.

    To treat children and teens with bipolar disorder, doctors often rely on information about treating adults. This is because there haven't been many studies on treating young people with the illness, although several have been started recently.

    One large study with adults funded by NIMH is the Systematic Treatment Enhancement Program for Bipolar Disorder. This study found that treating adults with medications and intensive psychotherapy for about nine months helped them get better. These adults got better faster and stayed well longer than adults treated with less intensive psychotherapy for six weeks. Combining medication treatment and psychotherapies may help young people with early-onset bipolar disorder as well. However, it's important for you to know that children sometimes respond differently to psychiatric medications than adults do.

    Medications

    Before starting medication, the doctor will want to determine your child's physical and mental health. This is called a "baseline" assessment. Your child will need regular follow-up visits to monitor treatment progress and side effects. Most children with bipolar disorder will also need long-term or even lifelong medication treatment. This is often the best way to manage symptoms and prevent relapse, or a return of symptoms.

    It's better to limit the number and dose of medications. A good way to remember this is "start low, go slow." Talk to the psychiatrist about using the smallest amount of medication that helps relieve your child's symptoms. To judge a medication's effectiveness, your child may need to take a medication for several weeks or months. The doctor needs this time to decide whether to switch to a different medication. Because children's symptoms are complex, it's not unusual for them to need more than one type of medication.

    Keep a daily log of your child's most troublesome symptoms. Doing so can make it easier for you, your child, and the doctor to decide whether a medication is helpful. Also, be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements your child is taking. Taking certain medications and supplements together may cause unwanted or dangerous effects.

    Some of the types of medications generally used to treat bipolar disorder are listed below. Information on medications can change.

    Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:

    • Lithium: Sometimes known as Eskalith or Lithobid, lithium was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
    • Valproc acid or vivalproex sodum (Depakote): This substance was approved by the FDA in 1995 for treating mania, and is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder. Also see the section in this booklet, "Should young women take valproic acid?"
    • Lamotrigine (Lamictal): More recently, this anticonvulsant received FDA approval for maintenance treatment of bipolar disorder.
    • Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.

    Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored fro new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional

    Lithium and Thyroid Function

    People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people. Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

    Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

    Should young women take valproic acid?

    Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20. PCOS causes a woman's eggs to develop cysts, or fluid-filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid. Young girls and woman taking valproic acid should be monitored carefully by a doctor.

    Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional," or "first-generation" anti-psychotics.

    Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.28 Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.

    Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.

    Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.

    Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.

    Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.29 To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.

    Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.

    Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

    Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.

    What are the side effects of these medications?

    Before your child starts taking a new medication, talk with the doctor or pharmacist about possible risks and benefits of taking that medication.

    The doctor or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than past treatments. However, everyone responds differently to medications, and in some cases, side effects may not appear until a person has taken a medication for some time.

    If your child develops any severe side effects from a medication, talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. Children and teens being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms or other uncomfortable or potentially dangerous withdrawal effects.

    The following sections describe some common side effects of the different types of medications used to treat bipolar disorder.

    Mood Stabilizers

    In some cases, lithium can cause side effects such as:

    • Restlessness
    • Frequent urination
    • Dry mouth
    • Bloating or indigestion
    • Acne
    • Joint or muscle pain
    • Brittle nails or hair.

    Lithium may cause other side effects not listed here. Tell the doctor about bothersome or unusual side effects as soon as possible.

    If your child is being treated with lithium, it is important for him or her to see the treating doctor regularly. The doctor needs to check the levels of lithium in the child's blood, as well as kidney function and thyroid function.

    Each mood stabilizing medication is different and can cause different types of side effects. Some common side effects of lamotrigine and valproic acid include:

    • Drowsiness
    • Dizziness
    • Headache
    • Diarrhea
    • Constipation
    • Heartburn
    • Mood swings
    • Stuffed or runny nose, or other cold-like symptoms.

    These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the specific medications your child is taking.

  • Atypical Antipsychotics Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:
    • Drowsiness
    • Dizziness when changing positions
    • Blurred vision
    • Rapid heartbeat
    • Sensitivity to the sun
    • Skin rashes
    • Menstrual problems for girls
    • Weight gain.

    Atypical antipsychotic medications can cause major weight gain and changes in metabolism. This may increase a person's risk of getting diabetes and high cholesterol. While taking an atypical antipsychotic medication, your child's weight, glucose levels, and lipid levels should be monitored regularly by a doctor.

    In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these movements. TD can range from mild to severe, and it cannot always be cured. Sometimes people with TD recover partially or fully after they stop taking the drug.

    Antidepressants FDA Warning on Antidepressants

    Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website .

    The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include:

    1. Headache, which usually goes away within a few days.
    2. Nausea (feeling sick to your stomach), which usually goes away within a few days.
    3. Sleep problems, such as sleeplessness or drowsiness. This may occur during the first few weeks but then goes away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
    4. Agitation (feeling jittery)
    5. Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.
    6. Some antidepressants are more likely to cause certain side effects than other antidepressants. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.
    Sexual Activity, Pregnancy, and Teens with Bipolar Disorder

    Many teens make risky choices about sex. The U.S. Centers for Disease Control and Prevention (CDC) recently reported that 26 percent of teenage girls in the United States have at least one of the four most common sexually transmitted diseases. This suggests that many teens are having unprotected sex or taking part in other risky behaviors.

    Bipolar disorder is also linked with impulsive and risky choices. Teenage girls with bipolar disorder who are pregnant or may become pregnant face special challenges because medications for the illness may have harmful effects on a developing fetus or nursing infant. Specifically, lithium and valproic acid should not be used during pregnancy. Also, some medications may reduce the effectiveness of birth control pills.

    Psychotherapy

    In addition to medication, psychotherapy ("talk" therapy) can be an effective treatment for bipolar disorder. Studies in adults show that it can provide support, education, and guidance to people with bipolar disorder and their families. Psychotherapy may also help children keep taking their medications to stay healthy and prevent relapse.

    Children and teens may also benefit from therapies that address problems at school, work, or in the community.

    Some psychotherapy treatments used for bipolar disorder include:

    1. Cognitive behavioral therapy helps young people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
    2. Family-focused therapy includes a child's family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their child. This therapy also improves communication and problem-solving.
    3. Interpersonal and social rhythm therapy helps children and teens with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
    4. Psychoeducation teaches young people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Psychoeducation also may be helpful for family members and caregivers.

    Other types of therapies may be tried as well, or used along with those mentioned above. The number, frequency, and type of psychotherapy sessions should be based on your child's treatment needs.

    A licensed psychologist, social worker, or counselor typically provides these therapies. This professional often works with your child's psychiatrist to monitor care. Some may also be licensed to prescribe medications; check the laws in your state.

    In addition to getting therapy to reduce symptoms of bipolar disorder, children and teens may also benefit from therapies that address problems at school, work, or in the community. Such therapies may target communication skills, problem-solving skills, or skills for school or work. Other programs, such as those provided by social welfare programs or support and advocacy groups, can help as well.

    Some children with bipolar disorder may also have learning disorders or language problems. Your child's school may need to make accommodations that reduce the stresses of a school day and provide proper support or interventions.

    What can children and teens with bipolar disorder expect from treatment?

    There is no cure for bipolar disorder, but it can be treated effectively over the long term. Doctors and families of children with bipolar disorder should keep track of symptoms and treatment effects to decide whether changes to the treatment plan are needed.

    Sometimes a child may switch from one type of bipolar disorder to another. This calls for a change in treatment. In the largest study to date on childhood bipolar disorder, the NIMH-funded Course and Outcome of Bipolar Illness in Youth (COBY) study, researchers found that roughly one out of three children with BP-NOS later switched to bipolar I or II. Also, roughly one out of five children who started out with a diagnosis of bipolar II switched to bipolar I. Because different medications may be more helpful for one type of symptom than another (manic or depressive), your child may need to change medications or try different treatments if his or her symptoms change.

    The COBY study also showed that treatment helped around 70 percent of children with bipolar disorder recover from their most recent episode (either manic or depressive). In this study, recovery meant having two or fewer symptoms for at least eight weeks in a row. On average, it took a little over a year and a half to recover. However, within the next year or so, symptoms returned in half of the children who recovered. Children with bipolar I or II tended to recover faster than those with BP-NOS, but their symptoms returned more frequently as well.

    If your child has other psychiatric illnesses, such as an anxiety disorder, eating disorder, or substance abuse disorder, he or she may be more likely to experience a relapse -- especially depressive symptoms. Scientists are unsure how these co-existing illnesses increase the chance of relapse.

    Working closely with your child's doctor and therapist and talking openly about treatment choices can make treatment more effective. You may need to talk about changing the treatment plan occasionally to help your child manage the illness most effectively.

    Also, you may wish to keep a chart of your child's daily mood symptoms, treatments, sleep patterns, and life events, which can help you and your child better understand the illness. Sometimes this is called a mood chart or a daily life chart. It can help the doctor track and treat the illness more effectively. Examples of mood charts can be found on the Internet.

    Recently, NIMH funded a clinical trial called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). This was the largest treatment study ever conducted for bipolar disorder. In a study on psychotherapies, STEP-BD researchers compared people in two groups. The first group was treated with collaborative care (three sessions of psychoeducation over six weeks). The second group was treated with medication and intensive psychotherapy (30 sessions over nine months of CBT, interpersonal and social rhythm therapy, or family-focused therapy). Researchers found that the second group had fewer relapses, lower hospitalization rates, and were better able to stick with their treatment plans. They were also more likely to get well faster and stay well longer.

    NIMH is supporting more research on which combinations of psychotherapy and medication work best. The goal is to help people with bipolar disorder live symptom-free for longer periods and to recover from episodes more quickly. Researchers also hope to determine whether psychotherapy helps delay the start of bipolar disorder in children at high risk for the illness.

    Where can families of children with bipolar disorder get help?

    As with other serious illnesses, taking care of a child with bipolar disorder is incredibly hard on the parents, family, and other caregivers. Caregivers often must tend to the medical needs of their child while dealing with how it affects their own health. The stress that caregivers are under may lead to missed work or lost free time. It can strain relationships with people who do not understand the situation and lead to physical and mental exhaustion.

    Stress from caregiving can make it hard to cope with your child's bipolar symptoms. One study shows that if a caregiver is under a lot of stress, his or her loved one has more trouble sticking to the treatment plan, which increases the chance for a major bipolar episode. It is important to take care of your own physical and mental health. You may also find it helpful to join a local support group. If your child's illness prevents you from attending a local support group, try an online support group.

    Where can I go for help?

    If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.

    • Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
    • Health maintenance organizations
    • Community mental health centers
    • Hospital psychiatry departments and outpatient clinics
    • Mental health programs at universities or medical schools
    • State hospital outpatient clinics
    • Family services, social agencies, or clergy
    • Peer support groups
    • Private clinics and facilities
    • Employee assistance programs
    • Local medical and/or psychiatric societies.

    You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help.

    What affects a child's risk of getting bipolar disorder?

    Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the building blocks of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

    Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, most children with a family history of bipolar disorder will not develop the illness.

    Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:

    • Missed work because of their illness
    • Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
    • Been treated or hospitalized for bipolar disorder.

    The researchers also identifies certain traits that appeared to run in families, including:

    • History of psychiatric hospitalization
    • Co-occurring obsessive-compulsive disorder (OCD)
    • Age at first manic episode
    • Number and frequency of manic episodes.

    Scientists continue to study these traits which may help them someday find the genes that cause bipolar disorder.

    However, genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how theses factors interact to cause bipolar disorder.

    How does bipolar disorder affect children and teens differently than adults?

    Bipolar disorder that starts during childhood or during the teen years is called early-onset bipolar disorder. Early-onset bipolar disorder seems to be more severe than the forms that first appear in older teens and adults. Youth with bipolar disorder are different from adults with bipolar disorder. Young people with the illness appear to have more frequent mood switches, are sick more often, and have more mixed episodes.

    Watch out for any sign of suicidal thinking or behaviors. Take these signs seriously. On average, people with early-onset bipolar disorder have greater risk for attempting suicide than those whose symptoms start in adulthood. One large study on bipolar disorder in children and teens found that more than one-third of study participants made at least one serious suicide attempt. Some suicide attempts are carefully planned and others are not. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that must be treated.

    How is bipolar disorder detected in children and teens?

    No blood tests or brain scans can diagnose bipolar disorder. However, a doctor may use tests like these to help rule out other possible causes for your child's symptoms. For example, the doctor may recommend testing for problems in learning, thinking, or speech and language. A careful medical exam may also detect problems that commonly co-occur with bipolar disorder and need to be treated, such as substance abuse.

    Doctors who have experience with diagnosing early-onset bipolar disorder, such as psychiatrists, psychologists, or other mental health specialists, will ask questions about changes in your child's mood. They will also ask about sleep patterns, activity or energy levels, and if your child has had any other mood or behavioral disorders. The doctor may also ask whether there is a family history of bipolar disorder or other psychiatric illnesses, such as depression or alcoholism.

    Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

    1. Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.
    2. Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.
    3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
    4. Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years (one year for children and adolescents). However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

    When children have manic symptoms that last for less than four days, experts recommend that they be diagnosed with BP-NOS. Some scientific evidence indicates that about one-third of these young people will develop longer episodes within a few years. If so, they meet the criteria for bipolar I or II.

    Also, researchers are working on whether certain symptoms mean a child should be diagnosed with bipolar disorder. For example, scientists are studying children with very severe, chronic irritability and symptoms of ADHD, but no clear episodes of mania. Some experts think these children should be diagnosed with mania. At the same time, there is scientific evidence that suggests these irritable children are different from children with bipolar disorder in the following key areas: the outcome of their illness, family history, and brain function.

    When you talk to your child's doctor or a mental health specialist, be sure to ask questions. Getting answers helps you understand the terms they use to describe your child's symptoms.

    What illnesses often co-exist with bipolar disorder in children and teens?

    Several illnesses may develop in people with bipolar disorder.

    Alcoholism. Adults with bipolar disorder are at very high risk of developing a substance abuse problem. Young people with bipolar disorder may have the same risk.

    ADHD. Many children with bipolar disorder have a history of ADHD. One study showed that ADHD is more common in people whose bipolar disorder started during childhood, compared with people whose bipolar disorder started later in life. Children who have co-occurring ADHD and bipolar disorder may have difficulty concentrating and controlling their activity. This may happen even when they are not manic or depressed.

    Anxiety Disorders. Anxiety disorders, such as separation anxiety and generalized anxiety disorder, also commonly co-occur with bipolar disorder. This may happen in both children and adults. Children who have both types of disorders tend to develop bipolar disorder at a younger age and have more hospital stays related to mental illness.

    Other Mental Disorders. Some mental disorders cause symptoms similar to bipolar disorder. Two examples are major depression (sometimes called unipolar depression) and ADHD. If you look at symptoms only, there is no way to tell the difference between major depression and a depressive episode in bipolar disorder. For this reason, be sure to tell a diagnosing doctor of any past manic symptoms or episodes your child may have had. In contrast, ADHD does not have episodes. ADHD symptoms may resemble mania in some ways, but they tend to be more constant than in a manic episode of bipolar disorder.

    What treatments are available for children and teens with bipolar disorder?

    To date, there is no cure for bipolar disorder. However, treatment with medications, psychotherapy (talk therapy), or both may help people get better.

    It's important for you to know that children sometimes respond differently to psychiatric medications than adults do.

    To treat children and teens with bipolar disorder, doctors often rely on information about treating adults. This is because there haven't been many studies on treating young people with the illness, although several have been started recently.

    One large study with adults funded by NIMH is the Systematic Treatment Enhancement Program for Bipolar Disorder. This study found that treating adults with medications and intensive psychotherapy for about nine months helped them get better. These adults got better faster and stayed well longer than adults treated with less intensive psychotherapy for six weeks. Combining medication treatment and psychotherapies may help young people with early-onset bipolar disorder as well. However, it's important for you to know that children sometimes respond differently to psychiatric medications than adults do.

    Medications

    Before starting medication, the doctor will want to determine your child's physical and mental health. This is called a "baseline" assessment. Your child will need regular follow-up visits to monitor treatment progress and side effects. Most children with bipolar disorder will also need long-term or even lifelong medication treatment. This is often the best way to manage symptoms and prevent relapse, or a return of symptoms.

    It's better to limit the number and dose of medications. A good way to remember this is "start low, go slow." Talk to the psychiatrist about using the smallest amount of medication that helps relieve your child's symptoms. To judge a medication's effectiveness, your child may need to take a medication for several weeks or months. The doctor needs this time to decide whether to switch to a different medication. Because children's symptoms are complex, it's not unusual for them to need more than one type of medication.

    Keep a daily log of your child's most troublesome symptoms. Doing so can make it easier for you, your child, and the doctor to decide whether a medication is helpful. Also, be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements your child is taking. Taking certain medications and supplements together may cause unwanted or dangerous effects.

    Some of the types of medications generally used to treat bipolar disorder are listed below. Information on medications can change.

    Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:

    • Lithium: Sometimes known as Eskalith or Lithobid, lithium was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
    • Valproc acid or vivalproex sodum (Depakote): This substance was approved by the FDA in 1995 for treating mania, and is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder. Also see the section in this booklet, "Should young women take valproic acid?"
    • Lamotrigine (Lamictal): More recently, this anticonvulsant received FDA approval for maintenance treatment of bipolar disorder.
    • Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.

    Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored fro new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional

    Lithium and Thyroid Function

    People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people. Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

    Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

    Should young women take valproic acid?

    Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20. PCOS causes a woman's eggs to develop cysts, or fluid-filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid. Young girls and woman taking valproic acid should be monitored carefully by a doctor.

    Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional," or "first-generation" anti-psychotics.

    Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.28 Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.

    Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.

    Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.

    Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.

    Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.29 To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.

    Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.

    Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

    Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.

    What are the side effects of these medications?

    Before your child starts taking a new medication, talk with the doctor or pharmacist about possible risks and benefits of taking that medication.

    The doctor or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than past treatments. However, everyone responds differently to medications, and in some cases, side effects may not appear until a person has taken a medication for some time.

    If your child develops any severe side effects from a medication, talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. Children and teens being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms or other uncomfortable or potentially dangerous withdrawal effects.

    The following sections describe some common side effects of the different types of medications used to treat bipolar disorder.

    Mood Stabilizers

    In some cases, lithium can cause side effects such as:

    • Restlessness
    • Frequent urination
    • Dry mouth
    • Bloating or indigestion
    • Acne
    • Joint or muscle pain
    • Brittle nails or hair.

    Lithium may cause other side effects not listed here. Tell the doctor about bothersome or unusual side effects as soon as possible.

    If your child is being treated with lithium, it is important for him or her to see the treating doctor regularly. The doctor needs to check the levels of lithium in the child's blood, as well as kidney function and thyroid function.

    Each mood stabilizing medication is different and can cause different types of side effects. Some common side effects of lamotrigine and valproic acid include:

    • Drowsiness
    • Dizziness
    • Headache
    • Diarrhea
    • Constipation
    • Heartburn
    • Mood swings
    • Stuffed or runny nose, or other cold-like symptoms.

    These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the specific medications your child is taking.

  • Atypical Antipsychotics Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:
    • Drowsiness
    • Dizziness when changing positions
    • Blurred vision
    • Rapid heartbeat
    • Sensitivity to the sun
    • Skin rashes
    • Menstrual problems for girls
    • Weight gain.

    Atypical antipsychotic medications can cause major weight gain and changes in metabolism. This may increase a person's risk of getting diabetes and high cholesterol. While taking an atypical antipsychotic medication, your child's weight, glucose levels, and lipid levels should be monitored regularly by a doctor.

    In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these movements. TD can range from mild to severe, and it cannot always be cured. Sometimes people with TD recover partially or fully after they stop taking the drug.

    Antidepressants FDA Warning on Antidepressants

    Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website .

    The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include:

    1. Headache, which usually goes away within a few days.
    2. Nausea (feeling sick to your stomach), which usually goes away within a few days.
    3. Sleep problems, such as sleeplessness or drowsiness. This may occur during the first few weeks but then goes away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
    4. Agitation (feeling jittery)
    5. Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.
    6. Some antidepressants are more likely to cause certain side effects than other antidepressants. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.
    Sexual Activity, Pregnancy, and Teens with Bipolar Disorder

    Many teens make risky choices about sex. The U.S. Centers for Disease Control and Prevention (CDC) recently reported that 26 percent of teenage girls in the United States have at least one of the four most common sexually transmitted diseases. This suggests that many teens are having unprotected sex or taking part in other risky behaviors.

    Bipolar disorder is also linked with impulsive and risky choices. Teenage girls with bipolar disorder who are pregnant or may become pregnant face special challenges because medications for the illness may have harmful effects on a developing fetus or nursing infant. Specifically, lithium and valproic acid should not be used during pregnancy. Also, some medications may reduce the effectiveness of birth control pills.

    Psychotherapy

    In addition to medication, psychotherapy ("talk" therapy) can be an effective treatment for bipolar disorder. Studies in adults show that it can provide support, education, and guidance to people with bipolar disorder and their families. Psychotherapy may also help children keep taking their medications to stay healthy and prevent relapse.

    Children and teens may also benefit from therapies that address problems at school, work, or in the community.

    Some psychotherapy treatments used for bipolar disorder include:

    1. Cognitive behavioral therapy helps young people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
    2. Family-focused therapy includes a child's family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their child. This therapy also improves communication and problem-solving.
    3. Interpersonal and social rhythm therapy helps children and teens with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
    4. Psychoeducation teaches young people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Psychoeducation also may be helpful for family members and caregivers.

    Other types of therapies may be tried as well, or used along with those mentioned above. The number, frequency, and type of psychotherapy sessions should be based on your child's treatment needs.

    A licensed psychologist, social worker, or counselor typically provides these therapies. This professional often works with your child's psychiatrist to monitor care. Some may also be licensed to prescribe medications; check the laws in your state.

    In addition to getting therapy to reduce symptoms of bipolar disorder, children and teens may also benefit from therapies that address problems at school, work, or in the community. Such therapies may target communication skills, problem-solving skills, or skills for school or work. Other programs, such as those provided by social welfare programs or support and advocacy groups, can help as well.

    Some children with bipolar disorder may also have learning disorders or language problems. Your child's school may need to make accommodations that reduce the stresses of a school day and provide proper support or interventions.

    What can children and teens with bipolar disorder expect from treatment?

    There is no cure for bipolar disorder, but it can be treated effectively over the long term. Doctors and families of children with bipolar disorder should keep track of symptoms and treatment effects to decide whether changes to the treatment plan are needed.

    Sometimes a child may switch from one type of bipolar disorder to another. This calls for a change in treatment. In the largest study to date on childhood bipolar disorder, the NIMH-funded Course and Outcome of Bipolar Illness in Youth (COBY) study, researchers found that roughly one out of three children with BP-NOS later switched to bipolar I or II. Also, roughly one out of five children who started out with a diagnosis of bipolar II switched to bipolar I. Because different medications may be more helpful for one type of symptom than another (manic or depressive), your child may need to change medications or try different treatments if his or her symptoms change.

    The COBY study also showed that treatment helped around 70 percent of children with bipolar disorder recover from their most recent episode (either manic or depressive). In this study, recovery meant having two or fewer symptoms for at least eight weeks in a row. On average, it took a little over a year and a half to recover. However, within the next year or so, symptoms returned in half of the children who recovered. Children with bipolar I or II tended to recover faster than those with BP-NOS, but their symptoms returned more frequently as well.

    If your child has other psychiatric illnesses, such as an anxiety disorder, eating disorder, or substance abuse disorder, he or she may be more likely to experience a relapse -- especially depressive symptoms. Scientists are unsure how these co-existing illnesses increase the chance of relapse.

    Working closely with your child's doctor and therapist and talking openly about treatment choices can make treatment more effective. You may need to talk about changing the treatment plan occasionally to help your child manage the

    Source: http://www.rxlist.com

    Youth with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

    Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. Symptoms of bipolar disorder are described below.

    Source: http://www.rxlist.com

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