Bipolar Disorder

Published OnFebruary 16, 2024

Health and Nutrition

Definition of Bipolar Disorder

It is a mood or affective disorder characterized by recurrent episodes of mania and depression in the same patient at different times

It was earlier known as manic depressive psychosis (MDP)

Old Diagnosis

  • Bipolar Disorder or manic-depressive illness has been recognized since atleast the time of Hippocrates who described such patients as “amic” and “melancholic”
  • In 1899, Emil Kraepelin defined manic-depressive illness and notes that persons with manic depressive illness lacked deterioration and dementia which is associated with schizophrenia

Classification of Bipolar Disorders

  • Bipolar I: One or more manic or mixed episodes, usually accompanied by major depressive episodes (M = F)
  • Bipolar II: One or more major depressive episodes accompanied by atleast one hypomanic episode (F > M)
  • Cyclothymic – At least 2 years of numerous periods of hypomanic and depressive symptoms
  • BD Not otherwise specified – Bipolar features that do not meet criteria for any specific bipolar disorders

Facts on Bipolar Disorder

  • It’s a common illness affecting 2% of the world population
  • It’s among 10 leading causes of medical disability in the world
  • 6th leading cause of medical disability in developed nations
  • The illness is symptomatic in half of the time
  • It can have impaired social function even when symptom free

Epidemiology

  • Approximately 25-50% of individuals with BMD attempt suicide and 11% actually commit suicide
  • Bipolar I occurs equally in both sexes while incidence of Bipolar II is higher in females than in males
  • Age range for both Bipolar I and Bipolar II is from childhood to 50 years with onset of mania in more than 50 years should lead to investigation for medical or neurological disorders such as cerebrovascular disease(eg stroke)

Etiology

  1. 1. Genetic- Highly heritable (80% genetic contribution)
  2. Biochemical causes
  3. Glutamate levels are increased in BD-postmortem studies
  4. Increase in epinephrine and NE causes mania with their decrease leading to depression.
  5. Hormonal imbalance and disruptions of hypothalamic pituitary adrenal axis may contribute
  6. Psychodynamic – mania serves as a defense against the feelings of depression
  7. Environmental-
  8. External stresses or external pressures
  9. Pregnancy – is a particular stress for women with a BD history and increases possibility of postpartum psychosis

Manic 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

Depressive Symptoms

  • Depressed or sad or low mood
  • Diminished interest or pleasure in all or almost all activities
  • Appetite and/or weight loss or changes
  • 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 or suicidal attempts

When do you suspect BD?

  • The patient has had repeated episodes of major depression
  • The first episode of major depression occurred before age 25
  • A first degree relative has BD
  • When not depressed, mood and energy are a bit higher than average, all the time
  • When depressed, symptoms are “atypical” : extremely low energy, excessive sleep(e.g more than 10 hours a day), mood is highly reactive to the actions and reactions of others and appetite is more likely increased than decreased.
  • Episodes of Major depression are brief
  • The patient has had psychosis during an episode of depression
  • The patient has had severe depression after giving birth to a child
  • The patient has had mania or hypomania while taking an antidepressant
  • The patient has had loss of response to an antidepressant
  • 3 or more antidepressants have been tried and none worked

Management of BD

Inpatient care-Indications

  1. Danger to self
  2. Danger to others
  3. Total inability to function
  4. Medical condition that warrant medication monitoring

Outpatient care-4 Goals

  1. Look at areas of stress and ways to handle  them
  2.  Monitor and support the patient on medication
  3.  Develop and maintain the therapeutic alliance
  4.  Education

Bipolar Medication and Why You Might Choose It

  1. Quetipine (Quitipin)- Depression and agitation are both severe, severe sleep patterns, decrease hallucinations, improve concentration, Anxiety is a significant symptom, no family history of diabetes
  2. Divalproex (Enchorate Chrono)- Need something strong and fast, Male, and not afraid of weight gain, rapid cycling, significant manic symptoms
  3. Carbamezepine-Rapid cycling, severe sleep problems, can’t take divalproex (afraid of weight gain)
  4. Lamotrigine-Depression is the dominant symptom, rapid cycling, afraid of weight gain
  5. Lithium-classic bipolar 1 pattern, euphoric mania and severe depressions, significant manic symptoms, suicide risk is a concern
  6. Olanzapine-emergency level symptoms, need help really fast, can use “as-needed basis”, not afraid of weight gain
  7. Clozapine- tried everything else, severe symptoms, ready for major weight gain, weekly blood tests, one of most effective meds
  8. Verapamil-possible alternative for pregnancy, low side effect risk, tried many other medications but not ready for clozapine
  9. Risperidone-for elderly at very low doses

ECT

ECT is effective for treatment of Mania

Combined use of ECT and mood stabilizers are safe and effective

Found to be safe in all trimesters of Pregnancy

Psychological Management

  • Cognitive Behavioural Therapy (CBT): Focuses on the relationship between thoughts, behaviours, and emotions to reduce symptoms and manage relapses.
  • Psychoeducation: Aims at empowering patients in becoming experts in managing their disorder by enhancing compliance with medication and stabilising moods.
  • Family-focused therapy (FFT): Improve communication and problem-solving skills in the family. Also addresses high expressed emotion (EE) which is a risk factor for relapse.

Prognostic Factors

Good Prognostic factors

  • Acute or abrupt onset
  • Typical clinical features
  • Severe depression
  • Well-adjusted premorbid personality
  • Good response to treatment

Poor prognostic factors

  • Co-morbid medical disorders, personality disorders or alcohol dependence
  • Catastrophic stress or chronic ongoing stress
  • Unfavorable early environment
  • Poor drug compliance