Bipolar disorder is a common and disabling psychiatric illness. It often misdiagnosed particularly in patients presenting with depressive episodes. Clinicians need to consider this diagnosis in all patients presenting with depressive symptoms since up to 20% of patients with unipolar depression will go on to develop a bipolar disorder. Even celebrities like Catherine Zeta-Jones have publicly spoken about having the illness so as to encourage others to seek help. The treatment of bipolar disorder can be challenging even though the treatment armamentarium is extensive particularly for manic and mixed episodes. Most patients will need a combination of medications along with adjunctive proven psychotherapies for optimal outcomes. Long term often lifelong maintenance treatment is indicated for most patients with this illness.
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What is Bipolar Disorder?
Bipolar Disorder is a serious psychiatric illness which affects mood, thoughts, behavior & ability to function. Individuals with Bipolar Disorder can quickly swing from extremes of happiness, high energy & activity levels to sadness, fatigue and despair. Bipolar Disorder affects about 4% of the U.S. population. Suicide occurs in 10%-15% of patients with the disorder.
Men and women are equally likely to be affected with onset usually occurring in the 20’s. Most patients are misdiagnosed initially. It can take up to 10 years to get a correct diagnosis.
When Was Bipolar Disorder First Described?
Bipolar Disorder as we know it has been described in clinical medicine for more than 5,000 years. The Ancient Greek physician and philosopher Aretaeus of Cappadocia wrote about a group of his patients who had extreme mood variants one day to the next.
In the 1900s German psychiatrist Emil Kraepelin studied the disorder and coined the term “manic-depressive insanity” to describe it.
The terms “manic-depressive illness” and “bipolar disorder” are comparatively recent, and date back to the 1950s and 1980’s (DSM III) respectively.
How is a Person Diagnosed With Bipolar Disorder?
The diagnosis of Bipolar Disorder is based on a careful longitudinal history from the patient and ideally from family members since many patients will deny manic or hypomanic episodes, considering them to be periods of optimal functioning.
A thorough mental status and physical exam is necessary to confirm the diagnosis, and to rule out secondary causes (medical illnesses, medications, drugs, etc.) of the mood symptoms particularly in patients presenting with symptoms for the first time after the age of 40.
Laboratory tests are usually normal and in a few instances neuroimaging tests may be necessary.
Based on the results of the evaluation, a person may be diagnosed with one of the following categories of Bipolar Disorder:
- Bipolar I Disorder - Presence of one or more manic or mixed (a mixture of manic and depressive symptoms in the same episode) episodes. Almost always individuals will have one or more major depressive episodes. The estimated heritability of liability to Bipolar Disorder is approx. 80%.
- Bipolar II Disorder - Presence of one or more major depressive episodes accompanied by at least one hypomanic episode. Suicide rates are higher in Bipolar II compared to Bipolar I.
- Cyclothymic Disorder - Presence of numerous hypomanic episodes and episodes of depression — but never a full manic episode, major depressive episode or a mixed episode. For a diagnosis of cyclothymic disorder, symptoms have to last two years or more (one year in children and adolescents). During that time, symptoms can never be absent for more than two months.
What are the Main Changes in DSM V for the Diagnosis of Bipolar Disorder?
- Increased activity/energy added as core mood elevation symptom
- The “ with mixed features” and “with anxious distress” specifiers added for manic, hypomanic and depressive episodes
- Manic episode with mixed features replaces mixed episode
- Antidepressant induced mania/hypomania persisting beyond the physiological event sufficient for manic/hypomanic episode
- The “level of concern for suicide” specifier added
Bipolar Disorder costs the U.S. $151 billion in 2009.
Winter entails more depression and summer more mania.
Two out of three Bipolar patients has a comorbid psychiatric illness.
Bipolar Disorder may lead to cognitive difficulties with multiple episodes.
Post-partum depression is often an undiagnosed Bipolar Disorder
How Do Doctors Treat Bipolar Disorder?
Untreated, Bipolar Disorder can be a very serious illness that affects the daily life and functioning of the patient and can lead to suicide. Fortunately, there are several treatment options available. In most patients, Bipolar Disorder requires LIFELONG TREATMENT.
- Hospitalization - Patients who have psychotic symptoms, are suicidal or homicidal or have severe illness may need to be hospitalized for stabilization.
- Initial Treatment - Most patients will receive either a mood stabilizer like lithium or valproate or an atypical antipsychotic often in combination with each other. Some patients will benefit from adjunctive benzodiazepines or hypnotics initially.
- Continued Treatment - Maintenance treatment is used to manage Bipolar Disorder on a long-term basis. Usually the dose and the combination of medications that gets you better keeps you better and should be continued for maintenance purposes. Non adherence is extremely common and can lead to relapse and hospitalization.
- Substance Abuse Treatment - Comorbid substance abuse is very common in Bipolar patients and can lead to non-response, relapse and difficulty achieving remission.
Finding the right medication or medications for patients can sometimes take time and the both clinicians and patients need to appreciate that. Otherwise it may lead to unnecessary changes in medications that may be premature. The choice of medications is very individualized based on the evidence base, past response or non-response and the side effect profile of the medications.
Psychosocial treatments have an important role in Bipolar Disorder. Proven therapies include CBT, family focused therapy, interpersonal and social rhythm therapy and group psychoeducation. These are as an adjunct to medications not as a substitute.
Among all newer antidepressants, Venlafaxine is the most likely to induce mania in Bipolar patients.
Can Someone With Bipolar Disorder Still Lead a Successful Life?
Yes! There are several successful people who have had Bipolar Disorder.
- Isaac Newton
- Catherine Zeta-Jones
- Russell Brand
- Winston Churchill
- Marilyn Monroe
- Frank Sinatra
- Vincent van Gogh
- Mel Gibson