14.5 — Bipolar Disorder and Psychosis

Two conditions where early treatment changes the long-term outcome substantially, and where the popular picture is badly wrong.

Bipolar disorder

Not mood swings. Not being changeable. Episodes lasting days to months, with a clear change from the person's normal state that other people can see.

Mania — at least a week of abnormally elevated, expansive or irritable mood plus increased energy, with several of: reduced need for sleep and not feeling tired; racing thoughts; rapid speech; grandiosity; distractibility; increased goal-directed activity; and risky behaviour — spending, driving, sex, business decisions. Severe enough to impair functioning, or requiring hospital, or with psychotic features.

Hypomania — the same picture, less severe, at least four days, without severe impairment or psychosis.

And depressive episodes (14.2), which in bipolar disorder are usually more frequent and account for far more of the illness than the highs do.

Bipolar I involves at least one manic episode. Bipolar II involves hypomania and depression, and is not a milder illness — the depressive burden is frequently greater.

Why it is missed for years. People seek help when depressed, not when hypomanic — hypomania frequently feels good and productive. So the presentation is depression, an antidepressant is prescribed, and in bipolar disorder an antidepressant alone can precipitate a switch into mania. Average time to correct diagnosis is measured in years.

Which is why one question matters: has there ever been a period of several days where you needed much less sleep and felt unusually energetic, fast and confident? If yes, tell whoever is treating your depression.

What helps. Mood stabilisers — lithium remains the best-established, with evidence for reducing episodes and, notably, for reducing suicide risk. Certain anticonvulsants and antipsychotics are also used. Medication is not optional in this condition, and stopping when well is the most common route back to hospital.

Psychological therapy alongside — particularly psychoeducation, and therapy focused on stabilising daily and sleep rhythms, which has real evidence.

And sleep protection, which is central. Sleep loss can trigger an episode, reliably enough that irregular hours, night shifts and long-haul travel are genuine risks. Regular sleep is treatment, not lifestyle advice.

Watch for the early signs. Most people have a consistent personal pattern — reduced sleep, increased talking, new projects, spending. Write yours down when well, share it with someone, and agree in advance what they should do.

Psychosis and schizophrenia

Psychosis means loss of contact with shared reality — not a diagnosis in itself, but a feature that appears in several conditions, including schizophrenia, bipolar disorder, severe depression, drug use and physical illness.

Positive symptoms — things added.

Hallucinations, most commonly hearing voices. They are experienced as real, and telling someone they are not is useless.

Delusions — fixed beliefs held despite contrary evidence. Being persecuted, being controlled, having special significance.

And disorganised thinking and speech.

Negative symptoms — things removed. Reduced motivation, flattened emotional expression, withdrawal, reduced speech. These are less dramatic and they cause more of the long-term disability, and they are frequently mistaken for laziness or depression.

Cognitive symptoms — problems with memory, attention and planning.

The three corrections

One: people with schizophrenia are not generally dangerous. They are considerably more likely to be victims of violence than perpetrators. The elevated risk of violence associated with the diagnosis is small in absolute terms and is concentrated in specific circumstances — untreated illness combined with substance use. The popular association is a distortion with real consequences for how people are treated.

Two: it is not split personality. That is a different and much rarer thing, and the confusion comes from the word's Greek roots.

Three: outcomes are better than people assume. A substantial proportion of people have one episode and recover, or have episodes with good functioning between them. The picture of inevitable deterioration is out of date.

Why early treatment matters so much

Duration of untreated psychosis predicts outcome. The longer the gap between symptoms starting and treatment, the worse the trajectory — and the average gap is over a year in many places.

Which makes recognising the early stage the single most valuable thing on this page.

The early signs, before full psychosis: withdrawal, dropping out of activities, unusual ideas beginning to form, suspiciousness, changed sleep, deteriorating function at work or study, and something that friends describe as not himself without being able to say why. Frequently mistaken for depression or for adolescence.

What helps

Antipsychotic medication. Effective for positive symptoms, less so for negative ones, with side effects that are real and need managing rather than dismissing. Getting the medication right frequently takes several attempts.

Cognitive behavioural therapy for psychosis has evidence as an addition to medication.

Family intervention — working with the household — has some of the strongest evidence in this area for reducing relapse.

Early intervention services, where they exist, improve outcomes substantially.

And cannabis is a genuine risk factor, particularly high-potency products and use starting in adolescence. The association is well established and the causal contribution is debated. For anybody with a family history, avoiding it is a straightforward precaution.

If somebody you know is developing this

Do not argue with the content. Debating a delusion does not work and damages the relationship. You can be honest without arguing: "I don't see it that way, and I can see it's frightening for you."

Focus on the distress, not the belief.

Do not leave it. The single most useful thing you can do is get them assessed early.

And if there is immediate risk to them or anybody else, call 112 and say what is happening.

What to do

For bipolar: if you have ever had several days of markedly reduced need for sleep with high energy, say so to whoever treats your low mood. That one disclosure prevents years of the wrong treatment.

Protect sleep as treatment, not as a habit.

Write your early-warning signs down when well and give them to somebody.

For psychosis: treat a marked, sustained change in a young person — withdrawal, function dropping, unusual ideas — as something to get assessed rather than to wait out. Early treatment is the variable that matters most.

And in India, Tele-MANAS on 14416, a psychiatrist for both conditions, and 112 where there is immediate risk.

Next: 14.6 covers the diagnoses that describe a person's whole pattern rather than an episode.