Bipolar Disorder

A guide for human resources and management

This guide is to aid employers on a common workplace illness that can be hard to identify, can affect employees’ performance at work and is a major cause of absenteeism.

bipolar I We highlight:

What bipolar disorder is
The difference between bipolar disorder and depression
How it affects people
How to identify it
How to help those affected when at work
How to help those affected and absent return to work

Part one: What is bipolar disorder?

Bipolar affective disorder is a common and at times serious disorder of mood, in which people experience both episodes of depression and episodes of high mood (mania or hypomania) over time. We all feel up and down in our moods at times, but in bipolar disorder a number of symptoms all occur together and may cause a person major functional impairment. In an acute episode of bipolar illness the mood swings can last days, weeks or even months. Bipolar affective disorder is a severe mental illness, which affects up to 5% of the working population. It is associated with substantial morbidity and mortality, and can affect every aspect of an individual’s life (1). Both males and females of any age can develop the illness (2). The typical age of onset of bipolar disorder in the twenties means that this is an illness predominantly of working-age adults.

Sometimes you may hear people refer to different types of bipolar disorder. Bipolar I disorder refers to people who have episodes of mania, whereas Bipolar II refers to people who have less severe highs, hypomania (or ‘mild mania’). A manic episode is characterized by high mood with a number of the other “high” symptoms (described in Part three). Sometimes psychotic symptoms such as delusions and hallucinations can be part of a manic episode. Manic episodes cause people problems both in their working life and in their relationships.

A less severe episode of high mood is called hypomania. Hypomania presents many of the same symptoms as mania, but to a lesser degree. Delusions and hallucinations are not seen in hypomanic episodes.

Part two: The difference between bipolar disorder and depression

bipolar II Bipolar disorder and depression are very similar illnesses with one major difference: people with bipolar disorder experience both episodes of depression and episodes of high mood. Because these two illnesses share the experience of low mood, some people who are diagnosed as having depression may actually have bipolar disorder. One reason for this misdiagnosis is that people with bipolar disorder often only seek treatment during a depressive episode. Depression alone is not enough to diagnose someone with bipolar disorder, no matter how severe the episode or even if bipolar runs in the family. On average it takes 10 years for an individual to receive a correct diagnosis of bipolar disorder.

Part three: What to look out for – How bipolar disorder affects people

When thinking about the symptoms of an episode of depression or high mood it is helpful to think of feelings, thoughts and behaviours.

Depression:

An episode of depression may include a number of feelings or emotions:

Feeling sad or low in mood
Feeling empty or hopeless
Feeling angry and irritable

Depression may also impact on peoples’ thoughts:

They may have guilty thoughts
Their thinking may be dulled with poor concentration and poor memory
They may be worried about minor issues and be pessimistic about the future
This may lead to them thinking about death and dying or even experiencing suicidal thoughts

Finally episodes of depression may include a number of changes in how people behave:

People with depression may have difficulty sleeping or sometimes sleep more
They may have poor appetite or sometimes will eat more
They may be less active and become easily tired
They may withdraw from contact with other people

Mania:

An episode of high mood may include the following:

Often when people feel ‘high’ they will be excessively happy, euphoric or elated
Sometimes, however, people will be irritable or impatient and ‘over-react’ to minor events

An episode of high mood may affect a person’s thinking in a number of ways:

They may experience racing thoughts
They may have grandiose ideas and plans
People on a high may be more creative
They may be unreasonably optimistic
Or may be very easily distracted

An episode of high mood may include the following behaviours:

People on a high are often over-active and much more talkative
They may be more socially active and even socially disinhibited
This may lead to people being argumentative and annoying to others
In the early stages of a high they may be more productive; but this often does
not last, and eventually their behaviour can cause problems such as risk-taking behaviour or reckless spending

Note that as in depression people’s experiences of manic episodes are different;
symptoms can vary from person to person and from episode to episode for any individual.

Part four – How to identify bipolar disorder in the workplace

Bipolar disorder is complex and it may be difficult to identify in the workplace.

Examples of behaviour include:

Health professionals may take on excessive or unmanageable workloads due to symptoms of mania. For example: wanting to get involved in lots of projects, clinical, research and teaching, or taking on excessive overtime and extra shifts
Working very long hours and showing high energy levels
Managers should be aware that during periods of mania, health professionals may feel invincible and may try to steal drugs from their place of work
They may be continually late for clinics and ward rounds, especially in the mornings
Performance may decline and healthcare professionals may become irritated by colleagues, especially during periods of depression
Employees with bipolar disorder may not disclose their condition to the employer. This may be through fear of stigma and discrimination, or they may not recognize that they are ill (3). If you suspect an employee has bipolar disorder you could seek advice from occupational health, and encourage them to speak to occupational health or to seek advice from their GP about the symptoms they are experiencing.

Part five – Will all employees need time off work?

Not all employees will need time off work, and for many being in work can have a therapeutic effect and assist in the management of the disorder. Work can provide an important social context, contribute to a sense of self-worth and purpose, provide daily structure and provide financial security (4-6).

However there may be times when the employee will need time out of the workplace. This may be due to an episode of depression or mania, which can, sometimes, lead to an admission to hospital or intensive daily treatment from the community mental health team. In addition, changes in medication may mean that the employee can’t work on a short time basis, as changes in medication can be associated with short-term relapse of symptoms or side-efects.

Part six – Returning to work

Obstacles to returning to work may include:

Fear of relapse
Reduced self-confidence
Fear of colleagues’ perceptions
Irritability
Fear of lack of support from employers
Fear that continued symptoms may interfere with work

Part seven - Advice for employers to assist an employee with bipolar disorder returning to work

With careful management and support, health professionals can and do work successfully with bipolar disorder.

It is important to maintain a reasonable level of contact with the employee whilst they are off work, although there may be times where the employee does not feel well enough to talk. Contact from the line manager can show the employee that they are missed and a valued member of the team. Contact should not be used as a means of ‘checking up’ but as an opportunity to highlight the support available to the employee.
The line manager can explore any obstacles to returning to work with the employee. The employee should lead this conversation as they will have a greater understanding of their illness. They will be able to identify whether any aspects of the job and returning to work may be problematic based on their current state of health. This can be done in the form of a return to work meeting, ideally before the employee’s first day back.
Suggest the employee seek advice about returning to work from their occupational health advisor – offer to refer in advance of any return to work date so that the advice has been received prior to the first day back.
Ask the employee and occupational health advisor what adjustments would accommodate the obstacles identified.
There are well-recognised triggers for episodes of bipolar disorder, such as sleep disruption. Therefore some working patterns such as shift work may not be suitable.
The employer may not be able to accommodate all adjustments but these can be negotiated between the employee and line manager; support from human resources and others with this process may be helpful.
Bipolar disorder is a fluctuating condition so the needs of the employee may be constantly changing. It is important to discuss with the employee regularly whether their needs are being met. A simple change may be all that is required to help the individual stay on an even keel and prevent future absence.

Reasonable adjustments may include:

A phased return to work
Flexible hours, particularly allowing for a late starting time
Reducing workload; the manager may need to monitor the employee closely to ensure that they do not work excessive hours or take on excessive workloads.
Reducing the number of clinics done per week and/or reducing the number of patients per clinic
Adjusting duties, especially shift work, in order to avoid disrupting the individual’s circadian rhythm
Adjusting tasks - for example, an employee may find it difficult dealing with face-to-face client/patient contact, therefore it may be necessary to remove them from these situations until they are feeling better

Ongoing support from the manager and advice from occupational health is essential.

Additional resources

References

Bipolar UK. Bipolar - The facts 2013.
Sanchez-Moreno J, Martinez-Aran A, Colom F, Scott J, Tabares-Seisdedos R, G GS. Neurocognitive dysfunctions in euthymic bipolar patients with and without prior history of alcohol use Journal of Clinical Psychiatry. 2009;70(8):1120-7.
Hatchard K. Disclosure of mental health Work. 2008;30:311-6.>
Boardman J. Work, employment and psychiatric disability. Advances in psychiatric treatment 2003;9:327-34.
Dunn E, Wewiorski N, Rogers S. The meaning and importance of employment to people in recovery from serious mental illness: results of a qualitative study Psychiatric Rehabilitation Journal 2008;32(1):59-62.
Waddell G, Burton K. Is work good for your health and well-being? London 2006.