National Institute for Health and Care Excellence (NICE) presented revised (in February 2016) Bipolar Guideline 185 (CG185), published in September, 2014.

NICE recommends that psychological treatment is of utmost importance in the management of bipolar patients.

  • NICE recommends people with bipolar depression in primary care should be of high intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples’ therapy) in line with recommendations 1.5.3.1-1.5.3.5 in NICE clinical guidelines on depression.
  • NICE research on unipolar depression I children and young people supports the effectiveness of cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and short-term family therapy.

What is Bipolar Disorder?

Bipolar disorder is a psychiatric condition which causes severe swings in the mood. It is also known as maniac – depressive disorder. ‘Mania” is feeling “high” or “overexcited”. It causes extreme shifts in the mood, activity and energy levels.

Bipolar patient encounters varied lengths of highs and lows which are different from normal ups and down which everyone experiences. A patient may experience extremely high and energetic and then he may go into severe paralysing episode of depression.

Please see the DSM-5 diagnostic criteria for manic episode and DSM-5 diagnostic criteria for hypomanic episode from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.

Bipolar is the cause of death in young age and one of the major disabilities in developed countries.

The peak age of onset is 15–19 years. And it has been found that there is a long delay before the patient is diagnosed.

Cause Of Bipolar Disorder

Researchers are still trying to find out the cause of bipolar disorder and different studies are still in the process of completion. However, the scientists agree that it usually runs in families. There are some studies showing that people with certain specific genes tend to have bipolar more than others. Also, there are some studies which show that there is imbalance of certain chemicals (serotonin and norepinephrine) in the brain. These chemicals play an important role in the regulation of mood.

Symptoms Of Mania

A patient of bipolar may experience following symptoms when having maniac episode.

  1. Extreme energy
  2. Lack of sleep
  3. Flight of ideas or thinking recklessly
  4. Pressurised speech or speaking fast
  5. Delusion of grandiosity (Patient may feel that he is an extremely important personality)
  6. Increased sexual desire
  7. Feeling irritable
  8. Feelings of aggression
  9. Tendency to overspend the money

Symptoms Of Hypomania

Hypomania is a less severe form of mania. The duration of the episode is brief, but it remains for at least 4 days. Hypomania is less likely to affect the functional capacity of an individual but it needs to be treated as it may lead to maniac episode. Hypomania can be treated as an outpatient and may not need inpatient treatment.

Symptoms Of Depression

Bipolar patients may have following symptoms when experiencing an episode of relentless depression.

·        Lack of energy
·        Lack of interest in daily activities
·        Feeling tired or lethargic
·        Lack of appetite and weight loss
·        Lack of sleep
·        Feeling sad
·        Feelings of worthlessness
·        Feelings of guilt for no obvious reason
·        Difficulty in concentration
·        Thoughts of self harm or suicide

Differential Diagnosis

Bipolar disorder presents few symptoms similar to some diseases while diagnosing. They are as follows:

  • Substance abuse
  • Schizophrenia
  • Manias can be secondary to organic conditions like hyperthyroidism, Cushing’s syndrome and stroke.

Workup

There is no test which can diagnose bipolar so the diagnosis is based on the following.

  • Taking a comprehensive history
  • Doing a relevant physical examination
  • MSE or mental status examination
  • Filling a mood disorder questionnaire

Laboratory Tests

Following tests should be done to rule out any organic cause of the condition.

  • FBC
  • Urea and electrolytes
  • Liver function tests
  • ESR
  • Urine analysis
  • CT head if abnormal neurological findings on examination or onset in late age.

Treatment

Mania and hypomania are treated with same medications in spite of difference in their clinical presentation.

Main aim of treatment is the safety of the patient, improvement in the symptoms and prevention of the recurrence.

First thing in treatment is to determine the state of mood of the patient whether the presentation is maniac, hypomania, depressive or mixed.

Non-pharmacologic Therapy

Recent revised NICE recommendations are all about this. Please see the recommendations for details.

  • Cognitive-behavioural therapy is an important part of the treatment where patients are given psycho education regarding their condition, importance of compliance with the medications, consequences of their condition and knowledge of the triggering factors.
  • Patients having a seasonal pattern of depression are given bright-light therapy.
  • Education regarding the personal relationships.

Pharmacotherapy

Pharmacotherapy depends upon the severity of the symptoms: The main drugs used are

  • Lithium (Currently first line choice of maintenance treatment) is a mood stabilizer.
  • Anti-epileptics like lamotrigine and carbamezapine
  • Anti-psychotics like olanzapine, risperidone, Paliperidone.
  • Benzodiazepines like lorazepam and clonazepam.

Patients are given the combinations of above mentioned drugs to treat their symptoms.

Clinical management Advantages Disadvantages
Mania Depression Maintenance
Mood stabilisers
Valproate +++ + ++ Useful in episodes with mixed features CYP450 inhibitor, not recommended in women at childbearing age
Lamotrigine − – – ++ +++ Depressive predominant polarity Slow titration
Lithium +++ ++ +++ Anti-suicidal properties Not recommended in renal failure
Carbamazepine +++ + ++ Effective in bipolar disorder with non-classic features CYP450 inducer
Oxcarbazepine + + + Fewer adverse effects than carbamazepine Hyponatraemia
Anti-psychotics
Aripiprazole +++ ++ Manic predominant polarity, good metabolic profile Akathisia
Asenapine +++ + + Possible treatment for depressive symptoms Moderate metabolic syndrome
Chlorpromazine ++ − – – + Rapid efficacy Risk of switch to depression, extrapyramidal symptoms
Clozapine + + ++ Resistant patients, few extrapyramidal symptoms Agranulocytosis, sialorrhoea, postural hypotension
Haloperidol +++ − – – + Rapid efficacy Risk of switch to depression, extrapyramidal symptoms
Lurasidone + +++ + Lack of anti-cholinergic effects Efficacy related to feeding, akathisia, sedation
Olanzapine +++ +++ * ++ Rapid efficacy Severe metabolic syndrome
Paliperidone ++ ++ Can be administered intramuscularly every month, minimal liver metabolism High doses are often needed
Quetiapine +++ +++ +++ Only anti-psychotic drug with indications for treatment of acute manic and depressive episodes and maintenance Sedation
Risperidone ++ ++  Common intramuscular administration every 2 weeks Risk of switch to depression, extrapyramidal symptoms
Ziprasidone ++ ++ Manic predominant polarity, good metabolic profile Efficacy related to feeding
Anti-depressants − – + + Applicable in resistant bipolar depression combined with mood stabilisers Risk of switch to mania
Electroconvulsive therapy ++ ++ + Recommended in pregnant women General anaesthesia needed, anterograde memory loss

Pharmacological management of bipolar disorder in mania, depression, and maintenance phases

ECT is for the patients who do not respond to the six medication combinations.

Prognosis

Prognosis is poor because of the poor compliance with the treatment. Rate of attempted suicide is higher in depressive episode and drug misuse is common in maniac episode.

In a study patients of bipolar 1 and 2 were followed up for 15 years. Patients showed a state of euthymia or normal mood for about 7.5 years. Depression was reported in 31 percent and 2 percent of bipolar 1 and bipolar 2 patients respectively. Mania, hypomania and mixed episodes were reported in 1.6 percent and 10 percent of the bipolar 1 and 2 patients respectively.

Where To Get Help