Explainer Series: Bipolar Disorder

SAFMH News Room

Welcome back to explainer blog series, where we unpack specific mental health conditions and share stories of those with lived experience. In this edition we are looking at bipolar disorder.

This disorder affects about 45 million people worldwide (WHO 2021). Locally, though our studies are not as robust, the estimated prevalence for those living with bipolar illness over their lifetime is between 3 and 4% (Spotlight 2021).

According to Dr Qhama Cossie, a psychiatrist at the Department of Psychiatry and Mental Health at the University of Cape Town, bipolar is a “mood disorder that is characterised by a person going through either very low moods in the form of a major depressive episode or episodes of an elevated mood known as hypomania or a highly euphoric mood known as mania. These periods of unstable moods can impact a person’s day-to-day functioning.”

Research indicates that people living with bipolar disorder experience periods of unusually intense emotion and changes in activity levels and sleep patterns – often without recognising that these changes could have undesirable or harmful effects. Symptoms of bipolar disorder can vary. Someone living with bipolar disorder may experience depressive episodes, manic episodes, or “mixed” episodes – these episodes consist of both depressive and manic symptoms that could last a week, or longer.

Marlene, who kindly shared her story with the SA Federation for Mental Health, had spent her early career as a creative set designer where she worked 18 hour days. Due to the manic nature of her role, she was never really aware that anything could be wrong.

 “I was working a lot and very hard so I kind of got away with my hyper-manic self.’’

It was not until the death of her father, which triggered major depression, that Marlene was diagnosed with bipolar II disorder.

Different types of bipolar disorder

According to the National Institute of Mental Health, there are 3 different types of bipolar disorder. These are bipolar I, bipolar II and cyclothymic (also known as cyclothymia) disorder:

  • Bipolar I Disorder: defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care.
  • Bipolar II Disorder: defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder.
  • Cyclothymic Disorder: defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years. However, symptoms don’t meet the diagnostic requirements for a hypomanic episode and a depressive episode.

Whilst all three types involve clear changes in mood, energy, and activity levels, each type can influence the severity of the specific episodes. For example, moods can range from extremely “up,” elated, irritable, or energised behaviour (known as “manic episodes”) to very “down,” sad, indifferent, or hopeless periods (known as “depressive episodes”). Less severe manic periods are known as “hypomanic episodes”.

When speaking of her initial diagnosis twenty years ago, Marlene said there was some shock, but she couldn’t really give it much thought at the time.

 “I didn’t really think about that, I didn’t really understand the implications. I didn’t really analyse it either. I think at the time I was so involved with the actual experience that I couldn’t think about it in any logical way, it was just an experience that was not meant to happen … it was just a massive depression. It was also not followed by a manic episode – so my manic episodes only started about three years ago and so the mania has had a larger impact on my life that the depression. The mania did a lot of damage… a lot of damage.”

For some people, depression is the dominant mood. Some people find that they frequently fluctuate between high and low moods or have long periods when their moods are stable.

“I think there are periods where you feel very down and there are periods where you feel very up. I don’t think it affects you on a daily basis – it takes a couple of days maybe a week for you to realise that you’re going through a really bad patch. For me, it’s a relief to go through a bit of a hyper-manic patch because everything is extenuated where the depression is really debilitating.”


When it comes to the causes of bipolar disorder, research has shown that there is no one single cause and it is in actual fact related to a combination of factors including:

  • Psychosocial factors: In some cases, a stressful life event can trigger a person’s first episode of bipolar disorder.
  • Brain Structures: New research suggests that the brain structure and function of people with bipolar disorder may be different from the brain structure and function of people who do not have bipolar disorder or other psychiatric disorders.
  • Genetics: Bipolar disorder often runs in families, and research suggests that this is mostly explained by heredity—people with certain genes are more likely to develop bipolar disorder than others.

In Marlene’s case, genetics has played a significant role in her diagnosis.

“It was a bit of a shock but at the same time there were so many people in my family that were bipolar that it kind of wasn’t such a big shock. I think to some extent, there was quite a lot of support in the family.”

When describing her experiences, Marlene points to the important role her psychiatrist has played.

“For a very very long time, after I was diagnosed, I was very stable, for about 13 years. I had a brilliant psychiatrist and I found it very manageable, I didn’t really think it was so bad actually and so I thought it would just carry on being manageable but then I moved cities and then my medication was messed around and that had a huge effect on me. So basically I think you become dependent on the psychiatrist – you have to have a great psychiatrist because a lot of it is manageable with medication.”

Marlene’s insistence on the importance of a psychiatrist is concerning when we look at South Africa and the pervasive shortage of mental health specialists working in the public healthcare sector in particular. According to a study from 2019, it is estimated that there was an average of 0.31 public sector psychiatrists per 100 000 uninsured people, and 0.97 public sector psychologists per 100 000 uninsured people.

A process

Marlene’s journey is like that of many people who are diagnosed with a mental health condition.

“I think my journey before the 20 years was a hyper-mania journey, then it was a depressive journey and then three years ago I hit the mania and the manic episode basically destroyed relationships because people find it very difficult to understand and deal with it. People get scared of the intensity of the mania. The last three years I ended up in hospital, I ended up in a home. It was a whole journey and I became really insecure about who I was and I wanted so badly to get out of it so I could get back to some kind of a normal life.”

As with many mental health conditions, stigma and discrimination abounds. This is especially true with a diagnosis like bipolar disorder that is difficult to understand and often portrayed in a negative light.

“I wish people understood it a bit more. I wish people weren’t so scared of it and I wished people knew that it wasn’t a permanent things, that it is a process. I wish people knew that someone with bipolar is doing the best they can under the circumstances. Sometimes I just feel like maybe it would’ve been easier if I had a terminal illness, that I would get more sympathy and more understanding than I do with this illness.”

Despite experiencing the discrimination, Marlene is adamant about helping people embrace their diagnosis and empowering others to not be so scared about talking about it. In her quest to break the stigma, Marlene designed an entire range of images for t-shirts and temporary tattoos that openly declared mental illness.

“I was told nobody would be willing to ‘expose’ themselves wearing these. I then emailed the designs to 52 Mental Health support groups and institutions asking if they could endorse the products, as my plan was to start an online shop. I received 4 incredible replies from SANE in Australia, NAMI in New York, UK who absolutely loved the idea and the Russell Brand team.”

Apart from her creative ventures, Marlene is also determined to be stable and well for the next twenty years.

“It’s very important to understand that the situation is completely manageable over time. Stability is possible.”


If you suspect that you or someone you know may be experiencing bipolar episodes, always seek the help of a mental health professional. If you are interested in connecting with the organisation in your province, feel free to reach out to us via our enquiries Help Desk. For those who are looking for more guidance, you can head to our website and check out our Information Library.

If you or your loved one is feeling hopeless and/or having suicidal thoughts, please call the SADAG Suicide Crisis Line on 0800 567 567 or SMS 31393. These numbers are free and counselling is available in all 11 official languages.

Image: Nick Fewings on Unsplash

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