Bipolar Disorder is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood clinically referred to asmania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time. These episodes are usually separated by periods of “normal” mood, but in some individuals, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. Bipolar disorder is a condition in which people experience abnormally elevated (manic or hypomanic) and abnormally depressed states for a period of time in a way that interferes with functioning.
Bipolar disorder has been estimated to afflict more than 5 million Americans—about 1 out of every 45 adults. It is equally prevalent in men and women, and is found across all cultures and ethnic groups. Not everyone’s symptoms are the same, and there is no blood test to confirm the disorder. Scientists believe that bipolar disorder may be caused by chemical imbalances in the brain. Bipolar disorder can appear to be unipolar depression. Diagnosing bipolar disorder is difficult, even for mental health professionals. What distinguishes bipolar disorder from unipolar depression is that the affected person jumps between states of mania and depression. Often bipolar is inconsistent among patients because some people feel depressed more often than not and experience little mania whereas others may predominantly experience manic symptoms.The mainstay of treatment is a mood stabilizer medication such as lithium carbonate or lamotrigine. Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizin g prodromal symptoms before full-blown recurrence, and, practicing the factors that lead to maintenance of remission.
Management
There are a number of pharmacological and psychotherapeutic techniques used to treat Bipolar Disorder. Individuals may use self-help and pursue a personal recovery journey.
Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (if mental health legislation allows and varying state-to-state regulations in the USA) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups, intensive outpatient programs. These are sometimes referred to partial-inpatient programs.
Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and, practicing the factors that lead to maintenance of remission. Cognitive behavioral therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioral therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge. Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.
Medication is another form of management. The mainstay of treatment is a mood stabilizer medication such as lithium carbonate or lamotrigine. Lamotrigine has been found to be best for preventing depressions, while lithium is the only drug proven to reduce suicide in bipolar patients. These two drugs comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and “gold standard” mood stabilizer is lithium, while almost as widely used is sodium valproate, also used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder, and lamotrigine, which is the first anticonvulsant shown to be of benefit in bipolar depression.
Treatment of the agitation in acute manic episodes has often required the use of atypical antipsychotic medications, such as quetiapine,olanzapine and chlorpromazine. More recently, olanzapine and quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder. A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.
The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes, especially if no mood stabilizer is used. However, most mood stabilizers are of limited effectiveness in depressive episodes. Rapid cycling can be induced or made worse by antidepressants, unless there is adjunctive treatment with a mood stabilizer. One large-scale study found that depression in bipolar disorder responds no better to an antidepressant with mood stabilizer than it does to a mood stabilizer alone. Recent research indicates that triacetyluridine may help improve symptoms of bipolar disorder.Clinical studies have shown that Omega 3 fatty acids may have beneficial effects on bipolar disorder.
Also, topiramate is an anticonvulsant often prescribed as a mood stabilizer. It is an off-label use when used to treat bipolar disorder. Unfortunately, its usefulness is likely minimal and side effects, such as significant cognitive impairment, undermine its efficacy (Kushner, et al. 2006 Bipolar Disorders 8; Chengappa, et al. 2006 J Clin Psych; 6).
When medication causes a reduction in symptoms or complete remission, it is important for someone with a bipolar disorder to understand they should continue to take the medicine. This can be complicated, as effective treatment may result in the reduction of manic symptoms and/or the medicine can be mood blunting or sedative, resulting in the person feeling they are stifled or that the medicine isn’t working. Either way, relapse is likely to occur if the medicine is discontinued.
For many individuals with bipolar disorder a good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder can have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar disorder can be a severely disabling medical condition. However, many individuals with bipolar disorder can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with bipolar disorder may have periods of normal or near normal functioning between episodes.
Ultimately one’s prognosis depends on many factors, several of which are within the control of the individual. Such factors may include: the right medicines, with the right dose of each; comprehensive knowledge of the disease and its effects; a positive relationship with a competent medical doctor and therapist; and good physical health, which includes exercise, nutrition, and a regulated stress level.
There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one’s energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one’s doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.