Bipolar disorder and management

Bipolar disorder

• Also known as manic depression, a mental illness that causes a person’s moods to swing from extremely happy and energized (mania) to extremely sad (depression)• Chronic illness; can be life-threatening• Most often diagnosed in adolescence

Epidemiology Mortality/Morbidity

Bipolar disorder has significant morbidity and mortality rates.

Approximately 25-50% of individuals with bipolar disorder attempt suicide, and 11% actually commit suicide.

Race: No racial predilection exists.

Sex

Bipolar I disorder occurs equally in both sexes; rapid-cycling bipolar disorder (4 or more episodes a year) is more common in women than in men.

Incidence of bipolar II disorder is higher in females than in males.

Epidemiology

Age

The age of onset of bipolar disorder varies greatly. The age range for both bipolar I and bipolar II is from

childhood to 50 years, with a mean age of approximately 21 years,(15-19 years),(20-24 years).

Onset of mania in people older than 50 years should lead to an investigation for medical or neurologic disorders such as cerebrovascular disease.

Contributing factors

Evidence is mounting of the contribution of glutamate to both bipolar and major depressions

catecholamine hypothesis, which holds that an increase in epinephrine and norepinephrine causes mania and a decrease

in epinephrine and norepinephrine causes depression.

Hormonal imbalances and disruptions of the hypothalamic-pituitary-adrenal axis involved in homeostasis and the stress response may also contribute to the clinical picture of bipolar

disorder.

Biochemical causes

Contributing factors

Mania serves as a defense against the feelings of depression

Psychodynamic

Environmental

External stresses or the external pressures may serve to exacerbate some underlying genetic or biochemical predisposition.

Pregnancy is a particular stress for women with a manic-depressive illness history and increases the possibility of postpartum psychosis

Mania-Clinical symptoms

• Inflated self-esteem or grandiosity.• Decreased need for sleep• More talkative than usual • Flight of ideas or subjective

experience that thoughts are racing.• Distractibility• Increase in goal-directed activity or

psychomotor agitation.• Excessive involvement in pleasurable

activities that have a high potential for painful consequences

Depression- Clinical symptoms• Depressed mood• Diminished interest or pleasure in all, or almost all, activities• Decreased or increased appetite• Significant weight loss or gain• Insomnia or hypersomnia • Psychomotor agitation or retardation• Fatigue or loss of energy • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think or concentrate• Recurrent thoughts of death• Recurrent suicidal ideation or attempts

Akiskal's Schema of Bipolar Subtypes

Bipolar I: full-blown maniaBipolar I ½: depression with protracted hypomaniaBipolar II: depression with hypomanic episodesBipolar II ½: cyclothymic disorder Bipolar III: hypomania due to antidepressant drugsBipolar III ½: hypomania and/or depression associated with substance useBipolar IV: depression associated with hyperthymic temperamentBipolar V: recurrent depressions that are admixed with dysphoric hypomaniaBipolar VI: late onset depression with mixed mood features, progressing to a dementia-like syndrome

Psychiatric Clinics of North America 22:3, September 1999; Medscape Family Medicine, 2005;7[1]

Bipolar Disorder Diagnosis• The Diagnostic and Statistical Manual of Mental Health

Disorders (DSM) is published by the American Psychiatric Association (APA) and is the guideline by which the medical community diagnoses mental health issues.

• The term “bipolar disorder” made its debut in the third edition of the DSM (DSM-III), published in 1980. This term replaced “manic depressive disorders,” and better represented the polarity between moods of mania and depression.

• The DSM-5, published in May 2013, has also seen some changes in regard to bipolar disorder.

DSM-5 criteria

Bipolar I

Manic episodes lasting at least a week, or by symptoms of mania so severe that a person requires immediate hospitalization. A person will also normally experience a depressive episode of about two weeks. For a bipolar I diagnosis, a person’s manic and depressive symptoms must deviate from their normal behavior.

Bipolar II

Cycle of depressive episodes shifting back and forth with hypomanic episodes, without experiencing full-blown manic or mixed episodes.

DSM-5 criteriaOther Specified Bipolar and Related Disorder (previously called Bipolar Not Otherwise Specified)

Those with a past history of a major depressive disorder who meet all the requirements for hypomania except the duration of their episodes. This can also include those exhibit too few symptoms of hypomania to be diagnosed with Bipolar II, though the duration of their episodes is 4 days or more.

Cyclothymia

At least 2 years of hypomanic episodes shifting back and forth with episodes of mild depression. This diagnosis is considered a mild form of bipolar disorder because the symptoms do not meet the requirements for other types of bipolar disorder.

AACAP guideline for assessment of bipolar in children

Non-pharmacological treatment• Interpersonal, family and group therapy• Cognitive-behavioral therapy (CBT)• Electroconvulsive therapy (ECT)• Psychoeducation

Basic principles to handle bipolar patients

• Take extra time to listen and communicate with patients and their families

• Encourage peer to peer support

Create and foster a therapeutic alliance

Offer education about the diagnosis and treatment• Educate patient and family about the seriousness of

the illness and benefits of appropriate therapy• Provide the patient with patient education materials

Basic principles to handle bipolar patients

• Educate the patient and family about medication treatment options, therapeutic effects, possible adverse effects, and the likely need for long term medication

• Encourage the patient and family to express their treatment preferences

Enhance adherence with treatment

Monitor and manage symptoms and risk• Encourage the patient to permit ongoing involvement of one

or more trusted family members or friends in the patient's treatment

• Solicit information from family and other third parties when assessing risk, especially suicide risk, substance use, and social isolation

• Encourage open discussion about risky behavior

• During times the patient is well, engage the patient and family (or partner) to develop interventions that target reckless behavior during future illness episodes

• Encourage self monitoring of mood and medication use

• Encourage regularity of sleep, daily activities, and medication use

Pharmacological treatment

For the depressive phase of this illness, anti-depressant medications can relieve depressed feelings, restore normal sleep patterns and appetite, and reduce anxiety.

Anti-depressant medications are not addictive.They slowly return the balance of

neurotransmitters in the brain, taking one to four weeks to achieve their positive effects.

Pharmacological treatmentDuring acute or severe episodes of mania, several

different medications are used. Some are used to calm the person’s manic excitement;

others help to stabilize the person’s mood.Some medications are also used as preventive measures

as they help to control mood swings and reduce the frequency and severity of depressive and manic phases.

Long term medication may be required to prevent recurrent episodes.

Agents used for bipolar disorder

Initial Treatment Guidelines for Bipolar Disorder

05/01/20

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