The common mental health problems

What Is Happiness To A Manic Depressive?

What it is

Bipolar affective disorder, previously known as manic depression, is one of the most under-researched of common mental health problems (Clement et al 2003). It is characterised by repeated episodes of elevated mood and energy (mania/hypomania) and lowered mood and decreased energy (depression) (WHO, 1992). Manic episodes consist of elevated, inflated and irritable mood, higher energy levels and drive and an increase in goal-directed and risky activity (e.g. becoming spendthrift and promiscuous) (Mansell and Pedley, 2007). Individuals may also experience psychotic symptoms such as delirium, hallucinations and thought disorder. Episodes begin abruptly and last for between two weeks and four-five months. Hypomania is characterised by most of the same episodes however symptoms do not include psychotic experiences and do not last over a week (last up to four days). In many cases other people notice the individual's behaviour changes however symptoms do not normally impair social activities or cause hospitalisation (APA, 2000). Many high functioning individuals have been reported to experience transient hypomanic episodes and it is widespread in the non-clinical population (Udachina and Mansell, 2007). Episodes of depression tend to last longer than manic episodes (6 months). An individual experiences a depressed mood with a loss of interest or drive and a decrease in activity due to reduced energy levels. Common symptoms include disturbed sleep, reduced concentration, self-confidence and appetite, ideas of guilt and pessimistic views of the future (WHO, 1992). Individuals can also experience 'mixed affective states' in which both manic and depressive moods are experienced. Generally all types of episodes will be interspersed with periods of more or less full recovery. (Wellman, 2007).

Approximately 1 in every 100 adults is affected by bipolar affective disorder at some point throughout their life (range 0.3% - 1.5% in European countries). The most likely time for onset is between 15-19 years of age (Weissman et al 1996) and most individuals experience symptoms before the age of 30. About 10-20% of sufferers take their own life and nearly one third of patients admit to at least one suicide attempt (Mller-Oerlinghausen et al, 2002).There are two types of disorder; Bipolar I and Bipolar II. In Bipolar I disorder, a patient suffers from high manic episodes which last longer than a week and are usually interspersed with low episodes of depression. Bipolar II sufferers experience hypomanic episodes together with depressive episodes but do not have manic episodes (NICE, 2006). Cyclothymia is a mild form of Bipolar II in which the mood swings are not as severe however can continue for longer periods of time eventually developing into full bipolar affective disorder (APA, 2000). Rapid cycling is a form of bipolar disorder in which the individual experiences four or more episodes of mood disorder in a period of a year (NICE, 2006). It can arise from inappropriate treatment/misdiagnosis of bipolar sufferers causing the illness to become accelerated (Ghaemi et al, 2000). Although manic episodes seem to define bipolar disorders, it is the depressive episodes which are more important in terms of treatment due to their higher disabling effects on everyday life (Judd and Akiskal, 2003).

In the majority of cases bipolar disorder involves epistasis (the interaction of multiple genes rather than one single gene being passed on causing the illness. To investigate the genetic influence, molecular genetic positional and candidate gene approaches are being used (Craddock and Sklar, 2009). These are types of screening which involve tagging mutant alleles and cloning them. No gene has been identified as of yet however certain regions of interest have been identified in genetic linkage studies. Most gene studies have investigated the neurotransmitter systems which are influenced by medication given to treat the disorder.


Happiness can be described as pleasure or satisfaction (Cambridge Dictionary, 2010). Research has found an inverse relationship between happiness and stress. A study examining the relationship between stress and happiness was carried out on 100 university students. The results show an inverse relationship between these variables. There is a clear linear correlation between happiness and perceived stress. The higher the stress levels experienced the less happy (pleased/satisfied) the individuals were (Schriffin et al, 2008). For the purpose of this study, if we equate happiness to a lack of stressful events we can quantify better the effects of happiness on sufferers of bipolar disorder.

Social Stressors are a key trigger to bipolar affective disorder. Experiencing episodes of mania or depression early on in life is more likely to have been triggered by life events than later episodes (Ambelas, 1987). Studies have also found that there is a significant increase in rates of negative life events before an individual relapses into mania or depression (Ellicott et al, 1990). Where there is less stress in a patient's life, there is a decrease in recurring symptoms. The severity of symptoms is also influenced by the patient's interpersonal life events (Hammen et al, 1992). Actively removing stress promotes happier living, reduces the chances of the patient relapsing and reduces the severity of his or her condition. The question is now, how can one alleviate stress in a sufferer's life and promote happiness.

Happiness in the social and family environment is beneficial for a patient suffering with bipolar. Normally, life stresses have a greater impact on depressive episodes than manic episodes (Johnson, 2005). For example an individual who experiences a death in the family is more likely go into severe depression than become manic (Malkoff-Schwartz et al, 2000). However, more recent studies have also shown that criticism and hostility from the family also spark depressive episodes (Yan et al, 2004). This is further backed up by studies showing bipolar patients are more likely to have sociotropy (excessive investment in interpersonal relationships) and its presence heavily influences the severity of depressive symptoms of (Sato et al, 2004). If bipolar patients have high sociotropy they require a greater amount of happiness in their lives as they will indefinitely be more sensitive to negative environments, comments or behaviour. It may not be possible to have control over negative life events such as death of relatives, however families and friends do have control over how they talk and behave with a person with bipolar. We can conclude that the way the family and friends treat a patient in terms of in a positive (happy) or negative (unhappy) way is a very important factor in determining if he/she relapses and how severe their condition becomes. Bipolar patients need happiness. It can come in the form of emotional support.

The absence of such emotional support from other people gives rise to more frequent relapses into depression and increases the severity of bipolar (Johnson et al, 2000). The evidence comes from studying 'expressed emotion' (EE). EE studies use structured observations of negative, hostile and unfriendly comments or behaviour from family members towards the person with bipolar. (The more negative the behaviour, the higher the EE). The study found that high levels of EE in relatives lead to increased rates of relapse (Miklowitz et al, 1988), especially when received from parents (Miklowitz et al, 2000). It was found that it was the non-verbal behaviour rather than verbal which determined high and low EE (Simoneau et al, 1998). Families that look away from the patient, show angry facial expressions or use a sarcastic tone of voice have high EE. Low EE families smile, look attentive and use a warm, gentle tone of voice which is more supportive. In a study of 125 individuals in family-focused treatment, high EE produced more depressive symptoms after 2-year follow-up (Kim and Miklowitz, 2004).

The evidence suggests that social stress contributes to the development of mania. The effects of unhappiness in the family unit, and the distress this causes within the individual are extremely important due to the way in which they promote the development of manic (as well as depressive) symptoms. It is important now, to find out how exactly lack of happiness and increased stress leads to depressive symptoms in terms of chemical changes in the brain.

One hypothesis claims that the hypothalamic-pituitary-adrenal (HPA) axis, which is one of the major hormonal systems, is activated during times of stress. In response to stress, neurons in the hypothalamus secrete corticotropin-releasing hormone CRH into the pituitary gland which stimulates production of adrenocorticotropic hormone ACTH. This hormone stimulates the adrenal glands to produce cortisol. Cortisol is a major regulator of the stress response. It provides negative feedback to the hypothalamus to inhibit the stress response so the levels of cortisol return to pre-stress levels (NICE, 2006). In depression (especially psychotic depression) there is a significant elevation in cortisol levels, which indicates dysfunctional HPA axis. This hypothesis is backed up by research showing that antidepressant medication used to treat major depression and bipolar, directly regulates HPA axis function (Pariante, 2006).

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