Rapid cycling can be confusing when mood shifts do not follow neat diagnostic lines. The first goal is mood stability — supported by sleep, routines, and careful treatment choices.
Key Takeaways
- Rapid cycling does not always fit neatly into official diagnostic categories, but that does not make the mood shifts less real or less important.
- Manic and depressive symptoms can happen at the same time, making mood shifts feel fast, mixed, or hard to label.
- Treatment usually begins with mood stabilization — including non-medication strategies — before addressing what remains.
- Regular sleep and daily routines can help stabilize the body clock, which may be especially important for rapid cycling.
Allow me to make a mess. Then I’ll try to clean it up.
The mess: There are no clear lines between rapid cycling and non-rapid-cycling bipolar. There are no lines between rapid cycling and “ultradian” cycling (more than one mood shift per day), nor between rapid cycling and mood instability arising from causes other than bipolar.
Worse, there are no lines between manic and depressed. These are not opposites. Manic symptoms and symptoms of depression can occur at the same time. Such a “mixed state” combination can shift rapidly, within hours, from more energized and active to irritable to depressed and sluggish — which sounds a lot like general mood instability, doesn’t it?
The clean-up: No lines are necessary. The treatment for all forms of cycling is the same: mood stabilization, including, critically, non-medication approaches. The goal is the same: Stop the cycling. Then treat whatever mood, energy, attention, or anxiety problems remain, taking care not to induce instability again.
No Clear Lines — No Diagnosis?
Cycle rates range from none — meaning a stable mood and steady energy — to rare, frequent, rapid, and ultradian cycling, as well as general mood instability.
Why does this matter? It matters because many clinicians have difficulty accepting that very rapid cycling is really bipolar. In part, that’s because the official definitions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5TR) require the duration of mood episodes to last more than four days.
Further, many clinicians — and patients — are reluctant to invoke “mental illness” for symptoms that can be part of the everyday human experience, such as mood instability. They don’t want to saddle people with a label that carries negative implications, such as a potentially lifelong need for treatment, the risk of mania, and medications with side effects and long-term risks.
These assumptions are incorrect, of course. Not all bipolar requires lifelong medications. Three out of four people with bipolarity will never have a manic episode, and some bipolar medications have very few side effects and long-term risks, such as lamotrigine (Lamictal).
How the DSM Defines Rapid Cycling
To be clear: The DSM does draw lines. Four or more mood episodes in a year is classified as rapid cycling. While it seemed to me that nearly everyone I treated experienced it, rapid cycling is not the norm in bipolar. It affects only 1 in 3 people, according to the highest estimates, or 1 in 5, according to the lower ones.
There’s no line between four episodes in a year and four episodes in a month, or four episodes in a week. These are obviously very different experiences, but they do not have separate names.
Likewise, ultradian cycling is not separately classified in the DSM. That is unfortunate, because here is where serious skepticism about a bipolar diagnosis can arise. Yet, ultradian cycling has been observed in studies with blind raters, biological markers, and genetic data. It’s especially common in prepubertal children with bipolar, where that diagnosis was controversial for a long time. While there is less controversy today, considerable skepticism remains.
Antidepressants Can Trigger Rapid Cycling
Here’s one clear treatment implication of rapid cycling: If there’s an antidepressant in the picture, consider slowly tapering it. Of course, anyone considering such a move should discuss it with their treatment team first. It’s easy to make things worse by taking too big a first step, tapering too rapidly, or removing a medication that later looks obviously necessary.
Therefore, discontinuing an antidepressant needs to be a highly planned process.
One crucial part of that plan, in my opinion — though it’s disappointing to note that this is not routine — is to make the very first step toward reducing antidepressants as small as possible. This first step must go well to prevent worsening symptoms, avoid withdrawal symptoms, and minimize intense worry that depression will return. Severe anxiety about symptom recurrence could bring about just that — a so-called “nocebo” effect.
In practical terms, “as small as possible” means obtaining a prescription for the smallest available dose and then chopping the pill at least in half, or perhaps even in quarters.
If my patients and I were really worried about worsening but determined to start a taper, we might even use a liquid version (available for most common antidepressants) to take a tiny first step.
Unfortunately, most insurance plans won’t cover large quantities of the smallest available dose, so chopping larger pills is often necessary in this approach. No wonder it’s not routine.
Who Is More Likely to Experience Rapid Cycling?
Rapid cycling is more common for:
- Female sex
- Bipolar 2 subtype
- Those with a history of childhood maltreatment
- Those with hypothyroidism
Isn’t that interesting? It’s highly possible that rapid cycling is trying to tell us something. One thing seems pretty certain: Stressful life events increase cycle frequency.
Another interesting variation is 24-hour cycling. Several case reports describe people who switched from depression to hypomania every other day. One woman’s pattern was so regular that she scheduled business meetings accordingly! Obviously, this suggests an internal calendar driven by the operations of a biological clock.
The Role of the Body Clock
Indeed, as a group, people living with bipolar tend to have a “looser clock,” one that is more likely to shift with external “time-giving” signals like light and darkness. One particular clock gene — one of the genes that encode proteins involved in setting and maintaining circadian rhythms — is more common in people with rapid cycling.
Consequently, while regular sleep rhythm — including regular bedtimes and rise times — is important for nearly everyone living with bipolar, it may be particularly important for those with rapid cycling.
Other daily rhythms also set and maintain the circadian rhythm, such as meal times and physical activity times. But for most people, regular sleep timing is the most powerful clock-setting behavior, and thus a potential non-medication mood stabilizer. The rest of a full program called social rhythm therapy is detailed in a workbook by Holly A. Swartz, MD, at the University of Pittsburgh.
This approach is highly beneficial for rapid cycling, and for nearly anyone living with bipolar — and even for good health for everyone else.
Effective Treatment Approaches for Mood Stability
The term “rapid cycling” covers a very broad range of bipolar experience. But it doesn’t call for a different treatment approach. With one notable exception. Several studies have found that non-rapid-cycling bipolar is more likely to have a great response to lithium.
This doesn’t mean that lithium won’t work in people with rapid cycles. Think of it the other way around: Long periods of stable mood interrupted by severe mood episodes less than four times per year is a bipolar variation that can often reach and maintain remission on lithium alone.
Otherwise, all bipolar variations are treated the same way: Use mood stabilizers — including social rhythm therapy — to reach a stable mood first. Then you can address any remaining challenges, such as a trauma history, attention problems, or interpersonal struggles.
Whatever your experience, I hope you have learned something new and useful here. Thanks for reading.
References
- Sjöholm LK et al. CRY2 Is Associated With Rapid Cycling in Bipolar Disorder Patients. PLoS One. September 9, 2010.
- Swartz HA. The Social Rhythm Therapy Workbook for Bipolar Disorder. New Harbinger Publications.