Rapid cycling bipolar disorder: what it means, symptoms and management

Bipolar disorder, previously called manic depression, is a long-term condition in which mood moves between high states and low states. The NHS says the main symptom is extreme changes in mood, with high moods (mania or hypomania) and low moods (depression) that usually last a few days or weeks at a time, and with times of stable mood in between that can last weeks, months or years.

Rapid cycling describes people for whom the episodes come close together. NICE Clinical Knowledge Summaries define it as the experience of at least four depressive, manic, hypomanic or mixed episodes within a 12-month period. NHS inform describes rapid cycling slightly differently, as repeated swings from a high to a low without a normal period in between, which is how many people experience it day to day. Both descriptions point to the same underlying difficulty: little time in a settled mood.

Rapid cycling can occur with either bipolar I disorder, which involves episodes of full mania, or bipolar II disorder, which involves hypomania and depression. Rethink Mental Illness explains both types and states plainly that rapid cycling is a descriptor applied to them rather than a third type.

Because the diagnosis depends on counting episodes, a clear history matters. NICE CKS set out what makes an episode. A manic episode is a period of at least a week of abnormally and persistently elevated, expansive or irritable mood with at least three additional symptoms and marked impairment, or which includes psychotic features. A hypomanic episode is similar but needs only 4 days and is not severe enough to cause marked impairment or to include psychotic features. A depressive episode lasts at least 2 weeks with low mood or loss of interest plus other symptoms. A mixed episode combines manic and depressive symptoms.

In practice a psychiatrist will ask about when each period began and ended, what it looked like and how it affected sleep, work and relationships, as well as family history and substance use. The NHS says bipolar disorder can take time to diagnose because the symptoms resemble other mental health conditions. Keeping a mood diary, and asking someone close to you to describe what they noticed, makes it easier to see the pattern and to count episodes accurately.

• High mood: very happy or irritable, lots of energy, needing little sleep, racing thoughts, fast speech, impulsive spending or risk-taking.

• Low mood: sadness, loss of interest, tiredness, sleeping too much or too little, worthlessness, difficulty concentrating, sometimes thoughts of self-harm.

• Mixed states: symptoms of depression and mania together, such as feeling hopeless while restless and overactive.

• Periods of stable mood between episodes, which may be short when cycling is frequent.

The NHS says the exact cause of bipolar disorder is not known, but you are more likely to have it if a parent, brother or sister has it. Rethink adds that no single gene has been linked to the condition and that stressful events can trigger episodes.

The NHS lists stress, not enough sleep and being too busy as things that can trigger high and low moods, and it advises avoiding recreational drugs, heavy alcohol use, shift work, night flights across time zones and large amounts of caffeine where possible. Rethink also says that if you take antidepressants, your doctor may advise withdrawing them when treating mania or hypomania. The sources used for this guide do not set out why some people cycle more quickly than others, and a specialist can look at medicines, substance use, sleep and other health conditions in your own case.

The NHS advises seeing a GP if you have extreme changes in your moods that last a long time or affect your everyday life, or if you have been diagnosed and treatments are not helping. If you already have a mental health specialist, speak to them. Anyone worried about someone else can encourage that person to see their GP.

If you are feeling suicidal, the NHS lists calling the Samaritans, going to A&E, contacting NHS 111, speaking to a friend or someone you trust, and making an urgent appointment with a GP or your care team as options. NICE CKS name suicide and deliberate self-harm as the most important complications of bipolar disorder, and describe consequences of acute episodes such as financial difficulties, accidents, damage to relationships and work, and harm to others. The NHS says to seek crisis help if you or someone else may be at risk.

The NHS says bipolar disorder cannot be cured but can be managed with medicines to stabilise mood and talking therapy such as CBT. Rethink explains that NICE guidance recommends mood stabilisers for mania, hypomania and depressive symptoms, including lithium and certain antipsychotic, anticonvulsant and benzodiazepine medicines. For long-term treatment lithium usually works better than other medicines according to Rethink, and if it does not suit you valproate, olanzapine or quetiapine may be offered.

The sources reviewed for this guide describe general bipolar treatment and do not give a separate treatment pathway for rapid cycling. In practice the specialist is likely to review the whole picture, including whether antidepressants are helping or unsettling mood, how well medicines are being taken, sleep, alcohol and drug use and physical health, and may adjust the plan. Ask your team how they will tell whether a change is working and how long it is worth trying it.

Rethink says a regular routine, a healthy diet, exercise and sleep help many people, and that your team should offer a combined healthy eating, exercise and sleep programme. The NHS advises not to stop bipolar medicine unless a doctor tells you to, even when you feel better, and to speak to a doctor before pregnancy because some bipolar medicines are not safe in pregnancy.

Frequent episodes can affect work, study and relationships, and Rethink says you should be offered support to return to work or to find other meaningful activity. Writing an advance statement, which tells professionals how you would like to be treated if you lose capacity, can give some control during the hardest periods. Peer support through Bipolar UK groups and forums helps many people feel less alone.

Rethink also says you must stop driving if you have an episode of severe depression, hypomania, mania or psychosis.

On the NHS the route is from the GP to a community mental health team and psychiatrist, with the GP continuing to monitor medicines and physical health once stable. NICE CKS says adults treated in secondary care may be transferred back to primary care for ongoing management once their condition has stabilised.

A private psychiatrist can be a way to see someone sooner or to obtain a second opinion about a diagnosis or medicines. Treatments follow the same national guidance, and a private psychiatrist will normally explain the plan so that your GP can be kept informed. If you are not happy with your treatment Rethink suggests talking to your doctor, asking for a second opinion, using an advocate or contacting the Patient Advice and Liaison Service.