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Bipolar disorder

Bipolar disorder is a common psychiatric disorder characterised by the presence of manic or hypomanic episodes, with or without depressive episodes as well. It's a chronic disorder in which the patient experiences periods of remission with the occasional aforementioned episodes.

The lifetime prevalence is 1-3%, and the disorder affects sexes equally. The age of onset is usually around 20 years. The etiology and pathogenesis is unknown.

Manic episodes are characterised by pathologically elevated mood and reckless or dangerous behaviour which requires hospitalisation. There may be symptoms of psychosis. These episodes can be thought of as the opposite of depressive episodes. Hypomanic episodes are similar but less severe, usually not requiring hospitalisation.

The diagnosis of bipolar disorder is clinical, based on diagnostic criteria. Medication is an important part of treatment, mainly by mood stabilising drugs like lithium, antiepileptics, and antipsychotics.

Definition

One distinguishes two major types of bipolar disorder, bipolar I disorder and bipolar II disorder. Bipolar I is the most severe, characterised by episodes of mania, while bipolar II disorder is less severe, characterised by episodes of hypomania. Episodes of depression may occur in both types. One often uses the term "bipolar depression" to mean the depression occuring as a feature of bipolar disorder.

Clinical features

Mania and hypomania are the key features of bipolar disorder. These episodes may progress rapidly, the patient progressing from being in remission to being manic in only a few days. Hypomanic episodes usually progress slower.

Mania

Mania (or manic episode) is a state of severe mood disturbances and cognitive changes. Where depression is a state of pathologically low mood, mania can be thought of as a state of pathologically high mood. Mania includes:

  • Persistently and abnormally elevated or irritable mood
  • Persistently and abnormally increased activity or energy
  • Increased self-esteem or grandiosity
  • Decreased need for sleep
  • Increased talkativeness
  • Quickly and erratically jumping between ideas and thoughts (flight of ideas)
  • Distractability
  • Increased goal-directed activity (at school, work, or sexually)
  • Disinhibition (e.g. walking naked in public)
  • Psychomotor agitation or hyperactivity
  • Excessive involvement in activities which have painful consequences (sexual indescretion, unreasonable purchases)
  • Disregard for social boundaries

For the episode to be defined as manic, the symptoms must be severe enough to necessitate hospitalisation. There may be features of psychosis as well (hallucinations, delusions).

Patients with mania can make fools of themselves to such an extent that it will severely negatively affect their life following the resolution of the episode. This can include exposing themselves naked to strangers, cheating on their loved ones, making irresponsible purchases, posting secrets on social media, and saying things to friends and family that they can't take back.

Hypomania

Hypomania (or hypomanic episode) is a state similar to mania, but less severe. It includes the same features as described above, except the symptoms are not so severe as to necessitate hospitalisation, and there are no features of psychosis.

Hypomanic episodes can also occur in bipolar I disorder.

Major depression

See also: Major depressive disorder

Bipolar depression is similar to "unipolar" depression, including features like depressed mood, diminished interest or pleasure in activities, weight loss, sleep disturbance (too much or too little), and so on.

Bipolar depressive episodes actually predominate the clinical course of bipolar disorder, occuring more frequently than manic and hypomanic episodes.

Mood episodes with mixed features

Some patients with bipolar disorder experience symptoms of both mania/hypomania and depression simultaneously.

Other types of bipolar disorder

Cyclothymic disorder

Cyclothymic disorder is characterised by periods of hypomanic symptoms and depressive symptoms where these symptoms are not severe enough to meet the diagnostic criteria for a hypomanic episode and depressive episode, respectively.

Substance/medication induced bipolar disorder

Substance/medication induced bipolar disorder is characterised by mania/hypomania following during or soon after using certain substances or medications, including illicit drugs, stimulating drugs, and corticosteroids.

Bipolar disorder due to another medical condition

Certain conditions, like Cushing syndrome, multiple sclerosis, and systemic lupus erythematosus, can cause bipolar disorder.

Diagnosis

Diagnosis is based on clinical features, when the diagnostic criteria (according to DSM or ICD) for bipolar disorder are fulfilled.

For a diagnosis of bipolar I disorder, the patient must have experienced one or more manic episodes. Depressive episodes usually occur but are not required for the diagnosis.

For a diagnosis of bipolar II disorder, the patient must have experienced one or more hypomanic episodes, as well as one or more depressive episodes.

YMRS

The Young Mania Rating Scale (YMRS) is a diagnostic questionnaire which is used to assess the presence and severity of mania. There are 11 items, each of which gives a set of points, and the points are summed to give a score. The presence and severity of mania is based on the score. There is a maximum of 60 points, and 8-20 points mean a "possibility of mild mania". >31 points mean "markedly manic".

Management

Untreated, manic and hypomanic episodes may last weeks or months, and so treatment is indicated. The mainstay of both acute and maintainance treatment is mood stabilisers like lithium, antiepileptics, and antipsychotics. The most commonly used antiepileptics are valproate and carbamazepine, and the most commonly used antipsychotics are aripiprazole, olanzapine, quetiapine, and risperidone. Benzodiazepines may be used as adjunctive therapy to treat insomnia, agitation, or anxiety.

Treatment of mania and hypomania

Mania and sometimes hypomania must be managed inpatient to prevent the patient from harming themselves or others.

Medications can be used to induce remission in mania and hypomania. For severe mania, the first choice may be either lithium or valproate combined with an antipsychotic. For hypomania and less severe mania, monotherapy with an antipsychotic, antiepileptic, or lithium is often sufficient.

Patients usually respond to the same treatment they've responded to previously, so in case mania or hypomania occurs in a patient with known bipolar disorder, trying the same treatment approach which worked last time is usually a good idea. This can also involve increasing the dosage of the maintainance treatment.

Non-pharmacological interventions are also helpful. Reducing stimuli, sometimes by isolating the patient, helps calm them down. Due to their tendency to make statements which can negatively affect them later, one should consider confiscating their phones and computers.

Maintenance treatment of bipolar disorder

Following resolution of the manic or hypomanic episode, there is a high risk of recurrence, and so maintenance treatment of bipolar disorder is indicated to reduce the incidence of recurrences. Maintenance treatment also prevent depressive episodes.

The medication options are the same as for the acute treatment. Patients who respond to acute pharacotherapy should continue with the same regimen, sometimes in a reduced dosage. Otherwise, lithium monotherapy is a good first choice, but valproate and quetiapine are also good options. Patients with frequenct relapses may benefit from using two mood stabilisers rather than monotherapy.

Psychoeducation, teaching the patient and family members about bipolar disorder and its treatment, is known to reduce the incidence of recurrence.

Antidepressants

Antidepressants are the most commonly prescribed drugs for bipolar patients, but the role of antidepressants in bipolar depression is controversial, as there is evidence that they may induce mania, or cause rapid cycling between depression and mania. There may be a use for antidepressants, when used together with mood stabilisers, in the use of acute bipolar depression.