[Health in the 100-Year Life Era] Repeated Depression and Happiness: Bipolar Disorder

Most Require Long-Term Treatment

Professor Hye-Yeon Park, Department of Psychiatry, Bundang Seoul National University Hospital.

#For the past month, I haven't been able to sleep at night. Even late at night, I don't feel sleepy; instead, my mind becomes clearer. Various ideas come to me, and I feel certain that if I start a business with them, I will succeed. Even though I only slept for two hours, I don't feel tired at all, and my body feels light. I keep calling acquaintances to discuss my business ideas urgently, but it seems they don't quite understand. Two years ago, after giving birth, I was depressed and lethargic, spending almost six months lying down, but now I feel more energetic and happier than ever.

'Bipolar disorder' is a mood disorder characterized by repeated episodes of elevated mood?mania or hypomania?and depressed mood, meaning frequent mood swings. In fact, most patients experience depressive episodes more often and for longer durations, but if mania appears at any time, it is diagnosed as Bipolar I disorder, and if hypomania appears, it is diagnosed as Bipolar II disorder. The main symptoms, as mentioned earlier, are mood instability with recurrent depression, often accompanied by mania or hypomania. Hypomania is diagnosed when a period of excessively elevated or irritable mood lasts for more than four days, and mania is diagnosed when symptoms last for more than one week or are severe enough to require hospitalization. During these times, mood and behavior differ from usual: patients become euphoric or elated, energetic, talkative, and have rapid thoughts. Additionally, activity levels increase, and they may act proactively or show impulsive tendencies such as overspending or reckless investments. In severe cases, psychotic symptoms like grandiosity, auditory hallucinations, or visual hallucinations may occur. During depressive episodes, conversely, emotions and behaviors slow down or become lethargic; patients feel fatigued, lose motivation and concentration, and reduce social interactions. Severe cases often involve suicidal thoughts. Manic episodes in bipolar disorder last on average two months, and depressive episodes last two to five months, alternating with symptom-free periods in between. The lifetime prevalence is about 0.5?2.5%, and onset often occurs in the 20s, earlier than major depressive disorder.

The onset of bipolar disorder involves a complex interplay of biological factors such as genetic influences and psychosocial factors. Imbalances in neurotransmitters that regulate mood and energy in the brain?such as serotonin, dopamine, and norepinephrine?and dysfunctions in the limbic system and frontal lobes related to mood regulation are known causes. Additionally, changes in female hormones and stress also contribute.

Bipolar disorder often requires long-term treatment due to recurrent mood episodes. It is common for other psychiatric disorders such as anxiety disorders or substance use disorders to co-occur, complicating the course. Acute treatment of mania primarily involves medication, and hospitalization is often necessary. Mood stabilizers like lithium and valproate, as well as antipsychotics, are mainly used; anticonvulsants such as lamotrigine and carbamazepine are also employed. Because bipolar depression differs from the depression seen in major depressive disorder, antidepressants are often ineffective or may even trigger a switch to mania, so they are generally not recommended. Therefore, mood stabilizers or antipsychotics are preferred. Non-pharmacological treatments include electroconvulsive therapy and transcranial magnetic stimulation, and psychotherapy addressing stress and conflicts can enhance treatment effectiveness.

Bipolar disorder is likely to develop into a chronic condition with frequent relapses. Depressive episodes are especially frequent and prolonged, and treatment response is slow. Furthermore, patients and caregivers often resist long-term medication, leading to treatment discontinuation. This increases the risk of relapse, and repeated relapses make treatment more difficult and raise suicide risk. Therefore, maintenance treatment for at least one to two years or longer is necessary.

Professor Hye-Yeon Park, Department of Psychiatry, Bundang Seoul National University Hospital

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