World Federation for Mental Health 1
W orldwide, the burden of mental illness is
great, and multiplied in the many
countries fraught with famine, civil
war, and disaster. One of the most debilitating of
all of the mental illnesses is Bipolar Disorder,
characterized by extreme mood swings between
depression and mania. It affects an estimated 27
million people worldwide, and has an enormous
impact on the quality of life: it is the sixth leading
cause of disability in terms of lost years of healthy
life in the developed world. Men, women, and
even children and adolescents can develop the
illness.
The impact of the disorder is also deeply
personal, affecting almost all facets of an
individual’s life. In some cases, a diagnosis of the
disorder prevents that individual's very acceptance
into society. For most, the disorder negatively
impacts relationships with family and friends, and
the ability to maintain employment and secure
adequate housing. But for all, the chronic nature of
the disorder and tendency for multiple relapses
means that they and their loved ones must put forth
significant effort – on a day-to-day basis – to get
and stay well.
Though there is no cure for the disorder,
For more information on the impact of culture on
mental health services and treatment, see the
World Mental Health Day 2007 campaign,
Mental Health in a Changing World:
The Impact of Culture and Diversity
[http://www.wfmh.org/00WorldMentalHealthDay.
htm]
effective treatments, including both therapy and
medication, are now able to ease its symptoms. In
many parts of the world where these treatments are
unavailable, traditional healers are sought to ease
symptoms of the disorder. But millions across the
globe are untreated, either lacking access to, or
stigmatized by seeking needed care.
Culture also influences the care that people
seek, how they talk about and express their
symptoms, the ways in which they and their
families cope, and the support systems they have
available to them (e.g. family, friends, and
community). Personal stories from various cultures
across the globe are included in this packet to
illustrate how those with the disorder and their
family and friends are affected by and coping with
this illness.
This packet also contains information on the
diagnosis and treatment of the disorder, as well as
important information for caregivers on helping
someone they love on the road to recovery. An
easy-to-read guide on diagnosis and treatment,
geared toward healthcare workers and traditional
healers around the world, is also included. This
guide will be especially valuable in regions of the
world where there is no psychiatrist or trained
mental health professional available to diagnose
and treat the disease.
Many people with the disorder have to wait too
long for a correct diagnosis, and many never get
treatment. It is our hope that this educational
packet will provide important information for
citizens, caregivers, healthcare workers and
traditional healers in communities around the
global on the diagnosis and treatment of Bipolar
2 World Federation for Mental Health
Disorder.
The preparation and production of this mental
health awareness packet was made possible
through the cooperation and effort of many
individuals and organizations. WFMH is most
grateful to its colleague and member organizations
that gave permission to use or adapt information
they have developed on bipolar disorder. Their
willingness to share their work with others reflects
their continuing commitment to strengthening the
global mental health movement. We also recognize
and thank those organizations listed in the
Resources section of this packet for the work they
do in assisting individuals and families in locating
useful referral assistance and information.
There are many grassroots patient/service
user/consumer and family/caregiver support groups
and organizations located in communities around
the world that offer assistance and support to
people living with mental illnesses such as bipolar
disorder and to their families and caregivers.
WFMH has been fortunate to be able to develop
and launch a comprehensive searchable online
directory listing nearly 3000 of these groups.
can be found on the
. The World Federation for Mental Health is
WFMH is most indebted to the science writers
and editors that assist WFMH in the research,
writing and editing of its mental health awareness
packets and materials. This Bipolar Disorder
packet is unique in that it contains not only
information for use in informing the general public
about diagnosis, treatment and recovery, but also
includes a special section geared to assist general
healthcare workers in their recognition and
understanding of Bipolar Disorder when they
encounter it in primary healthcare clinics in the
community public healthcare setting. The writers
of the packet, Robin Peth-Pierce and Margaret
Whittemore, worked extremely hard to make these
materials as accurate and internationally relevant as
possible. We are also grateful to the members of
the WFMH Board of Directors who reviewed
sections of the materials during the draft stage and
who made useful and insightful comments and
suggestions. Special thanks are due Dr. Patt
Franciosi, WFMH’s Vice-President for Program
Development, for her invaluable assistance and
advice throughout the project. Dr. Mary A. Fristad,
(Director, Research & Psychological Services,
Division of Child & Adolescent Psychiatry, The
Ohio State University) provided very helpful
review and comment assistance for the project,
especially on Chapter 3, “Growing Up with Bipolar
Disorder”.
Due to a major medical emergency affecting our
layout and design specialist, WFMH Director of
Promotion & Prevention Dr. Elena Berger and
Gemma Griffin, Intern for the WFMH Africa
Initiative, undertook the task of completing the
design and layout process. We are deeply grateful
for their efforts.
This international mental health awareness
packet was supported through an unrestricted
educational grant from AstraZeneca. WFMH
expresses appreciation to AstraZeneca for its
interest in getting useful, accurate and evidence-
based information and awareness materials into the
hands of grassroots mental health consumer/patient
family/caregiver and citizen advocacy organizations
worldwide.
pleased to make this awareness packet available to
you, and hopes that you find it of value in your
local community-based efforts.
Preston J. Garrison
Secretary-General & CEO
World Federation for Mental Health
 World Federation for Mental Health 3

As story illustrates, the extreme mood swings

of Bipolar Disorder can wreak havoc on daily life,
negatively impacting work productivity and the ability
to make and keep close relationships. Bipolar Disorder,
once commonly known as manic-depressive illness, is
characterised by mood swings from mania to
depression, punctuated by periods of stable mood in
between where one is free of these symptoms. It is a
disorder of the brain thought to be caused by a
combination of changes in brain functioning, genetics,
and a person’s environment.
With treatment, which typically includes therapy and
4 World Federation for Mental Health

medication, those with the disorder can lead healthy, signs and symptoms, occur differently in each person
productive lives. However, for many people, five and diagnosed with Bipolar Disorder. Many of these signs
sometimes ten years pass before their signs and and symptoms can be missed – or misinterpreted as
symptoms are even properly diagnosed as Bipolar another disorder. Careful consideration should be given
Disorder,1 as reported in a survey of patients in thirty to the person’s culture and context when diagnoses are
European countries. And, for those who are correctly made, as well as ruling out other medical problems.
diagnosed, treatment may not be available in their The Diagnostic and Statistical Manual of Mental
country. For some, the stigma of even seeking help is Disorders (DSM-IV) is the most commonly used tool to
too great, particularly in cultures where those with diagnose bipolar and other mental disorders. For more
mental illness are viewed as “evil spirits” or as having a information on the DSM-IV, go to the website
weakness in character. Untreated, Bipolar Disorder http://www.psychiatryonline.com/resourceTOC.aspx?res
prevents many with the illness from being able to hold ourceID=1.
down jobs and secure housing, painfully disrupts
relationships with family and friends, and in extreme
cases, cuts lives short due to suicide.
Signs and symptoms of mania
or a manic episode include:
It is now commonly acknowledged that there is a - Increased energy, activity,
spectrum of bipolar illness which includes several types and restlessness
of Bipolar Disorder. These include the most common - Excessively "high", overly
or classic form of the illness, , good, euphoric mood
which is characterised by recurrent episodes of mania - Extreme irritability
and depression, and , which - Racing thoughts and
involves milder episodes of mania that alternate with talking very fast, jumping
depression. In some people, the illness involves “rapid from one idea to another
cycling”, whereby four or more episodes (during the - Distractibility, can't
last 12 months) of this cycle occur. These episodes of concentrate well
mania and depression are often punctuated by periods - Little sleep needed
of normal mood in between. When depression or mania - Unrealistic belief in one's
recurs, this is known as a relapse. abilities and powers
Episodes of mania and depression, as well as their - Poor judgment
- Spending sprees
- A lasting period of
behaviour that is different
The World Health Organization (WHO) from usual
estimates that globally, some 27 million people - Increased sexual drive
are affected by Bipolar Disorder. Many also - Abuse of drugs,
remain undiagnosed, and do not receive particularly cocaine,
treatment. Left untreated, Bipolar Disorder is alcohol, and sleeping
significantly disabling, both for those with the medications
disorder, and their family and friends. It affects - Provocative, intrusive, or
every aspect of life, from gainful employment to aggressive behaviour
maintaining important relationships with loved - Denial that anything is
ones. It is the 6th leading cause of disability in wrong
terms of lost years of healthy life (people aged
15-44) in the developed world. The disorder has Signs and symptoms of
a high rate of recurrence, and an approximately depression (or a depressive
15% risk of death by suicide – the third leading episode) include:
cause of death among people aged 15-24 years. - Lasting sad, anxious, or
empty mood

- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities once
enjoyed
- Decreased energy, a feeling of fatigue or of
being "slowed down"
- Difficulty concentrating, remembering, making
decisions
- Restlessness or irritability
- Sleeping too much, or can't sleep
- Change in appetite and/or unintended weight
loss or gain
- Chronic pain or other persistent bodily
symptoms that are not caused by physical illness
or injury
- Thoughts of death or suicide, or suicide attempts
If you or someone you know has these symptoms, seek
help immediately. Many people with these symptoms
have Bipolar Disorder and don’t know that they have it,
thinking these mood swings are just a normal part of
life. Seeking help is important: with the right diagnosis
and proper treatment, those with the disorder can live a
healthy and fulfilling life.
Get help if:
- You think you have manic episodes [see the
symptoms of mania on page 4] which include
three or more of the symptoms listed above most
of the day, nearly every day, for 1 week or longer.
- You think you may have episodes of depression
[see symptoms of depression on pages 4-5],
which include five or more of these symptoms
listed above that last most of the day, nearly
every day, for a period of 2 weeks or longer.
- You fluctuate between these two moods.
- These “ups” and “downs" are interfering with
your home and work life.
World Federation for Mental Health 5
If you are concerned that you or someone you love has
some of these symptoms, talk to your family doctor or
healthcare worker at a local clinic. Worldwide, help is
available in many different places, including:
- National, regional or provincial health clinics
providing mental health care
- Mental health non-governmental organisations
(NGOs)
- Mental health specialists, such as psychiatrists,
psychologists, social workers, or mental health
counsellors, where available
- Religious leaders/counsellors
- Traditional healers in the local community
- Hospital psychiatry departments and outpatient
clinics
- University- or medical school-affiliated
programs
- Hospital or hospital outpatient clinics
- Social service agencies
- Private clinics and facilities
- Employee assistance programs in the workplace
- Local medical or psychiatric societies
With the proper diagnosis and effective treatment, those
with the disorder can live each day to the fullest and
prevent relapse. Information on effective treatments
and ways to prevent relapse and promote recovery are
included in the next chapters.
1. PL Morselli, R Elgie, BM Cesana (2004). GAMIANEurope/
BEAM survey II: cross-national analysis of unemployment,
family history, treatment satisfaction and impact
of the bipolar disorder on life style. Bipolar Disorders 6 (6),
487–497.
 Mood Chart
Adapted from Sachs, G (1996): J. Clin. Psychopharm. 16:2 (suppl 1) p47S

Exercise /Medication
Date Energy/Mood Sleep Irritability Events/Notes/Observations
(enter amounts, note dose changes)
Exercise How med 1 med 2 med 3 med 4 (can use two check marks: check one, or
type long 0-3 scale Questions to ask, connections you suspect;
worst and best for each day) hours
Walk Low Agitation/
nl
Swim energy/mood anxiety/ “up”
(circle for
Run or significant events that might affect mood
menses) Bike — interactions, successes, disappointments,

not
not

work
work

mood

cannot
cannot
Etc.

normal
anniversaries, illness, losses, etc.

impaired
impaired
impaired
impaired
normal sleep

increased sleep
insomnia
mg mg mg mg +++ ++ + + ++ +++
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31 weight =
Adapted by Peter M. Brigham, MD 1997-8
 World Federation for Mental Health 7

A diagnosis of Bipolar Disorder can, at first, be

overwhelming. There are many questions. "Why me?"
"What causes it?" "How will it affect my life?" "How
will the illness progress?" "What are my chances of
getting better?" "Will I need to go to the hospital?" The
important thing to remember is that you can get better:

Bipolar Disorder can affect anyone, regardless of

race, gender, or ethnicity.1,2 Across the globe, the
World Health Organization estimates that 27 million
people are affected by the disorder. Men, women
and children and adolescents all can be diagnosed
with the disorder.

Many people newly diagnosed with the disorder

may be frustrated because they don’t understand
how they “got it”. There is no single cause for
Bipolar Disorder; instead, many factors appear to
work together to cause the illness, including genetics
(the disorder is one of the most heritable of all of the
mental illnesses), brain functioning, and
environmental factors.
8 World Federation for Mental Health
Over the past decade, several genes have been
inked to Bipolar Disorder;3,4 the studies have been
repeated in several countries, strengthening the
results. Teams of international researchers continue
to learn how these genes interact with other factors
to actually cause the disorder. The hope is to
target the enzyme produced by one of these genes,
which may lead to the development of new and
more effective treatments.
Most people diagnosed with Bipolar Disorder have
already been living and coping with the symptoms
their diagnosis. In most cases, once
their treatment begins, they begin to feel better.
However, everyone is different, and the experience
of living with Bipolar Disorder is mixed. Many
describe it as both physically mentally painful,
affecting every aspect of their lives. For some, the
illness involves recurrent episodes of mania and
depression, known as Bipolar I. Others will develop
a milder version of mania, known as hypomania,
which alternates with the depression, known as
Bipolar II. In some, the mood shifts will occur more
frequently, with four or more of these episodes
within one year, known as Rapid Cycling Bipolar
Disorder. Recent research indicates that the disorder
may be more accurately characterised as a spectrum
disorder, with many variations. How one person
experiences the disorder will not be the same as
another.
The dramatic mood swings that characterise the
disorder will typically recur throughout life. If you
have the disorder, you may be free of symptoms for
varying amounts of time between episodes, or you
may continue to have symptoms. Paying close
attention to your symptoms is critical. You may
begin to recognise warning signs and triggers for
your mood swings. Working with your healthcare
provider on appropriate treatment(s) will help
manage the illness and its impact on your life. A
very small percentage of people experience chronic
unremitting symptoms, despite treatment.5
Another critical factor affecting the progression
of the illness is the presence of other medical
illnesses and mental disorders, known as comorbid
conditions. It is common for someone with Bipolar
Disorder to have other mental disorders (e.g. panic
disorder), and alcohol or substance abuse problems.
These comorbid conditions will affect the
progression of Bipolar Disorder, particularly if they
remain undiagnosed and untreated.
Because there is, as yet, no cure for the illness, the
disorder must be treated throughout life, and
managed on a daily basis to help prevent
recurrences. Left untreated, the natural course of
bipolar disorder generally worsens. But with
effective treatment, you can live an enjoyable,
productive life. New research has shown that
medications taken to keep mood swings at bay
reduce changes to the brain usually seen as the
disease progresses if untreated.6
Once Bipolar Disorder is diagnosed and well-
managed, hospital visits are usually not needed.
However, for those who have not yet received a
diagnosis, or whose mania or depression are
dangerous to themselves or others, hospitalisation
may be required to get back on track.
These are all important questions you should ask your
doctor. Learning about the disorder is the first step
toward recovery. Learning about the disorder also
means understanding that the disorder must be managed
for a lifetime.
It is also important to know that those with the
disorder are also at high risk for substance abuse and
suicide; while suicide is relatively rare, the risk is still
relatively high for those living with the disorder.
Untreated
Bipolar Disorder is commonly associated with
substance use, abuse, and dependency. Many with the
disorder will try to “self-medicate” to make themselves
feel better instead of seeking treatment.
Sixty percent of those who have Bipolar Disorder I
abuse alcohol or drugs during their lifetime,
. Those with both Bipolar Disorder and
substance abuse have poorer outcomes, are more
difficult to treat, and have an increased rate of suicide.7,8
Patients with a dual diagnosis of substance abuse and
Bipolar Disorder require careful evaluation and the
creation of more complex treatment plans.
 World Federation for Mental Health 9

My Story: Jorge, 25, Montevideo, Uruguay

10 World Federation for Mental Health

It is not uncommon for professionals, strong connections to family and com-

people with Bipolar Disorder to become suicidal.
People with Bipolar Disorder have about a 1 in 5
chance of completing suicide, and their risk for suicide
is more than 20 times that of the general population.9
For those with Bipolar Disorder, a lifetime battle
with substance abuse is a significant predictor of suicide
attempts. Those with Bipolar Disorder and comorbid
substance abuse disorders have a higher rate of at-
tempted suicide than those without comorbid substance
abuse disorders.10
Signs and symptoms that may accompany suicidal
feelings include:
- talking about feeling suicidal or wanting to die,
feeling hopeless, that nothing will ever change or
get better
- feeling helpless, that nothing one does makes any
difference
- feeling like a burden to family and friends
- abusing alcohol or drugs
- putting affairs in order (e.g., organizing finances
or giving away possessions to prepare for one’s
death)
- writing a suicide note
- putting oneself in harm’s way, or in situations
where there is a danger of being killed
munity support groups, restricted access to highly lethal
means of suicide, and skills in problem solving and
conflict resolution. All of these are important
components in reducing the risk of suicide.11
The importance of getting a correct diagnosis and
seeking treatment immediately cannot be understated.
The disorder affects not only an individual – but the
families, friends, and colleagues around them.
Effective treatment can change lives, as echoed by a
2005 global survey conducted by the World Federation
for Mental Health (for more information contact
info@wfmh.com):
- The vast majority (79%) of those with the
disorder in all countries say successful treatment
would lead to significant quality of life changes
in terms of increased functionality/improved
lifestyle such as maintaining a job, having relat-
ionships, living independently, and
achieving goals.
Seeking diagnosis and treatment for yourself,
or someone you love who may have Bipolar
Disorder, will significantly improve the quality
of life.

Those with Bipolar Disorder (and other serious mental

illnesses) should create a “plan for life” outlining steps
to take should they become suicidal or unable to care
for themselves. See an example “plan for life" at
http://www.dbsalliance.org/site/PageServer?pagename=
crisis_suicide_suicide#Create%20a%20Plan%20for%
20Life which includes contact information for family
members, friends and doctors. Those with the disorder
are also urged to fill out a Psychiatric Advance
Directive, which lays out a plan for treatment, should an
episode of depression or mania render them incapable.
For information on how to create a Psychiatric Advance
Directive, see http://www.nrc-pad.org
With effective care and treatment for the disorder,
the risk of suicide can be reduced. To reduce the chance
of suicide, the treatment plan for those with Bipolar
Disorder and comorbid substance abuse should include
access to and ongoing relationships with healthcare
 World Federation for Mental Health 11

6 Blumberg HP, Kaufman J, Martin A, Charney DS, Krystal

JH, and Peterson, BS. (2004). Significance Of Adolescent
Neurodevelopment For The Neural Circuitry Of Bipolar
1 Weissman MM, Bland RC, Canino GJ, et al. (1996).
Disorder. Adolescent Brain Development: Vulnerabilities
Cross-National Epidemiology of Major Depression and
and Opportunities. Annals of the New York Academy of
Bipolar Disorder, Journal of the American Medical Association,
Sciences, 1021: 376-383.
24/31: 276(4).
7 Regier DA, Farmer ME, Rae DS et al. (1990), Comorbidity
2 WHO. International Consortium in psychiatric epidemiology.
of mental disorders with alcohol and other drug abuse.
Cross national comparisons of the prevalences and correlates
Results from the Epidemiologic Catchment Area (ECA)
of mental disorders. Bulletin of the World Health Organization
Study. Journal of the American Medical Association,
78(4): 413-426, 2000.
264(19): 2511-2518.
3 Baum AE, Akula N, Cabanero M, Cardona I, CoronaW,
8 Sonne SC, Brady KT (2002). Bipolar disorder and alcoholism.
Klemens B, Schulze TG, Cichon S, Rietschel M, Nöthen
Available at: http://pubs.niaaa.nih.gov/publications/arh26-2/103-
MM, Georgi A, Schumacher J, Schwarz M, Abou Jamra R,
108.htm.
Höfels S, Propping P, Satagopan J, Detera-Wadleigh SD,
9 Dalton EJ, Cate-Carter TD, Mundo E et al. (2003). Suicide
Hardy J, McMahon FJ. (2007). A genome-wide association
risk in bipolar patients: the role of co-morbid substance
study implicates diacylglycerol kinase eta (DGKH) and several
use disorders. Bipolar Disorders 5(1): 58-61.
other genes in the etiology of bipolar disorder. The
10 Bipolar Disorder More Prevalent And Costly Than
Journal of Molecular Psychiatry. E-pub ahead of print.
Believed; Lithium Could Curb Suicide Rate. Science Daily,
4 Lin, P, McInnis MG, Potash JB,Willour VL, MacKinnon
June 20, 2005.
DF, Miao K, DePaulo JR, and Zandi PP. (2005). Assessment
11 Dalton J, Cate-Carter TD, Mundo E, Parikh SV, Kennedy
of the Effect of Age at Onset on Linkage to Bipolar
JL (2003). Suicide risk in bipolar patients: the role of comorbid
Disorder: Evidence on Chromosomes 18p and 21q. American
substance use disorders. Bipolar Disorders 5 (1):
Journal of Human Genetics, 77: 545-555.
58–61.
5 Bipolar Disorder (2007). The National Institute of Mental
Health. The U.S. Department of Health and Human Services:
Rockville, MD.
12 World Federation for Mental Health

Childhood should be a time of play, exploration, and

making new friends. But as Tia’s story illustrates,
undiagnosed and untreated Bipolar Disorder makes
navigating early childhood and adolescence difficult for
children and their families. In children and adolescents,
the disorder is often referred to as Childhood-Onset
Bipolar Spectrum Disorder.

The last decade of research has shown that Childhood-

Onset Bipolar Spectrum Disorder is different – and
more severe – than that diagnosed in older adolescents
and adults.
When the illness begins before, or soon after
puberty, children and adolescents with the disorder
often experience very fast mood swings between
depression and mania, sometimes many times within a
day, or over a period of several days. This is known as
a mixed state.

They can feel agitated,
restless, and have high energy –
but also may feel worthless and
self-destructive. While mixed
states are not as common in
adults (unless induced by
antidepressant treatment), they
are a true hallmark of
Childhood-Onset Bipolar
Spectrum Disorder.
Given this constant mixed
state of emotions, the moods of children with the
disorder are often irritable, and prone to destructive
outbursts. At times they almost cannot stand to be in
their own bodies. They are often inflexible and
oppositional, and may have periods of explosive rage,
with long-lasting tantrums.
Many parents and families may struggle for years
before getting a proper diagnosis for their child or
adolescent. For many parents and families, how do
they know if their child or adolescent is simply moody,
or whether it is something more?
Children and adolescents diagnosed with the
disorder often exhibit (for
months or even years), (short periods of
intense mood changes and irritability), and
(without periods of remission).
Mania in children and adolescents is different than
mania seen in adults, and many symptoms of mania are
developmentally appropriate in certain age groups
and/or overlap with other common childhood mental
disorders. Symptoms of mania in children and
adolescents include:1
- euphoric or expansive mood
- irritability
- grandiosity
- decreased need for sleep
- pressured speech
- flight of ideas/racing thoughts
- distractibility
- increased goal-directed activity in social,
academic, or sexual arena/psychomotor agitation
- increased involvement in pleasurable activities or
activities with high potential for harm
Childhood-Onset Bipolar Spectrum Disorder
World Federation for Mental Health 13
characterised by the onset of manic or mixed episodes,
rather than a depressive episode, which is more
common in adults with the disorder. Depressive
symptoms in children and adolescents include:2
- irritability
- depressed mood, persistent sadness, frequent
crying
- thoughts of death or suicide
- loss of enjoyment in favorite activities
- frequent complaints of physical illnesses such as
headaches or stomach aches
- low energy level, fatigue, poor concentration,
complaints of boredom
- major change in eating or sleeping patterns, such
as oversleeping or overeating
- feeling very guilty about things beyond their
control or thinking they are no good
For examples of behaviours of children and
adolescents with Childhood-Onset Bipolar Spectrum
Disorder (as well as corresponding developmentally-
appropriate behaviours) see the table titled Examples of
Developmentally Typical and Atypical Behaviours on
page 15.
Children and adolescents can have various types of the
disorder, and symptoms can occur along a broad
spectrum. In children and adolescents, diagnoses along
the spectrum include:
- The most severe form of the disorder,
characterised primarily by a manic state or
mixed episode state.
- . Symptoms alternate between
depressive and hypomanic states.
- . Symptoms include depression
and hypomania, but are less intense.
-
(NOS). The most common diagnosis for
children and adolescents on the bipolar
spectrum.3 Children are often diagnosed with
BP-NOS if they are one symptom short of the
other diagnoses, the duration of episodes is
insufficient, or the episodes are not clearly
defined.
A evaluation of the child or
adolescent should be conducted to make a diagnosis of
the disorder, which should include gathering
information from both child and parents (including a
family and medical history) and creating a timeline of
is the moods of the child or adolescent. In most cases, an
14 World Federation for Mental Health

of the child or adolescent must be done

before a final diagnosis of Bipolar Disorder can be
made. A complete physical exam should also be
conducted to rule out other illnesses.
Estimates of Bipolar Disorder in children vary
widely from country to country. Estimates differ For children and adolescents with the disorder, their
primarily due to environmental or cultural differences chances for recovery are affected by other comorbid
and the criteria used in each country to diagnose the conditions they may have, how well they stay on their
disorder. Estimates of Bipolar Disorder in various treatment plan, and the support systems they have
countries can be found at http://www.blackwell- available to them (e.g. home, school, community).
synergy.com/doi/pdf/10.1111/j.1399-5618.2005.00262.x Many children and adolescents reach recovery, but
?cookieSet=1. recurrences are common. For example, a recent study
of children and adolescents with the disorder shows that
they average 16 cycles of mood changes a year, and 2
1/2 years after diagnosis, four out of five have at least
Often, those with Childhood-Onset Bipolar Disorder are one recurrence.6
diagnosed with other mental health disorders, known as New research shows that because the disease
comorbid conditions. manifests itself more severely in children,
These other diagnoses can is the best chance for children
It is important to note
mask or co-occur with to achieve stable moods and improve the course of the
that suicidal
Bipolar Disorder:4 disorder, as well as the quality of life in adulthood.7
behaviours are more
- attention-deficit
frequent in children
disorder with
diagnosed with
hyperactivity Parenting any child is a challenge. Parenting a child
Bipolar Disorder than
(ADHD) with Bipolar Disorder requires empathy, patience, time,
in other psychiatric
- disruptive behaviour and flexibility. Parents of children diagnosed with the
disorders. Every child
disorders disorder should:8
and adolescent should
- anxiety disorders - Be
be evaluated for these
- substance abuse - Keep a and environment
behaviours.
- developmental and for your child
intellectual disabilities - Be (e.g., listen when your child is
In adolescents, bipolar disorder is often ready to talk)
misdiagnosed as borderline personality disorder, post- - (praise specific behaviours, and
traumatic stress disorder (PTSD), or schizophrenia. measure success in comparison to “usual”
Studies have indicated between 40-90% of children behaviours)
with bipolar disorder also have ADHD, and around 50% - (replace don’ts with do’s:
have comorbid conduct disorder.5 The correct diagnosis “Don’t hit your brother” should be “Please keep
of Bipolar Disorder – as well as other existing comorbid your hands and feet to yourself”)
disorders – is important to stabilise the child and to - (be sure to build in a buffer
prevent symptoms from worsening. of time and energy into your day so that you are
prepared for unexpected events)
- (avoid tackling
Once a diagnosis of Bipolar Disorder is made in problems and issues important to school or
children or adolescents, treatment can help to stabilise family functioning when the child’s mood is not
mood states and improve symptoms. Treatments for stable)
Bipolar Disorder in children include both therapy and With the correct diagnosis, a child or adolescent
medication. Specific information on treatments for with Bipolar Disorder can be stabilised, and a treatment
children and adolescents with the disorder are included plan can be put into place to begin the road to recovery.
in Chapter Four, page 18.
 Examples of Developmentally Typical and Atypical Behaviours8

Typical Atypical
Elated mood An 8 year old who is highly energetic A 7 year old who feels he is the
and happy on Thanksgiving day when luckiest child on earth, that
he sees his cousins everything is wonderful and happy
in his life and acts in an
exaggerated manner as a result
Irritability A 5 year old who, after a full day of A 10 year old who runs through the
playing, stomps up the stairs when her house knocking everything off of
parents tell her she is being cranky tables and throwing toys after his
and needs to go to bed mother tells him to go take a
shower
Grandiosity A 9 year old child vehemently argues An 8 year old who searches for
that he is the best runner in his school colleges on the Internet because she
plans to start college in the fall
rather than 3rd grade
Decreased need for A 9 year old cannot sleep the night A 7 year old who goes to his room
sleep before his 10th birthday party and is for bed at 8pm, but organises his
energetic the whole day despite toys and draws pictures until 2am
getting 6 hours of sleep, but falls into and wakes up ready for the day at
bed at 7pm after the party 6am
Flight of ideas An 8 year old who jumps from math A 14 year old who repeatedly
to gym to art back to math in the becomes so distracted as he
description of his school day describes events that even friends
and family cannot understand him
Distractibility A 10 year old who has difficulty A 10 year old normally calm
focusing on her work and frequently student cannot remain seated and
leaves her seat the day before holiday attentive for 30 minutes and gets up
break to sharpen her pencil or get a
different book every 5 minutes
Increase in goal- A high school student zooms around A high school student collects
directed behaviour collecting college information college information, starts an art
because he is excited about future project for professional display,
prospects begins repainting his bedroom and
plans a party at his home for the
weekend all in a one-hour period
Hypersexuality A 13 year old boy who looks at A 9 year old boy who touches his
pictures of scantily clad women on teacher’s breasts and slaps her
the Internet bottom; a 17 year old who has four
sexual partners and wants to have
sex several times every day
Involvement in A 7 year old, who after seeing BMX An 11 year old packs and prepares
behaviours with a bike racing on television, rides his to ride his bike across the United
high potential for bike at top speed through his quiet States because he saw a TV story
danger neighborhood about someone doing this

Akello lives in Uganda. She describes her efforts
to get treatment for Bipolar Disorder, which is
very difficult in this sub-Saharan region.
I think I have bipolar disorder. I have never been
formally diagnosed by a psychiatrist, but after many
conversations with the nurses and the health care
workers at the local health clinic that helps people with
HIV/AIDS, we all think that this is the most likely
diagnosis. I go to this health clinic here, run by a local
non-governmental organisation (NGO) since there are
no psychiatrists in our rural community, and I cannot
afford to go to the city to the hospital to be diagnosed. I
am also afraid if I went, I would be put in the mental
hospital there. So, I am staying home, working in my
community, and trying to stay stable for myself and my
family.
There is very little medical help for people with
mental illness in this country, and especially in my
community. Because we live in a rural area and getting
medication is difficult for many things, and for mental
illness, it is nearly impossible. My nurse and doctor
work with a psychiatrist in the city to try and get
medications, which they know work to control the
symptoms of the disorder. But we never know what we
are going to be able to get. Many of the medications
are not available here; they are very expensive. I never
am able to stay on any medication for very long, as our
supply runs out. It is frustrating to know that there are
treatments that can make me better, but I sometimes
cannot get them.
The nurses at the local clinic have also been
working with the traditional healer in my town, a
herbalist. She has been helping me in between my
acute periods to cope with my illness using natural
remedies and talking with me. Together, we are learning
about this illness, and how to recognize the warning
signs for an episode. She orders books and pamphlets
in the mail. She is also the one that usually contacts the
nurse when she sees that I am beginning to have
problems that she feels she cannot manage without
medication.
She has also been very helpful with the rest of our
community in helping them understand that I am not
dangerous or possessed by evil spirits but have an
illness. There is quite a lot of stigma about mental
World Federation for Mental Health 17
illnesses in my country. Some are still very suspicious
of me, particularly the men in our community. They
don’t want their wives helping me, and one husband
threatened to beat his wife if she talked to me. It is not
easy for any of us.
The nurse at the local clinic said that she had
recently heard from a university in the United States
that was interested in studying people with mental
illness here. She was very hopeful and said this may
really help me and help our community and country get
better services and treatment for people like me. We
need help to train our nurses and healers about mental
illnesses, and teach our communities that these are real
diseases, just like HIV/AIDS.
I am hopeful. But for the moment, I just live one day
at a time and feel lucky I have the support that I do. It
isn’t perfect, but it is much better than it was.
I am very thankful to the nurses and healthcare workers
at the clinic, and my healer. They have all been very
kind and helpful to me, even when none of us under-
stood what was wrong with me. If it weren’t for them, I
am not sure where I would be.
Worldwide, 27 million people are affected by Bipolar
Disorder. Many others remain undiagnosed, and more
lack access to effective treatment, as the case study
illustrates. Even with access to effective care, treating
the disorder can be a challenge for patients and doctors
because of the disorder’s constantly shifting moods.
Establishing and maintaining a treatment plan requires
both doctors and patients to be vigilant and flexible.
The two most widely used treatments for the disorder
include and , also known as
psychotherapy or talk therapy. Attending peer support
groups also helps those with the disorder to cope with
day-to-day challenges.
There is no cure for the disorder. However, with
proper treatment, most people who have bipolar
disorder—even those with the most severe forms—can
stabilise their mood swings and related symptoms.1
Once a diagnosis of the disorder is made, a treatment
plan should be put into place. There are two important
characteristics to every treatment plan:
- In most
cases, bipolar disorder is much better controlled
18 World Federation for Mental Health
if treatment is continuous – than if it is on and
off. But even when there are no breaks in
treatment, mood changes can occur and should
be reported immediately to the doctor so that
adjustments can be made to the treatment plan
and possibly prevent a full-blown episode.
Working closely with the doctor and communi-
cating openly about treatment concerns and
options can make a difference in the
effectiveness of treatment.
- Treating children and adolescents with the disorder
Keeping a chart of daily mood
symptoms, treatments, sleep patterns, and life
events may help people with bipolar disorder and
their families to better understand the illness, and
help doctors to treat the illness most effectively.
Medications and therapy are the primary ways to
alleviate symptoms of the disorder. A comprehensive
approach which includes medication and psychotherapy
is recommended. Many guidelines have been published
in recent years outlining the specific medications and
therapies that have been effective in the treatment of
Bipolar Disorder in adults2,3,4,5 as well as children and
adolescents.6 The most recent guidelines indicate that
for treatment of the disorder in , individuals need
a combination of the following:
- . Medications such as
lithium, lamotrigine, and olanzapine are
currently recommended options for maintenance
therapy;
- Atypical antipsychotics
(e.g. olanzapine, risperidone, quetiapine),
lithium, and valproate are all medications that are
recommended for the treatment of mania;
- Most guidelines
recommend an antidepressant only if in
combination with a mood stabiliser (e.g. lithium,
valproate) or antimanic agent for the treatment of
Bipolar Depression since antidepressants alone
may induce switching to mania or hypomania,
mixed episodes, and rapid cycling. Current
research is focused on finding better ways to
treat this hard-to-treat phase of the disorder.
See http://www.annals-general-psychiatry.com/
content/6/1/27 for more detailed information on
treating bipolar depression.
- A
comprehensive and coordinated approach, which
includes both medication and psychotherapy, is
recommended to provide optimal care for those
with bipolar disorder.7
For a copy of these most recent guidelines, see
http://www.annals-general-psychiatry.com/content
/6/1/27.
is even more complex than treating adults, both due to
the severity of the disorder in this age group, and the
lack of information about what works. Unfortunately,
research on the disorder in children lags far behind
what is know about treating adults. The most recent
guidelines8 indicate that for treatment of the disorder in
, combination treatment
(medications and psychotherapy) is recommended:
- . Medications such as
lithium, divalproex sodium, or carbamazapine
are most commonly used to treat children and
adolescents; risperidone [see statement at
http://www.fda.gov/bbs/topics/NEWS/2007/
NEW01686.html] and aripiprizole [see statement
at http://www.fda.gov/ cder/foi/esum/2007/021
436s017_Aripiprazole_ ClinPharm-BioPharm_
BPCA.pdf] were recently approved in the U.S.
for use in children and adolescents in the U.S.
- (mania and
depression). Additional medications are also
needed to treat the acute phases of the disorder.
Because of the severity and complexity of the
disorder in young children and adolescents,
many treatment pathways [see http://www.
bpkids.org/site/DocServer/treatment_
guidelines.pdf] are used.
- . Once a
child is stabilised with medication, therapy can
help build skills and provide families with the
information and support they need to help their
child or adolescent. A comprehensive and
coordinated approach to medication and
psychotherapy is recommended for optimal care
for children and adolescents with bipolar
disorder.
Because the treatment of the disorder is
in both adults and children and adults, healthcare
professionals should provide a treatment plan tailored
to

There are three primary goals in using medication to
treat the disorder. These include stabilising the patient’s
moods (e.g., extreme agitation or suicidal impulses),
recovery from the current episode (mania or
depression), and preventing a relapse. The nature of
Bipolar Disorder, with its cyclical mood swings,
requires more than one medication. Four main types of
medications are used to treat various symptoms of
Bipolar Disorder:
- Mood stabilisers
- Anticonvulsant medications
- Antipsychotic medications
- Antidepressants
Mood stabilisers, anticonvulsant medications and
antipsychotic medications are used to stabilise and
maintain mood. The depressive phase is one of the
most difficult aspects of the disorder to treat.
Antidepressants can be prescribed, but only in
combination with antimanic medications to prevent
switching to mania or hypomania, mixed episodes, and
rapid cycling that the use of antidepressants alone can
cause.
Medications can help ease the symptoms of the
disorder. Learn about your medications. The more you
know about your medications and understand them, the
better off you will be. Ask your doctor:
- What is the name of the medication, and what is
it supposed to do?
- How and when do I take it, and when do I stop
taking it?
- What foods, drinks, other medications, or
activities should I avoid while taking the
prescribed medication?
- What are the side effects, and what should I do if
they occur?
- Is there any written information available about
the medication?
To help these medicines work the best they can,
patients and their families must actively participate in
their treatment. This means telling your doctor about
past medical problems, other medications taken,
anticipated life changes (e.g., pregnancy), and after
medication treatment is ongoing, any side effects that
may occur. All medications should be taken as directed
by your doctor.
World Federation for Mental Health 19
Many patients with Bipolar Disorder fail to take their
medications as directed due to side effects.
Discontinuation of medication can lead to a recurrence
of the disorder, and potentially, hospitalisation or
suicide. Not everyone will have the side effects listed
on the medications. It is very important to talk with
your doctor about the potential side effects of each
medication, and to develop a plan to manage these side
effects. This step will help to prevent medication
discontinuation. For more information on side effects
of medications commonly used for Bipolar Disorder, see
http://www.nami.org/Template.cfm?Section=By_Illness
&Template=/TaggedPage/TaggedPageDisplay.cfm&TPL
ID=54&ContentID=23037&lstid=325.
There are four types of therapy commonly used to treat
Bipolar Disorder. All of the therapies teach patients life
skills such as finding a place to live, getting and
keeping a job, and managing money. These therapies
also teach strategies for managing the mood states that
can interfere with these daily activities.
- (FFT), which requires
the participation and input of participants' family
members and is focused on enhancing family
coping with the illness, communication, and
problem-solving.
- (PEP),
which teaches the patient and family members
about the disorder, and skills to manage
symptoms more effectively, including affect
regulation, problem-solving and communication.
- (CBT), which is
focused on helping the person understand
distortions in thinking and activity, and learn new
ways of coping with the illness.
-
(IPSRT), which is focused on helping the
participant stabilise his or her daily routines and
sleep/wake cycles, and solve key relationship
problems.
A recent study has shown that those who undergo
intensive psychotherapy – in addition to medication –
report better life satisfaction and better relationship
skills than those who received only brief therapy and
medication.9
Choosing a therapist should be done carefully. Rather
20 World Federation for Mental Health

than simply choosing one from a phone book, ask for a managing their lives, and offer structured activities to
referral from a primary health care provider, church, or cope positively with the disease.
local mental health agency, or family and friends. If
you are not comfortable asking family or friends, 12

referral hotlines of In situations where medication, psychosocial treatment,

professional and the combination of these interventions prove
organisations, ineffective, or work too slowly to relieve severe
including your state or symptoms (for example, psychosis or suicidality),
local medical society, electroconvulsive therapy (ECT) may be considered.
and other professional ECT may also be considered to treat acute episodes
organisations and when medical conditions, including pregnancy, make
groups can also make the use of medications too risky.
referrals to therapists ECT is a highly effective treatment for severe
(see Resources, pages depressive, manic, and/or mixed episodes. ECT
38-40). involves the application of electrical stimulus to the
The therapist should brain to produce very short (30 second) generalized
be someone whom you seizures. The procedure is done under anaesthesia and
can trust. Finding a the patient doesn’t feel any pain. For the procedure to
“good fit” with a therapist will be a key to successfully be therapeutic, it is generally done 6-12 times over a
completing therapy. The key to finding a good fit is to period of a few weeks. The possibility of long-lasting
find someone you are with – someone memory problems, although a concern in the past, has
with whom you are able to be honest and open. If you been significantly reduced with modern ECT tech-
cannot provide information about your life and your niques. However, the potential benefits and risks of
disorder, you cannot expect to make good progress. ECT, and of available alternative interventions, should
Because therapy can be time consuming, do not invest be carefully reviewed and discussed with individuals
in a therapy relationship that is not comfortable for you. considering this treatment and, where appropriate, with
Give it a chance, but if it is not working, seek another family or friends.
therapist who meets your needs. Herbal or natural supplements, such as St. John’s
wort (Hypericum perforatum), have not been well
studied, and little is known about their effects on the
In addition to medication and therapy, peer support disorder. Because the FDA does not regulate their
groups, or group meetings of others with the disorder, production, different brands of these supplements can
can help. These groups, contain varying amounts of the active ingredient.
when organised and well- peer Before trying herbal or natural supplements, it is
run, provide insight into day- support important to discuss them with your doctor. There is
to-day coping with the evidence that St. John’s wort can reduce the
disorder. Studies worldwide effectiveness of certain medications, including some
have confirmed the real used to treat HIV/AIDS, heart disease, cancer, as well
importance of peer support as oral contraceptives (see http://www.fda.gov/CDER/
groups10,11 in helping those drug/advisory/stjwort.htm). In addition, like
with the disorder to stay on prescription antidepressants, St. John’s wort may cause
their treatment plans. a switch into mania in some individuals with bipolar
Although support groups disorder, especially if no mood stabiliser is being taken.
are not for everyone, Omega-3 fatty acids found in fish oil13 and EMP+, a
participation in these groups vitamin-mineral complex, are also being studied to
may help those with Bipolar determine their usefulness, alone and when added to
Disorder to feel less isolated conventional medications, for long-term treatment of
and alone when coping with bipolar disorder,14 but there is no conclusive
the disorder. These groups also provide an opportunity information at this time.
to see how others with the disorder are successfully

As the case study at the beginning of this chapter
describes, the availability of treatment for Bipolar
Disorder varies worldwide. In most developed nations,
psychiatrists diagnose and treat the disorder. However,
in developing and third world countries, mental health
services commonly are provided mainly by
nongovernmental organisations (NGOs). An estimated
93 percent of African and 80 percent of Southeast Asian
countries have NGOs in the mental health sector. These
organisations provide diverse services—including
advocacy, informal support, housing, suicide
prevention, substance abuse/misuse counselling,
rehabilitation, research, and other programmes—that
complement, or in some cases substitute for, public and
private clinical services.15 In some countries and
cultures, a traditional healer is also used to help treat the
disease.
The challenge for many countries is to provide the
continuous and consistent care needed to most
effectively treat the disorder. New research shows that
for developing countries, the most cost-effective way to
treat Bipolar Disorder is with older mood-stabilising
drugs plus psychosocial treatment.16 For many low and
middle-income countries, investing in this type of
treatment could greatly reduce both the significant
individual and costly economic burden of Bipolar
Disease. See http://www.dcp2.org/pubs/DCP/31/ for
more information on this study.
1 The National Institute of Mental Health. Bipolar Disorder.
With Addendum January 2007. Department of Health and
Human Services: Rockville, MD.
2 Psychiatry Guest Editor’s Column— International Consensus
Group on Bipolar I Depression Treatment Guidelines:
Synopsis and Discussion. Journal of Clinical Psychiatry,
April 2004.
3 Goodwin GM, for the Consensus Group of the British
Association for Psychopharmacology. Evidence-based guidelines
for treating bipolar disorder: recommendations from
the British Association for Psychopharmacology. Journal of
Psychopharmacology 17(2) (2003) 149–173.
4 American Psychiatric Association. (2002, April). Practice
guideline for the treatment of patients with bipolar disorder
(revision). American Journal of Psychiatry, 159(4) Suppl., 1-
50; Chou, J.C-Y. (2004, September). Review and update of
the American Psychiatric Association practice guideline for
bipolar disorder. Primary Psychiatry 11(9), 73-84. BIPOLAR
2C.
5 Fountoulakis KN, Vieta E, Siamouli M, Valenti M, Magiria
S, Oral T, Fresno D, Giannakopoulos P, Kaprinis
GS.Treatment of bipolar disorder: a complex treatment for
a multi-facet disorder. (2007). Annals of General Psychiatry,
Oct 9; 6(1):27 [Epub ahead of print].
World Federation for Mental Health 21
6 Kowatch RA, Fristad M, Birmaher B,Wagner KD, Findling
RL, Hellander M; Child PsychiatricWorkgroup on Bipolar
Disorder. (2005). Treatment guidelines for children and
adolescents with bipolar disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, Mar; 44(3):213-
35.
7 Yatham, L.N., Kennedy, S.H., O’Donovan, C., Parikh, S.,
MacQueen, G., McIntyre, R. et al. (2005). Canadian Network
for Mood and Anxiety Treatments (CANMAT) guidelines
for the management of patients with bipolar disorder:
Consensus and controversies. Bipolar Disorders, 7 (Suppl 3)
5-69. Retrieved October 11, 2007 from:
http://www.canmat.org/resources/PDF/Bipolar_Guidelines.
pdf
8 Kowatch RA, Fristad M, Birmaher B,Wagner KD, Findling
RL, Hellander M; Child PsychiatricWorkgroup on
Bipolar Disorder. (2005). Treatment guidelines for children
and adolescents with bipolar disorder. Journal of the American
Academy of Child and Adolescent Psychiatry,
44(3):213-35.
9 Goldberg JF, Perlis, RH, Ghaemi SN, Calabrese JR, Bowden
CL.,Wisniewski S, Miklowitz, DJ, Sachs GS, Thase
ME. (2007). Adjunctive Antidepressant Use and Symptomatic
Recovery Among Bipolar Depressed Patients With
Concomitant Manic Symptoms: Findings From the STEPBD.
American Journal of Psychiatry, 164: 1348-1355.
10 Depression and Bipolar Support Alliance, 1999. Retrieved
from website (www.dbsalliance.org) on November 2, 2007.
11 Tse, S., Doughty, C., Bristol, F. (2004). Peer Support
Groups for People With Bipolar Disorders in New Zealand:
A Pilot Study on Critical Success Factors. The International
Journal of Psychosocial Rehabilitation, 9, 1, 47-58.
12 This section on Other Treatments is excerpted and adapted
from The National Institute of Mental Health. Bipolar Disorder.
With Addendum January 2007. Department of
Health and Human Services: Rockville, MD.
13 Stoll AL, et al. (1999). Omega-3 fatty acids in bipolar disorder:
A preliminary double-blind, placebo-controlled trial.
Archives of General Psychiatry, 56(5): 407–412.
14 Stoll AL, et al. (1999). Omega-3 fatty acids in bipolar disorder:
A preliminary double-blind, placebo-controlled trial.
Archives of General Psychiatry, 56(5): 407–412.
15 Hyman S, Chisholm D, Kessler R, Patel V, and Whiteford H,
“Mental Disorders.” 2006. Disease Control Priorities in
Developing Countries (2nd Edition), ed. , 605-626. New York:
Oxford University Press. DOI: 10.1596/978-0-821-36179-
5/Chpt-31.
16 Hyman S, Chisholm D, Kessler R, Patel V, and Whiteford H,
“Mental Disorders.” 2006. Disease Control Priorities in
Developing Countries (2nd Edition), ed. , 605-626. New York:
Oxford University Press. DOI: 10.1596/978-0-821-36179-
5/Chpt-31. Table 31.4.
22 World Federation for Mental Health

Bipolar Disorder often makes those with the disorder

feel powerless over its shifting moods. But those with
the disorder can lead a full and productive life by taking
care to manage the disorder, day-by-day. Medications,
therapy, and a network of supportive family, friends and
organisations are an essential part of helping you to get
well and stay well. There are four important steps to
managing the disorder, from preventing a relapse to
promoting recovery. These are:
- Stay on your treatment plan
- Track your moods and feelings
- Take care of your whole self
- Create a support system of family, friends, and
organisations to help

Bipolar Disorder is a brain disorder where differences

in the structure and function of the brain, along with a
genetic predisposition to the disorder and other
environmental factors, act together to cause the disease.
Though there is no cure , it is a treatable condition,
but one that must be managed every day.
Just as a map guides lost travelers to geographic
landmarks, a good treatment plan, including both
medication and therapy, can help to stabilise moods and
help prevent episodes. A key component to staying
well is the development of a good treatment plan which
outlines needed medications and therapy, and
importantly, a plan for insuring continued mental health
care during times of crisis.

Medication is essential to making you feel
better. Because of the disorder's shifting moods, more
than one medication is needed to help you stay well.
And, as time passes, these medications may need to be
adjusted, and some may need to be changed due to side
effects. But do not stop taking medication without first
talking to your doctor. Remember that every person
responds differently to medications, and what works for
others may not work for you. Track the medications
you are taking in a diary, which will help determine if
the medications are working for you.
Several types of therapy, also called
psychotherapy, are used to help provide the needed
skills for managing the disorder and daily life. Therapy
can also teach you the “triggers” for moods – what
someone says or does, or thoughts that triggered a
“black” or low mood. Because the disorder also affects
the entire family, marriage and family therapy can also
help to improve the relationships with those close to
you. Attend all of your therapy appointments; results
are not instant, but can be long-lasting. Research has
shown that medications PLUS psychotherapy produce
better outcomes for people with the disorder.
One important
component to managing the disorder is establishing a
plan for when you yourself are unable to direct your
own care (e.g. during times of severe mania or
depression). Establish a Psychiatric Advance Directive
(PAD) for times when you cannot manage a relapse to
insure that your care will continue as you wish. For a
sample PAD go to http://www.nrc-pad.org.
A mood chart (see page 6) is a good way to help you,
your doctor, and your family to manage your disorder. A
mood chart is a diary in which you keep track of your
daily feelings, activities, sleep pattern, medication and
side-effects, and important life events.
This chart will help you to better see changes in
sleep and mood. More importantly, you will be able to
see a pattern of sleep and mood and determine what
triggers your episodes of mania or depression (e.g. lack
of sleep). At the first sign of these triggers, be vigilant
in caring for yourself. Keeping track of medicines,
moods, sleep, and feelings over time will help to better
manage symptoms and prevent relapses.
World Federation for Mental Health 23
While your doctor can help you to manage the
symptoms of the disorder, you must also take care of
your physical self, including getting proper nutrition,
exercise and sleep, as well as organizing and planning
daily routines in order to reduce the stress in your life.
Take care of
your physical self by exercising, eating right, and
maintaining healthy sleep habits, which can help to
prevent relapse.
Exercising is good for both your
physical and mental health; it releases the
chemicals in the brain (serotonin and dopamine)
that depressed people lack1. Establishing a
regular exercise routine will help maintain a
healthy weight and reduce stress levels,
important for someone with the disorder. In
addition to exercise, other techniques to help
lower your stress include relaxation, meditation
and deep breathing. These techniques, widely
used around the world, are a low-cost way to
reduce stress on your own.
Some medications for the disorder
may cause you to gain weight. A healthy diet
which includes whole grains, fresh fruits and
vegetables and is low in fat will help you to
maintain a healthy weight. See your doctor for
help in planning healthy meals.
Loss of sleep (even one
night) can trigger mania, and sleeping too much
may contribute to an episode of depression. Set
and stick to bedtime and morning routines to be
sure you are getting enough sleep. If you have
trouble sleeping or are sleeping too much, tell
your doctor.
. Stress, both at work
and at home, can trigger episodes of illness, so it
is important to avoid or reduce stress in your
daily life. Keep your working hours
predictable so as not to cause a change in sleep
habits, and an onset of illness. Openly
communicate with family and friends about what
is going on in your life to foster better
relationships.
Unfortunately, many people
with Bipolar Disorder abuse alcohol or drugs
during their illness. Use of these substances may
trigger episodes and may interfere with your
prescribed medications. If you think you may
24 World Federation for Mental Health

have a problem with alcohol and/or drugs, seek
treatment immediately. Do not wait.
Avoid stress by
creating daily routines. Planning your day’s
activities will help to manage the many daily life
tasks you have to do. Create and maintain a
monthly calendar to help to track daily
medications, therapy appointments, and other
events.
participation in these groups may help those with
the disorder to feel less isolated and alone. These
groups provide an opportunity to see how others
with the disorder are successfully managing their
lives, and offer structured activities to cope
positively with the disease.

A network of family and friends can make all the

difference for someone with Bipolar Disorder. Seek out
friends and family, as well as local organisations, for Many local community organisations, together with
help in managing the disorder. national mental health organisations, can help by
A providing information and resources on many issues,
diagnosis of Bipolar Disorder can be overwhelming from finding mental health service providers to
at first. But family and friends can make a big resolving issues of employment and housing, two
difference in helping you to cope with the diagnosis things which can be particularly stressful for
and deal with Bipolar Disorder on an everyday someone with the disorder. Stable employment and
basis. Family and friends can do many things - most good housing are both critical factors in maintaining
of all being supportive
a stable environment and reducing stress.
and listening, and
With careful planning and care, those with the
accepting you as you
disorder can lead full and productive lives. The
are. Family and
roadmap for recovery and the prevention of relapse
friends can also help
includes staying on your treatment plan, carefully
you to create and stick
tracking your moods and feelings, taking care of your
to your treatment
whole self, and creating a support system of family,
plan, lessening the
friends, and organisations to partner with you in
chance of relapse.
managing this lifelong illness.
Seek out your friends
who will stick by you
and help you through
the tough times. Ask 1 Dimeo, F., Bauer, M., Varahram, I., Proest, G. and Halter,
them for specific help if needed to create the daily U. (2001), Benefits from aerobic exercise in patients with
routines which will keep you stable, or for help with major depression: a pilot study. The British Journal of Sports
Medicine, 35: 114-117
getting the required services or resolving insurance 2 Depression and Bipolar Support Alliance, 1999. Retrieved
matters. from website (www.dbsalliance.org) on November 2, 2007.
3 Tse, S., Doughty, C., Bristol, F. (2004). Peer Support Groups
for PeopleWith Bipolar Disorders in New Zealand: A Pilot
Study on Critical Success Factors. The International Journal
of Psychosocial Rehabilitation, 9, 1, 47-58.
In addition to medication
and therapy, peer support groups, or group meetings
of others with the disorder, can help. These groups,
when organised and well-run, provide insight into
day-to-day coping with the disorder. Studies
worldwide2,3 show that these groups can help those
with the disorder to stay on their treatment plans.
Although support groups are not for everyone,

My family tends to push things under the rug, and
pretend they are not there. And for many years, my
sister’s illness was that one thing we hardly ever talked
about. And if we did, it was only among our immediate
family, and often, in whispers.
I’m not sure why we never talked about it more
openly, since several people from our family have been
diagnosed with Bipolar Disorder over the years – and
there are a few more that haven’t been diagnosed, but
should have been. Like the great patriarch himself, my
grandfather. He was quite a man, starting a print shop
when he was 14 years old, all by himself; but that is
another story.
For my sister, it wasn’t until her last “episode” that
my family began to open up about her illness, and seek
help and support from the rest of our family. Cecily was
missing for several days, and we were all terrified.
Finally, my brother and I tracked her down through her
fervent credit card activity, and we had to fly to New
Zealand to bring her home. She was completely out of
it, nearly hallucinating. She had stopped taking her
medication entirely. We managed to have Cecily
admitted to a hospital to get her stabilised; one week
later, we brought her home. After that, one of us stayed
with her around the clock for nearly a month. A few
cousins pitched in during that time to help, and many
others were on the phone offering help, calling various
private community health service organisations and
psychiatrists to find a day programme for her, and
finding out if her insurance would cover the cost of any
of these facilities. Several of my aunts and uncles sent
money to help cover the costs of treatment where
insurance would not.
It was really a difficult but eye-opening time for all
of us, but especially for Cecily. She realised how much
we all loved her and were rooting for her, and that we
weren’t talking about her behind her back, but really
wanted to help in any way we could. Cecily began
talking openly about her experiences with this illness,
and how it made her feel. We all began to listen – to
really listen to what life was like for her. My aunt who
World Federation for Mental Health 25
has Bipolar Disorder and lives in the U.S. called every
other day to talk to Cecily – and to all of us. She began
to teach us about the resources available beyond our
family, including peer support groups and online chat
rooms, and also the research that is underway, and best
places to go for information.
Because she, too, had been diagnosed with the
illness, she knew what it was like, and was an incredible
resource. Most importantly, my aunt was full of hope
for Cecily that she could recover from this episode and
move on. But she was cautious. Her parting comment
on each call was, “Don’t forget, knowledge is the key:
know yourself, know your illness, and know your
warning signs for relapse. It is the only way you can
successfully live with the disorder your whole life”.
So, we have all spent quite a bit of time online, in
the library. We have spent a lot of time with Cecily,
learning how we can support her and help her cope
with her illness.
Really, she has needed us to just listen, not judge,
and to accept her as she is – as a person living and
coping with Bipolar Disorder. We have also spent a lot
more time talking with each other. None of it has been
easy, but it has been an incredibly rewarding experience
for everyone in our family. Over the past year, our
entire extended family has been transformed into a very
close-knit group. For that, we all owe our thanks to
Cecily.
For someone coping with a serious mental illness like
Bipolar Disorder, having a friend or family member
they can count on can make all the difference.
It is a myth that you cannot help someone with
Bipolar Disorder. For someone with the disorder,
coping with the illness and everyday life – navigating
school, work, and home issues – can be overwhelming,
especially during an episode of depression or mania.
Friends and family members are essential to helping
someone with Bipolar Disorder reach recovery, cope
with the illness day-by-day – and most importantly,
26 World Federation for Mental Health
maintain daily routines that will help to keep them well.
There are many things you can do for
someone with the disorder, including:
- let them know that you are there for them
- let them know that they can get through this and
live a full life
- encourage and support their treatment
- let them know they are not alone
- let them know you accept them just as they are
- be there for them when they need you
There are also several things that friends
and family can do when someone they know is
diagnosed with the disorder. They can:
- help them get a correct diagnosis
- learn about the disorder and what it will take to
make them better
- help them through the manic phase of the
disorder, which can be a highly stressful
experience
- help them through the difficult-to-treat
depressive phase of the disorder
- help them to recognise the warning signs, signals
and symptoms of a relapse by tracking the moods
of the person
Many with the disorder wait years to receive a correct
diagnosis. Bipolar Disorder is often misdiagnosed as
depression (because this is often the phase when they
seek help), schizophrenia, other anxiety disorders, or
borderline personality disorder. In younger children,
the bipolar symptoms of inattention, impulsivity, and
even hyperactivity overlap with those for attention
deficit hyperactivity disorder (ADHD).
If you think someone that you love may be bipolar
(see the overview of Bipolar Disorder in Chapter One),
you can get help for them. Help can be found at:
- community, regional or provincial health centers
- non-governmental organisations (NGOs)
- university or medical school departments of
psychiatry
- hospital departments of psychiatry
- public mental health clinics
- and, in times of crisis, a hospital emergency
room
By learning as much as you can about this complex
mental disorder, you can help a family member or
friend live life to their fullest potential.
Many with the disorder suffer for years
undiagnosed, unable to maintain employment, secure
housing, or keep close relationships with family and
friends.
Learn about how the extreme states of the disorder
and for some, the rapid cycling between them, make
everyday tasks difficult. Learn how the disorder affects
children differently, with its rapid cycling, mixed states
(with few periods of wellness in between) which cause
them to be irritable, inflexible, and oppositional.
Significant research – on how to better diagnose and
treat the disorder – is underway worldwide. A
substantial amount of information is now available
(both on the Internet and in the library) to help friends
or family members learn about the disorder; see the
Resources section on pages 38-40.
During the manic phase of the disorder, a friend can
truly make all the difference. During this time, patients
may be “over the top”, and engage in impulsive and
potentially harmful behaviours. With increased energy
levels and little need for sleep, friends or family
members with the disorder may become incoherent,
take risks they otherwise would not, and attempt to
accomplish seemingly impossible tasks. In some cases,
this phase requires hospitalisation to insure the safety of
patients.
Recognise the warning signs of . Some of
these include increased energy with little need for sleep,
different speech patterns (incoherent speech), impaired
judgment, often including inappropriate humor and
behaviours, or else impulsive behaviours and financial
extravagance and grandiose thinking. For a list of
warning signs of mania, see Chapter One, Signs and
Symptoms of Mania, page 4. If you see signs of mania
occurring in a family member or friend with the
disorder, contact their healthcare provider, or if the
person is in danger, seek treatment from a hospital
emergency room.
A family member or friend can also make a big
difference when a friend is in the depressive phase of
Bipolar Disorder. During this often debilitating and
difficult to treat phase of the disorder, everyday tasks
are often impossible to accomplish – tasks such as
 World Federation for Mental Health 27

going to work or school, and most importantly, provider (missing appointments, etc.)
maintaining close relationships with loved ones. - Starting to hear or see things that others do not
Left untreated, some people in the depressive state - Abandoning usual routines such as going to
experience suicidal feelings. If a family member or school or taking part in family activities
friend is diagnosed with Bipolar Disorder, it is - Big changes in sleep patterns or appetite, not
important to learn the warning signs of depression and caring about appearance and difficulties with
suicide, and listen and act on any suicide threats a your physical coordination or short-term memory
friend or family member makes. If you notice a friend - Having troubling mood swings, feeling out of
wrapping up his/her “loose ends", talking about suicide control or being very agitated, having thoughts of
and/or methods to complete it, or appearing to be suicide or violence
despondent, seek help for them immediately. Contact - Doing outrageous things that make others think
their healthcare professional, or if necessary, seek you are out of touch with reality
treatment from a hospital emergency room. - Finding yourself unable to let go of an idea,
Recognise the warning signs of . Some of thought, or phrase
these include changes in activity or energy level - Having trouble thinking or speaking clearly or
(decreased energy and fatigue), physical changes (e.g. making yourself understood
unexplained aches and pains and weight loss or gain) - Feeling flat or not being able to enjoy things that
and emotional pain (e.g. prolonged sadness, usually give pleasure
unexplained, uncontrollable crying, feelings of guilt and - Being unable to make even routine decisions
worthlessness). For a list of warning signs, see Chapter
One, Signs and Symptoms of Depression, pages 4-5.
Research is underway to reduce the rate of relapse. A
new 12-session therapy program, led by trained mental
health clinicians, helps to reduce the rate of relapse by
helping those with the disorder to closely monitor their
mood, assess their own
Medication and therapy can personal triggers, and
help control the symptoms of identify the early warning
Bipolar Disorder. However, signs of oncoming illness.
even with these treatments,
many people with the Participants in the
disorder relapse; as many as program lowered their
40 percent in the first year, risk of relapse to 20% in
and almost 75 percent over the first year.3 This
five years.1 Relapse often research shows that
occurs when a person has paying attention to your
stopped taking medication or mood matters.
the medication no longer
works, or the person has
started to abuse alcohol or
drugs. Relapses will happen,
but by keeping a mood diary, Helping a loved one with
you can learn the triggers for the disorder can be
a relapse. difficult. There are many
Early warning signs of a significant and difficult
relapse include:2 issues facing the lifelong
- Not wanting to take caregiver of someone with
medications or the disorder. These issues
cooperate with include:4
your health care
28 World Federation for Mental Health

- Directive to spell out the care a person should

The receive during a crisis.
nature of the disorder means that caregivers Family members and friends play a significant role
often do not know what will happen next. Given in helping a loved one to manage this lifelong mental
that, caregivers find it difficult to plan for the illness. Learn about the disorder, and help a loved one
future (e.g. their own employment and personal get a correct diagnosis. Your care, concern and
relationships). guidance, especially during times of crisis, will help
- them recover more quickly. As a caregiver, reach out to
others for support and information as you help a loved
Stigma about mental one on the road to wellness.
illness exists
worldwide. Due to
the stigma of mental
illness, many
caregivers remain 1 Mental Health Research Institute Of Victoria (2007, August
24). Bipolar Disorder Relapses Halved with New Program.
isolated, unwilling Science Daily.
to seek personal or 2 The Cope Program Guide (2007). Taking care of Yourself;
professional help. Looking after Someone you Care About. AstraZeneca
Pharmaceuticals.
- 3 Mental Health Research Institute Of Victoria (2007, August
Both the 24). Bipolar Disorder Relapses Halved with New Program.
caregiver and the Science Daily.
4 Partially excerpted from Lindon, D. (2007). Five Key Facts
person with Bipolar about Mental Health Carers. The Princess Royal Trust for
Disorder may be Carers. Retrieved from www.carers.org
unable to maintain
employment, a situation often worsened by
uncontrollable spending during the manic phase
of Bipolar Disorder.
- Many caregivers are alone in
caring for a loved one or friend with the disorder.
Day-to-day, they have little time to themselves,
which affects their own physical and mental
health.
- . One of the
most difficult issues when taking care of
someone with the disorder means dealing with
the risk of suicide. The burden of
preventing these attempts, or dealing with
unsuccessful ones, is emotionally draining.
Those caring for someone with Bipolar Disorder
also need to take care of themselves. Ways to do this
include:
- Enlisting others to help you care for the person
with the disorder. Getting a much-needed break
will help to recharge your energy levels.
- Interacting with other caregivers to share success
stories and problem-solve.
- Know your limits – and that you cannot be there
for every emergency; be sure that your family
member or friend has a Psychiatric Advance

The diagnosis of and treatment for Bipolar Disorder is a
major challenge around the world. For many with the
disorder, five and sometimes even ten years pass before
their signs and symptoms are properly diagnosed, as the
journal Bipolar Disorders reported in a survey of
patients in thirty European countries.1 And, for those
who are correctly diagnosed, treatment may not be
available in their community.
For some, the stigma of even seeking help is too
great, particularly in cultures where those with mental
illness are viewed as “evil spirits”, or as having a
weakness in character. Untreated, Bipolar Disorder
prevents many from being able to hold down jobs and
secure housing, and disrupts relationships with family
and friends. In extreme cases, the disorder cuts lives
short due to suicide.
In summary, many individuals with Bipolar Disorder
remain untreated, even though effective treatments
exist; it is estimated that about half of those with the
disorder worldwide do not receive treatment.2
There are many ways that healthcare professionals
can help people cope with this disabling disorder. This
Guide provides information to help you understand:
I. The of the disorder and the stigma
surrounding it
II. The of the disorder in adults – and
children and adolescents
III. How to handle an of depression or
mania
IV. the disorder in adults, and children and
adolescents
V. the disorder on a
VI.Working with
VII.The importance of healthcare professionals
Also included in this Guide is a case study of an
individual with Bipolar Disorder. This case study, as
well as the other stories included in the chapters of this
packet, illustrates the difficulties that many with the
disorder – regardless of race, country or culture –
encounter when seeking diagnosis and treatment.
World Federation for Mental Health 29
I was finally diagnosed with Bipolar Disorder about 20
years ago, in my early thirties, after many years of
knowing that I was different from other people. I have
always had very intense mood swings, for as long as I
can remember. As an adult, I have also been prone to
very long periods of what I considered heightened
productivity, which were usually followed by very low
periods, where I sequestered myself in my room for
weeks, claiming I had a migraine.
But I am a film director in Cairo. I am around many
emotional people, very artistic people, and live in an
intense and sporadic work environment. My mood
swings and erratic behaviour fit relatively easily into
this landscape. In fact, I had come to rely on my manic
periods to make many of my movies. But I knew it was
not normal. And it was only because of my family that I
sought help. My wife said she would take our three
small children and leave me, move back to Alexandria
to her family if I did not do something about my
behaviour. She was fearful for herself and our children
because of my violent outbursts. She also said the
hours I kept were not healthy, and she did not like the
children learning from my chaotic schedule.
I went to our family doctor, a private Western doctor
we use because we can afford it; we are blessed in that
manner. Our doctor immediately seemed to think I had
Bipolar Disorder. He had learned about the illness in
medical school, but had seen few cases of it in Cairo –
probably because many here do not seek help. He gave
me the number of a psychiatrist; it took me over a
month to get an appointment, and after that, several
months to be diagnosed and to begin treatment. There
are not a lot of psychiatrists in Egypt, something like 1
per 70,000 people, so getting an appointment, even in
Cairo – even for someone who can afford private care –
can take time.
Most people in my country are not as lucky as I am
and have very limited options, if any. This lack of
treatment is something that has been occupying my
30 World Federation for Mental Health
mind quite a lot now. In fact, I am working on a film
about a poor Muslim woman who has Bipolar Disorder,
based on a story I wrote about mental illness in my
country.
Having a mental illness here, for me, has provided a
very informative lens through which to view the
experience of being Egyptian. We live in a very
complicated culture, with our history, our religious
beliefs, and the influence of the West on our daily lives.
Even seeking treatment in my country, one must hurdle
many things: spiritual, cultural, logistical, financial,
and emotional obstacles.
I am very hopeful about this latest film, that it may
even help people in our country understand mental
illness better. I have learned a lot in the last 20 years,
about myself, my illness, and my country. Managing my
illness is a daily job for me; and I need a lot of help
with it, from my family and my doctors. I now work
very hard to maintain a regular work schedule, and
consistent sleep and meal schedules. I no longer drink
coffee or alcohol. I pray regularly. I keep track of my
emotions using a mood chart (see page 6). I spend a lot
of time with my family.
I am truly blessed. My illness is a difficult one, but
through it, I have learned to appreciate my life, my
culture, and the people around me.
An estimated 27 million people worldwide have Bipolar
Disorder. The disorder typically emerges in adol-
escence or early adulthood but, in some cases, appears
during childhood [see Chapter 3], or it is diagnosed
during middle age.
Episodes of depression and mania – or a
combination of the two (called a “mixed” state) –
typically recur and may become more frequent over
time.3 There is no single cause for Bipolar Disorder;
instead, many factors appear to work together to cause
Mental disorders are stigmatised in many countries
and cultures, preventing people from seeking the
effective treatments that have been developed.4
Healthcare professionals can play a significant role in
stopping discrimination against individuals with
Bipolar Disorder and other mental illnesses by
communities, families, and individuals that
these are
the illness, including genetics, brain functioning, and
environmental factors.
A diagnosis of Bipolar Disorder can be overwhelming.
While those diagnosed with the disorder will be
relieved to have a name for feelings they have been
experiencing for many years, they often have a large
number of questions and concerns.
Many will ask “Why me?” and “What does this
mean?” or “What is going to happen to me?” Others
may try to resist any more information, which can
complicate the treatment and course of the current
episode and disorder.
As a healthcare professional, you play a critical role
in encouraging a patient to about the disorder.
Learning about this disorder is the first step toward
recovery. Learning about the disorder also means
understanding that this disorder must be managed for a
lifetime – and requires daily self care.
You don’t have to be a psychiatrist or psychologist
to recognise the symptoms of Bipolar Disorder. The
first step in recognising the illness is becoming familiar
with the signs and symptoms of the illness, including
depression and mania (see Chapter One). The
International Classification of Diseases (ICD-10)
[http://www.who.int/classifications/icd/en/] and the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) [http://www.psychiatryonline.com/resource
TOC.aspx?resourceID=1] are used globally to diagnose
bipolar and other mental disorders, and can provide
further guidance on diagnosis of the disorder. Careful
consideration should also be given to the person’s
culture and context when diagnoses are made, as well
as ruling out other medical problems
The first important step in diagnosing the disorder is
to learn all you can about the person’s history of moods
and behaviour over time. Equally important is learning
about the history of the illness in other family
members, since Bipolar Disorder is one of the most
highly heritable of all of the mental disorders. This
history can be gathered through conversations with the
person and/or close relatives or friends.
There are many different tools available to assist
healthcare professionals in assessing the likelihood of
this illness. One of these tools, from the Canadian
Network for Mood and Anxiety Treatments, suggests:5

- to screen for the disorder
- to screen for the disorder
- the consideration of
- Screen patients who present with depressive
symptoms for a history of hypomanic or manic
symptoms
- Consider an underlying mood disorder in patients
presenting with unexplained vague/non-specific
somatic symptoms or reverse vegetative
symptoms (e.g. hypersomnia and hyperphagia)
- Listen to the patient’s unprompted presenting
complaints
- Ask open-ended and non-leading general
questions about the common symptoms of
depression and mania
- Ask questions about specific symptoms of
depression and mania, including how long the
symptoms have been present during the current
episode, how long they lasted during prior
episodes (if applicable), and whether they have
caused problems in social relationships or work
- Always ask about suicidal ideation
- Ask about psychotic symptoms
- Consider asking the patient to complete a Mood
Disorder Questionnaire
- Ask about a family history of Bipolar Disorder
- Interview family or friends regarding prior
episodes of mania or hypomania
- If unclear, ask patients to do prospective mood
ratings and assess when patients are rating
symptoms in manic or hypomanic range
- General medical conditions that may produce
similar symptoms
- Alcohol and other substance abuse
- Medications that may produce similar symptoms
If you have made a determination of Bipolar
Disorder, you can further evaluate to determine which
type of the disorder may be present.
New research indicates that people can have symptoms
anywhere along the spectrum of bipolar illness. This
spectrum includes:
World Federation for Mental Health 31
- , which is characterised by
recurrent episodes of mania and depression; for
a list of signs of depression and mania see
Chapter One.
- , which involves milder
episodes of mania (called hypomania) alternating
with depression. Often, these episodes are
punctuated by periods of normal mood in
between.
- , a milder form of the illness, is also
part of the bipolar spectrum. This type of the
disorder consists of short periods of mild
depression and short periods of hypomania
(lasting a few days to a few weeks), separated by
short periods of normal mood. Individuals with
Cyclothymia are never free of symptoms of
either depression or hypomania for more than
two months at a time.
-
(BP-NOS) for bipolar symptoms that don’t fit
into any of the other categories, such as, for
example, someone who appears to have manic or
hypomanic episodes with no depressive episodes.
Diagnosing the disorder in children and adolescents is
difficult because children are naturally growing and
changing, and developmental considerations must
always be kept in mind when determining whether a
behaviour is a “symptom” or merely a reflection of
youth.
For example, many elementary school children are
highly energetic and can talk fast when excited. The
behaviours in question need to occur across different
settings (e.g. home and school) and cause impairment in
order to be deemed a symptom.
Diagnosing the disorder in youth is also difficult
because the disorder looks different in children and
adolescents than it does in adults. Rather than the well-
defined episodes of depression and mania seen in
adults, children and adolescents spend more time in
mixed states, which cycle rapidly.
Diagnosis of the disorder in children is also
complicated because its symptoms [see Chapter Three]
can resemble (or co-occur with) those of other common
childhood-onset psychiatric disorders, particularly for
children in the manic state. The bipolar symptoms of
inattention, impulsivity, and even hyperactivity overlap
with those of attention deficit hyperactivity disorder.
32 World Federation for Mental Health

Because of the difficulty in diagnosing the disorder doors open and

in youth, it is critical to get a longitudinal perspective of accessible.7 Learning
the child's behaviour to determine how best to under- more about strategies to
stand what is observed on any given day. A thorough calm and help It is not uncommon for
evaluation should be done by a healthcare professional, aggressive individuals people with Bipolar
who should:6 may be useful for Disorder to become
- Create a to determine the episodic healthcare professionals suicidal or engage in
nature of symptoms and their relationship to involved in the continual risky behaviour. It is
relevant developmental issues care of people with important that any
- Conduct a structured interview to determine mental illness, healthcare professional
and/or other particularly those who watch for the signs and
that may exist are receiving little or no symptoms that may
- Generate a 3-generation or diagram to treatment for their accompany suicidal
determine family history and family dynamic illnesses. feelings [see Chapter 2
information In working with list] and for other risk-
- Administer a someone who appears to taking activities. It is
be , the most also critical to educate
- Complete a to track outcomes critical step is to insure family members and
- Generate a so the family can monitor his or her safety, which friends to take seriously
treatment and share results with treatment may mean taking the any talk of suicide or
providers person to the nearest wanting to die or other
For more information on diagnosing children and hospital emergency indications of
adolescents with Bipolar Disorder, see Chapter room. Once the acute recklessness. Another
Three. risk has been minimised, useful tool is to
then a healthcare encourage a person with
professional can begin Bipolar Disorder to
to work with the person develop a “plan for life”
Very often, a healthcare professional may be called in to to determine the factors [see Chapter Two, page
handle an bipolar episode. The first job will be to that led to the suicidal 10] outlining the steps to
assess the person’s danger to him or herself or others. crisis, and begin to take when they become
This can be scary or intimidating for someone who has stabilise their client’s suicidal or unable to care
never before worked with persons diagnosed with life. for themselves.
mental illness. Research indicates
It is important to recognise that people with Bipolar that developing a strong therapeutic alliance between
Disorder are like anyone else, and have reasons for their the healthcare provider and the person under their care
behaviour, whether real or imagined. If they appear to should be central to the treatment plan. Allow the
be aggressive or severely depressed, asking concerned patient to rely on the relationship as a source of safety
questions about why they are upset or angry, and being and support.8
willing to listen to them, can help. Healthcare professionals caring for individuals with
However, be particularly alert to any of the Bipolar Disorder should become familiar with some of
following aggressive behaviours: the warning signs for suicide [see Chapter 2 list on page
- Signs of violence, e.g., threatening, talking 10], and strategies to help their patients. The World
loudly or abusively Health Organization (WHO) has available a series of
- Breathing heavily fact sheets [http://www.who.int/mental_health
- Excessive fidgeting /resources/suicide/en/index.html], translated into many
- Slapping or punching inanimate objects languages, which are geared toward various healthcare
In working with someone who appears to be professionals and provide information on preventing
aggressive, it is also a good idea to have another person suicide in multiple settings (e.g. primary health care,
nearby for assistance as necessary. In addition, avoid prisons, school settings).
being cornered or cornering the person, and keep all
 World Federation for Mental Health 33

For more information on treating depression, see the

There are treatments that can help those with the World Federation for Mental Health,
disorder to live healthy and productive lives. “Breaking through Barriers,” web resource
and are the two primary [http://www.breaking-through-barriers.com/]
methods used to alleviate the symptoms of the disorder. available in ten languages.
.
Because of the tendency for a relapse, a com-
prehensive approach toward care – which emphasises
For more detailed information on these guidelines for
both continuous treatment and daily self-care – is
treating Bipolar Disorder go to
recommended to help them get and stay well.
http://www.annals-general-psychiatry.com
Many treatment guidelines have been published that
/content/6/1/27#IDAOIWLK.
provide guidance for healthcare professionals treating
someone with the disorder. These guidelines provide
specific information on the medications and therapies
that best treat the disorder. There are separate
guidelines for the treatment of adults – and children and
Treating children and adolescents with the disorder is
adolescents.
even more complex than treating adults, due both to the
severity of the disorder in this age group (see Chapter
Three), and the lack of information about what works.
The most recent guidelines published in a peer-
Unfortunately, research on the disorder in children lags
reviewed journal indicate the following strategies for
far behind what is know about treating adults.11 The
treating Bipolar Disorder in adults:
most recent guidelines indicate the following strategies
- . It is widely accepted
for treatment of the disorder in children and
that lithium is moderately useful during all
adolescents:
phases of bipolar illness and it might possess a
- . Medications such as
specific effectiveness on suicidal prevention.
lithium, divalproex sodium, or carbamazapine
- . Both first and second
are most commonly used to treat children and
generation antipsychotics are widely used, and
adolescents.
the FDA has approved olanzapine, risperidone,
- (mania, depression
quetiapine, ziprasidone and aripiprazole for the
and mixed states). Additional medications are
treatment of acute mania. These could also be
also needed to treat the acute phases of the
useful in the treatment of bipolar depression, but
disorder. Because of the severity and complexity
only limited data exists so far to support the use
of the disorder in young children and
of quetiapine monotherapy or the olanzapine-
adolescents, there are many different treatment
fluoxetine combination. Some, but not all,
pathways; see Chapter Three.
anticonvulsants possess a broad spectrum of
- . Once a
effectiveness, including mixed dysphoric and
child is stabilised with medication, therapy can
rapid-cycling forms.
help build skills and provide families with the
- . Lamotrigine may be
information and support they need to help their
effective in the treatment of depression but not
child or adolescent. A coordinated approach to
mania. Antidepressant use is controversial.
medication and psychotherapy is recommended
Guidelines suggest their cautious use in
for optimal care for children and adolescents
combination with an antimanic agent, because
with bipolar disorder.
they are supposed to induce switching to mania
or hypomania, mixed episodes and rapid cycling.
- A
There are two important points to consider when
coordinated approach, which includes both
prescribing medication: the ability of the person to stay
medication and therapy, is recommended to
on their medication, known as ,
provide optimal care for those with Bipolar
and the side effects of the prescribed medication.
Disorder.10
- . Even where medication
34 World Federation for Mental Health
is available, one in three people with Bipolar
Disorder fails to take at least 30% of prescribed
medication.12 Helping a person stick to their
treatment plan can be the most important thing a
healthcare professional can do.
- Many of
the medications used to treat Bipolar Disorder
have significant side effects, which need to be
monitored. Healthcare providers who are not
trained in this area or otherwise cannot evaluate
the effects of the medications should periodically
seek assistance from someone who can.
Healthcare professionals and others involved in the
care of people with Bipolar Disorder should be aware
that many with the disorder might try to “self-medicate”
with alcohol or drugs to feel better.
Sixty percent of those with Bipolar Disorder I will
abuse alcohol or drugs during their lifetime,13 a rate of
abuse that is higher than that of any other psychiatric
diagnosis. Those with both Bipolar Disorder and
substance abuse have poorer outcomes, are more
difficult to treat, and have an increased rate of
suicide.14,15 A person with a dual diagnosis of substance
abuse and Bipolar Disorder requires careful evaluation,
and the creation of a more complex treatment plan.
There are several types of therapy commonly used to
treat adults and children with Bipolar Disorder. These
therapies teach adults strategies for managing the
moods that can interfere with daily activities, and teach
life skills such as finding a place to live, getting and
keeping a job, and managing money. For children and
their families, psychoeducational psychotherapy can
help to educate parents and children about the child’s
illness and provide family members with skills to cope
with the illness:
- Family-focused therapy (FFT), which requires
the input of participants' family members and is
focused on enhancing family coping skills,
communication, and problem solving
- Cognitive behavioural therapy (CBT), which is
focused on helping the person understand
distortions in thinking and activity, and learn new
ways of coping with the illness
- Interpersonal and social rhythm therapy
(IPSRT), which is focused on helping the
participant stabilise his or her daily routines and
sleep/wake cycles, and solve key relationship
problems
- Psychoeducational psychotherapy (PEP),
which involves teaching parents and children
about Bipolar Disorder and coping mechanisms
16
In many parts of the world, medication(s) and
treatments are not available, or if they are, may not be
affordable, or may only be available during acute
episodes.
There are alternative treatments for Bipolar
Disorder, some proven to work, some not proven, that
can be considered when conventional treatments are not
effective or available.
Electroconvulsive therapy [see Chapter Four, page
20] is one treatment that has been studied and can be
highly effective for severe depressive, manic, and/or
mixed episodes. Other treatments that have been used
across the world to help people with this disorder
include various herbal or natural supplements [Chapter
Four, page 20], relaxation techniques, hypnosis,
exercise regimens, and special diets.
Healthcare professionals should be sure not to rely
on unproven techniques when conventional treatments
are available. However, in regions where conventional
treatments are not available or only can be obtained on
a sporadic basis, some alternative treatments may be
helpful in promoting healthy daily living and in
preventing, delaying, or reducing the severity of the
episodes.
There are many that those with Bipolar
Disorder can use to get and stay well. Some of these
strategies may also prevent, delay, or reduce the
severity of episodes. Healthcare professionals should
ensure that the people in their care use these strategies
on a day-to-day basis:
A mood chart is a good way to
help a person, a healthcare professional, and family
members manage the illness. Mood tracking is not a
difficult or labour-intensive task. There are many mood
charts available on the Internet in varying forms [see

the example of a Mood Chart on page 6].
A simple calendar can also work, or a notebook.
The key is keeping a daily record of feelings, moods,
activities, sleep, medication and side effects, talk or
group therapy, any other illnesses (even a cold or the
flu), changes in schedule or work, new medications
(including any over-the-counter medications), or any
significant life event. For women, keeping track of
menstrual cycles can be useful. It is often helpful to ask
a family member or very close friend to keep a separate
mood chart, as this may also help to reveal early
warning signs of an episode.
Healthcare professionals can and should take an
active role to encourage a person with Bipolar Disorder
to keep track of their moods on a daily basis. Mood
charts will show changes in mood, sleep, and activities.
More importantly, a mood chart will reveal individual
patterns that may help determine warning signs and
triggers of future episodes.
For people with
Bipolar Disorder, it is important to pay close attention
to any changes, even if slight, in mood or level of
activity. Each person may have different triggers for an
episode, and recognising these before the onset of an
episode may help to stave off or reduce the length
and/or severity of the episode. While each person has
their own triggers, some general changes to watch for
include the following:
- Suicidal, or violent feelings toward others
- Any changes in mood or activity
- Changes in sleep patterns (e.g, needing less than
normal)
- Changes in medications or the side effects of
medications
- Changes in interest in family, work, or other
activities.
It is also important to be aware that when treating
physical illnesses, like a cold or the flu, over-the-
counter medications (or those taken prior to surgery)
may trigger an episode. Healthcare professionals need
to work together to ensure everyone treating the person
is aware of the patient’s Bipolar Disorder, even if they
are treating other medical illnesses or symptoms.
One important
component to managing Bipolar Disorder is to establish
a plan for when the person with the illness in unable to
direct their own care (e.g. during periods of severe
mania or depression). Healthcare professionals should
World Federation for Mental Health 35
work with the person and family members to establish a
Psychiatric Advance Directive (PAD) for those times to
ensure care will continue as requested and necessary. A
sample PAD [see http://www.nrc.pad.org] can be used
as a guideline.
People with
Bipolar Disorder are often able to reduce the minor
mood swings that can lead to episodes by maintaining
healthy habits. Talk to your patients about how to do
this, and encourage the following lifestyle choices:
- Eating a balanced diet
- Getting ample sleep and maintaining a stable
sleep pattern
- Creating a daily routine and maintaining a
regular pattern of activity
- Reducing stress
- Exercising
- Avoiding alcohol and use of illicit substances
- Seeking support from friends and family, and/or
others with the disorder17
For more information on helping a person with
Bipolar Disorder take care of themselves mentally and
physically, see Chapter Five.
. Identifying life goals and looking
toward the future can assist in the process of recovery
for someone with Bipolar Disorder. The U.S.
Depression and Bipolar Support Alliance has created a
list of self-reflective questions to help people determine
these goals. Initially, small or even daily goals may be
as much as someone can do, but over time, long-term
goals may also be possible.
Healthcare professionals can work with patients on a
periodic, regular basis to answer some, if not all, of the
following questions:18
- What motivates me?
- What interests me?
- What would I do more of if I could?
- What do I want?
- What do I care about, or what did I care about
before my illness?
- Where do I want my life to go?
- What brings me joy?
- What are my hopes and dreams?
. It can be helpful for people
with Bipolar Disorder to take control of their illness by
continually learning new information about the
disorder. Healthcare professionals can assist by finding
36 World Federation for Mental Health
this information and providing it to their patients and/or
encouraging them to seek information on their own.
There are many sources for information. Reading
books, researching on the Internet, participating in a
chat room, attending lectures, or joining a peer support
or advocacy group are all ways to continue to learn
about the disorder. See the Resources Section in this
packet for places to find news and ongoing research
about the disorder.
There are groups around the
globe to support people with Bipolar Disorder, many of
which are peer-initiated. While healthcare professionals
are not likely to be a part of these groups, encouraging
patient participation in these can have multiple positive
effects.
These groups can help patients 1) develop close
relationships and partnerships with other people with
the disorder 2) find acceptance and comfort in
discussing personal experiences and 3) provide
increased awareness about the disorder, the treatments
available, and ways to cope.19
Peer support groups can be found in many
communities, through advocacy organisations, and on
the Internet.
Healthcare professionals should also consider working
hand-in-hand with family members and close friends in
the care of someone with Bipolar Disorder. Family
members and close friends play a critical role in the
diagnosis, treatment, and the day-to-day management of
the disorder.
There are many ways that family members and
friends can help. They can remind their loved one to
take their medications, help keep track of their moods,
and look for warning signs.20
They can help gather information about the disorder,
including any new effective treatments that have been
developed.
Most importantly, they can offer support and love,
and remind the person that they are not alone. Chapter
Six in this packet focuses on the many ways family and
friends can help someone with the illness
As a healthcare professional, it is important to be
aware that family members may have a difficult time
understanding the disorder. In some cases, they may be
hostile or overly critical of a person with Bipolar
Disorder, which can be very detrimental to the
successful treatment and recovery of that person.
There are many ways a healthcare professional can
intervene to make these relationships more productive,
including:
- Educating family members about the illness
- Providing the caregiver with options for relief in
the care of the person with the illness, or working
with them to find additional help to provide care
- Working with and supporting them individually
- Connecting them to support groups in their
community or on the Internet
Healthcare professionals are a critical piece in the
recovery and stability of people with Bipolar Disorder,
and serve as a significant resource to them and their
families. In addition to taking care of their patients,
however, healthcare providers need to take care of
themselves.
Recent research is beginning to show secondary
trauma in healthcare professionals, particularly those
who respond to violent events or natural disasters.
Working with people with mental illness, especially in
situations where resources are few and treatments not
available, can be very difficult for anyone.
Research is ongoing into the effects of secondary
traumatisation on healthcare workers, but recently
developed strategies to prevent secondary
traumatisation include:
- Balancing caseloads and accessible supervision
- Allowing sufficient release time and safe
physical space
- Respecting one's own limits and maintaining
time for self-care activities
- Self-nurturing and seeking connection.21
For healthcare workers around the globe, particularly in
places with few resources, diagnosing and treating
Bipolar Disorder, as well as other mental illnesses, is a
challenging yet rewarding job. The hope and good
health that you bring to those with Bipolar Disorder
changes the landscape of their lives. Your help
improves their chances for adequate housing, keeping a
job, and most importantly, maintaining relationships
with loved ones.
Whether you work at a local non-governmental
organisation (NGO) or are a healthcare professional
meeting the broad-ranging needs of many, it is our hope
 World Federation for Mental Health 37

that this packet provides specific information on (CANMAT) guidelines for the management of patients
with bipolar disorder: consensus and controversies (2005).
diagnosing and treating the disorder. Bipolar Disorders 7 (Suppl. 3): 5-69.
13 Regier DA, Farmer ME, Rae DS et al. (1990). Comorbidity
For additional information about the disorder, review of mental disorders with alcohol and other drug abuse.
the following chapters: Results from the Epidemiologic Catchment Area (ECA)
Study. Journal of the American Medical Association,
A Diagnosis of Bipolar Disorder [Chapter One] 264(19):2511-2518.
Learning about My Bipolar Disorder [Chapter Two] 14 Sonne SC, Brady KT (2002). Bipolar disorder and alcoholism.
Bipolar Disorder in Children and Adolescents [Chapter Available at: http://pubs.niaaa.nih.gov/publications/arh26-2/
103-108.htm.
Three] 15 Dalton EJ, Cate-Carter TD, Mundo E et al. (2003). Suicide
Treating Bipolar Disorder [Chapter Four] risk in bipolar patients: the role of co-morbid substance use
The Road to Recovery [Chapter Five] disorders. Bipolar Disorders 5(1): 58-61.
16 Goldberg JF, Perlis, RH, Ghaemi SN, Calabrese JR, Bowden
Helping Someone with Bipolar Disorder [Chapter Six] CL.,Wisniewski S, Miklowitz, DJ, Sachs GS, Thase
ME. (2007). Adjunctive Antidepressant Use and Symptomatic
Recovery Among Bipolar Depressed PatientsWith
Concomitant Manic Symptoms: Findings From the STEPBD.
1 Morselli PL, Elgie R, Cesana BM (2004). GAMIANEurope/ American Journal of Psychiatry, 164: 1348-1355.
BEAM survey II: cross-national analysis of unemployment, 17 Kahn DA, Ross R, Printz DJ, Sachs GS (2004). Treatment
family history, treatment satisfaction and impact of Bipolar Disorder: A Guide for Patients and Families.
of the bipolar disorder on life style. Bipolar Disorders 6 (6), NDMDA (now DBSA) Expert Consensus Guideline Series.
487–497. http://www.psychguides.com/Bipolar%20Handout.pdf
2 Kohn R, Saxena S, Levav I, and Saraceno, B (2004). The 18 Depression and Bipolar Support Alliance (2006). Recovery
treatment gap in mental health care. Bulletin of the World Steps. Available at: www.dbsalliance.org
Health Organization, Volume 82, Volume 82 (11), 811-890. 19 Tse S, Doughty C, Bristol F (2004). Peer Support Groups
3 Excerpted and adapted from the National Institute for People with Bipolar Disorders in New Zealand: A Pilot
of Mental Health website, Study on Critical Success Factors. The International Journal
http://www.nimh.nih.gov/health/topics/bipolar-disorder/ of Psychosocial Rehabilitation 9 (1): 47-58.
index.shtml 20 Canadian Network for Mood and Anxiety Treatments
4 Weiss MG, Jadhav S, Raguram R, et al (2001). Psychiatric (CANMAT) guidelines for the management of patients
Stigma across Cultures: Local Validation in Bangalore and with bipolar disorder: consensus and controversies (2005),
London. Anthropology and Medicine 8 (1), 71-87. Bipolar Disorders 7 (Suppl. 3): 5-69.
5 Excerpted and adapted from the Canadian Network for 21 Zimering R, Munroe J, Gulliver SB (2003). Secondary
Mood and Anxiety Treatments (CANMAT) guidelines for Traumatization in Mental Health Care Providers. Psychiatric
the management of patients with bipolar disorder: consensus Times, XX (4). http://www.psychiatrictimes.com/p030443.html
and controversies (2005). Bipolar Disorders 7 (Suppl. 3),
5-69.
6 Quinn CA & Fristad MA (2004). Defining and identifying
early onset bipolar spectrum disorder. Current Psychiatry
Reports, 6, 101-107.
7 Patel V (2003).Where There is No Psychiatrist: A Mental
Healthcare Manual. Gaskell.
8 Canadian Association for Suicide Prevention (2004).Working
With the Client Who is Suicidal: A Tool for Adult Mental Health
and Addiction Services. http://www.health.gov.bc.ca/mhd/pdf/
working_with_the_client_who_is_suicidal_(final)l.pdf
9 Fountoulakis KN, Vieta E, Siamouli M, Valenti M, Magiria
S, Oral T, Fresno D, Giannakopoulos P, Kaprinis GS.
(2007). Treatment of bipolar disorder: a complex treatment
for a multi-faceted disorder. Annals of General Psychiatry
9;6:27.
10 Yatham, L.N., Kennedy, S.H., O’Donovan, C., Parikh, S.,
MacQueen, G., McIntyre, R. et al. (2005). Canadian Network
for Mood and Anxiety Treatments (CANMAT) guidelines
for the management of patients with bipolar disorder:
Consensus and controversies. Bipolar Disorders, 7 (Suppl 3)
5-69. Retrieved October 11, 2007 from http://www.canmat.org/
resources/PDF/Bipolar_Guidelines.pdf
11 Kowatch RA, Fristad M, Birmaher B,Wagner KD, Findling
RL, Hellander M; Child Psychiatric Workgroup on Bipolar
Disorder. (2005). Treatment guidelines for children and
adolescents with bipolar disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 44(3):213-35.
12 Canadian Network for Mood and Anxiety Treatments
38 World Federation for Mental Health
American Academy of Child & Adolescent
Psychiatry
3615 Wisconsin Avenue, N.W.
Washington, DC 20016-3007 USA
www.aacap.org
American Association for Marriage and Family
Therapy (AAMFT)
112 South Alfred Street
Alexandria, VA 22314-3061 USA
www.aamft.org
American Psychiatric Association
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209-3901 USA
www.psych.org
Association France Depression
E-mail: info@france-depression.org
www.france-depression.org
The Australian Psychological Society
PO Box 38
Finders Lane
Vic 8009 AUSTRALIA
www.psychology.org.au
Balance New Zealand Manic Depressive Network
76 Virginia Road
Wanganui 06 345 2264 NEW ZEALAND
Beyond Blue
(Bipartisan Initiative of the Australian state and
territory governments)
PO Box 6100
HawthornWest 3122 AUSTRALIA
http://www.beyondblue.org.au
The Black Dog Institute
Hospital Road
Prince of Wales Hospital
Randwick NSW 2031 AUSTRALIA
http://www.blackdoginstitute.org.au/
The Brazilian Association of Families, Friends and
Sufferers from Affective Disorders (ABRATA)
Av. Paulista, 2644-7 andar - Conj. 71
01310-300 - Sao Paulo - SP, BRAZIL
55 11 256.4831 / 55 11 256.4698 (phone)
apoio@abrata.org.br
http://www.abrata.org.br
Breaking Through Barriers Resource
http://www.breaking-through-barriers.com/
Canadian Mental Health Association
National Office
Phenix Professional Building
595 Montreal Road, Suite 303
Ottawa, Ontario K1K 4L3 CANADA
www.cmha.ca
Child & Adolescent Bipolar Foundation (CABF)
820 Davis Street, Suite 520
Evanston, IL 60201 USA
www.bpkids.org
Continuing Medical Education- LLC
Online Symposia
2801 McGaw Ave.
Irvine, CA 92614-5835 USA
www.cmellc.com/onlinesymposia
Depression & Bipolar Support Association (DBSA)
730 North Franklin Street, Suite 501
Chicago, IL 60610-7224 USA
www.ndmda.org
 World Federation for Mental Health 39

Deutsche Gesellschaft fur Bipolare Storungen e. V. International Society for Affective Disorders
(DBBS e.V.) Institute of Psychiatry
Postfach 920249 PO72 Kings College London,
21132 Hamburg GERMANY Denmark Hill
www.dgbs.de London SE5 84F
UNITED KINGDOM
European Federation of Associations of Families of Office: 020 7848 0295
People with Mental Illness (EUFAMI) Fax: 020 7848 0298
Diestsevest 100 Email: caroline.holebrook@iop.kcl.ac.uk
B-3000 Leuven BELGIUM http://www.isad.org.uk
www.eufami.org
International Society for Bipolar Disorders (ISBD)
Global Alliance of Mental Illness Advocacy PO Box 7168
Networks (GAMIAN-Europe) Pittsburgh, PA 15213-6940 USA
c/p FIAB, rue Washington 60 www.isbd.org
B-1050 Brussels BELGIUM
www.gamian.eu Keio University Hospital
35 Shinanocho
THE GLOBAL ONLINE DIRECTORY OF Shinjuku-ku, Tokyo 160-8582 JAPAN
MENTAL HEALTH PATIENT/SERVICE Tel: 03-3353-1121 (Main)
USER, FAMILY MEMBER/CAREGIVER http://www.hosp.med.keio.ac.jp/ (website in
SUPPORT GROUPS, AND MENTAL Japanese)
HEALTH ADVOCACY AND
AWARENESS ORGANIZATIONS Mental Health America
www.wfmh.org/00GlobalAd.htm 2000 North Beauregard Street, Sixth Floor
Alexandria, VA 22311 USA
Global Initiative on Psychiatry www.nmha.org
PO Box 1282
1200 BG Hilversum NETHERLANDS Mental Health Europe (MHE)
www.gip-global.org Boulevard Clovis 7
B-1000 Brussels BELGIUM
Fundacion bipolares de Argentina (Fubipa) www.mhe-sme.org
www.fubipa.org.ar
Mental Health Foundation
International Foundation for Research & Education London Office, Ninth Floor
on Depression (iFred) Sea Containers House
2017-D Renard Court 20 Upper Ground
Annapolis, MD 21401 USA London SE1 9QB
www.ifred.org UNITED KINGDOM
www.mentalhealth.org.uk
40 World Federation for Mental Health

Mental Health Foundation of Australia Umegaoka Tokyo Metropolitan Hospital

270 Church Street 6-37-10 Matsubara, Setagaya-ku, Tokyo 156-0043
Richmond, Vic 3121 AUSTRALIA JAPAN
www.mhfa.org.au Tel: 03-3323-1621 (Main)
Free telephone consultation service: 03-3323-7621
Mood Disorder Association of Manitoba http://www.byouin.metro.tokyo.jp/umegaoka/index
4 Fort Street, Suite 100 .html (website in Japanese)
Winnipeg, Manitoba R3C1C4 CANADA
www.depression.mb.ca Vereniging voor Manisch Depressieven en
Betrokkenen (VMDB)
National Alliance on Mental Illness (NAMI) Kaap Hoorndreef 56-C,
2107Wilson Boulevard, Suite 300 3563 AV Utrecht NETHERLANDS
Arlington, VA 22201-3042 USA www.nsmd.nl
www.nami.org
World Federation for Mental Health
National Institute of Mental Health (NIMH) 6564 Loisdale Court, Suite 301
6001 Executive Boulevard Springfield, Virginia 22150-1812 USA
Bethesda, MD 20892 USA Telephone: +1-703-313-8680
www.nimh.nih.gov E-mail: info@wfmh.com
www.wfmh.org
SAMHSA Mental Health Information Center
PO Box 42557 World Health Organization
Washington DC 20015, USA Division of Mental Health and Substance Abuse
www.mentalhealth.samhsa.gov Geneva CH-1211 SWITZERLAND
www.who.int
The South African Depression and Anxiety Group
(SADAG)
E-mail: operations@anxiety.org.za
www.anxiety.org.za