Bipolar disorder: presentation and management

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.

Bipolar I disorder: at least one manic episode, which may have been preceded by and may be followed by hypomanic or major depressive episodes.Manic episode last at least 7 days, manic symptoms that are so severe the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks

Bipolar II disorder: at least one hypomanic episode and a current or past major depressive episode.

Cyclothymic Disorder (also called Cyclothymia)— defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

Sometimes a person might experience symptoms of bipolar disorder that do not match the three categories listed above, which is referred to as “other specified and unspecified bipolar and related disorders.”

Bipolar disorder is influenced by developmental, genetic, neurobiological, and psychological factors.
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Bipolar disorder is influenced by developmental, genetic, neurobiological, and psychological factors. Probably multiple gene loci are involved in heredity. Environmental or psychosocial stressors and immunologic factors are associated with bipolar disorder.

Clinical presentation

Different types of episodes may occur sequentially with or without a period of normal mood (euthymia) between. There can be mood fluctuations that continue for months or after one episode, there can be years without recurrence of any type of mood episode. Major depressive episodes include: Delusions, hallucinations, and suicide attempts are more common in bipolar depression than in unipolar depression.

Manic episode

Acute mania usually begins abruptly, and symptoms increase over several days. Bizarre behavior, hallucinations, and paranoid or grandiose delusions may occur. There is marked impairment in functioning. Manic episodes may be precipitated by stressors, sleep deprivation, antidepressants, central nervous system (CNS) stimulants, or bright light.

Hypomanic episode

There is no marked impairment in social or occupational functioning, no delusions, and no hallucinations. Some patients may be more productive than usual, but 5% to 15% of patients may rapidly switch to a manic episode.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, classifies bipolar disorders as (1) bipolar I, (2) bipolar II, (3) cyclothymic disorder, and (4) bipolar disorder not otherwise specified. A medical, psychiatric, and medication history; physical examination; and laboratory testing are necessary to rule out organic causes of mania or depression.

Course of illness

Childhood onset is associated with more mood episodes, rapid cycling, and comorbid psychiatric conditions.

Rapid cyclers, 20% of bipolar patients, have four or more episodes per year (major depressive, manic, or hypomanic). Rapid-cycling is associated with frequent and severe episodes of depression and a poorer long-term prognosis.

Women are more likely to have increased depressive symptoms, older age of onset, better adherence, and thyroid abnormalities. Men may have more manic episodes and substance use.

Suicide attempts occur in up to 50% of patients with bipolar disorder, and ~10% to 19% of individuals with bipolar I disorder commit suicide. Episodes may become longer in duration and more frequent with aging.

Treatment

Non-pharmacologic approaches include: 1) psychotherapy (e.g., individual, group, and family), interpersonal therapy, and/or cognitive behavioral therapy, 2) stress reduction techniques, relaxation therapy, massage, and yoga, 3) sleep (regular bedtime and awake schedule; avoid alcohol or caffeine intake prior to bedtime), 4) nutrition (regular intake of protein-rich foods or drinks and essential fatty acids; supplemental vitamins and minerals), and 5) exercise (regular aerobic and weight training at least three times a week).

Bipolar patients should remain on a mood stabilizer (e.g., lithium, valproate, and carbamazepine) lifelong. During acute episodes, medications can be added and then tapered after stabilization.

Lithium, divalproex sodium (valproate), extended-release carbamazepine, aripiprazole, asenapine, olanzapine, quetiapine, risperidone, and ziprasidone are currently approved by the FDA for treatment of acute mania. Lithium, divalproex sodium, aripiprazole, olanzapine, and lamotrigine are approved for maintenance treatment.

Lithium is the drug of choice for bipolar disorder with euphoric mania, whereas valproate has better efficacy for mixed states, irritable/dysphoric mania, and rapid cycling.

Combination therapies (e.g., lithium plus valproate or carbamazepine; lithium or valproate plus a second-generation antipsychotic) may provide better acute response and prevention of relapse and recurrence than monotherapy in some bipolar patients, especially those with mixed states or rapid cycling.

Useful guidelines include the following: Canadian Network for Mood and Anxiety Treatments (CANMAT); International Society for Bipolar Disorders Guidelines; Practice Guideline for the Treatment of Patients with Bipolar Disorder (Revision) published by the American Psychiatric Association; Texas Medication Algorithm Project developed by the Texas Department of Mental Health and Mental Retardation; and Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder, developed by the American Academy of Child and Adolescent Psychiatry.

Alternative Medication Treatment

High-potency benzodiazepines (e.g., clonazepam and lorazepam) are commonly used alternatives to (or adjuncts to) antipsychotics for acute mania, agitation, anxiety, panic, and insomnia or in those who cannot take mood stabilizers. Intramuscular (IM) lorazepam may be used for acute agitation. A relative contraindication for long term benzodiazepines is a history of drug or alcohol abuse or dependency.

Data suggest that adjunctive antidepressants may be no better than placebo for acute bipolar depression when combined with mood stabilizers. Many clinicians consider them third line for acute bipolar depression, except in those with no history of severe and/or recent mania or potentially in bipolar II patients. The rate of mood switching from depression to mania with tricyclic antidepressants and venlafaxine is higher than the rate associated with use of selective serotonin reuptake inhibitors. Before initiating an antidepressant, be sure the patients has a therapeutic dose or blood level of a primary mood stabilizer. Be cautious in using antidepressants in those with a history of mania after a depressive episode, and those with frequent cycling must be treated cautiously with antidepressants. Generally, the antidepressant should be withdrawn 2 to 6 months after remission.

Special Populations

Prophylaxis with mood stabilizers (e.g., lithium or valproate) is recommended immediately postpartum to decrease the risk of depressive relapse in bipolar women. The occurrence of Epstein anomaly in infants exposed to lithium during the first trimester is estimated at 1:1000 to 1:2000.

When lithium is used during pregnancy, use the lowest effective dose to prevent relapse, thus lessening the risk of “floppy” infant syndrome, hypothyroidism, and nontoxic goiter in the infant. Breast-feeding is usually discouraged for women taking lithium.

When valproate is taken during the first trimester, the risk of neural tube defects is ~5%. For carbamazepine, the risk is estimated to be 0.5% to 1%. Administration of folic acid can reduce the risk of neural tube defects.

Women taking valproate may breast-feed, but mother and infant should have identical laboratory monitoring.

A guideline for treatment of children and adolescents with bipolar disorder is Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder.

The elimination half-life of lithium and valproate increases with age. Demented patients can have increased sensitivity to side effects of mood stabilizers and antipsychotics.

Reference

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