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Formerly known as manic depression, bipolar disorder is now the term used to describe this psychiatric condition that involves both depressive and manic episodes. There are three types:

  • Bipolar 1 disorder – there is underlying depression, interspersed with episodes of main (usually depressive and manic episodes occur in the ratio 1:1)
  • Bipolar 2 disorder – the depression is more predominant, and the ratio of depressive to manic episodes is about 5:1. Manic episodes may only be slight (i.e. sub-mania), or precipitated by anti-depressant medication
  • Rapid cycling bipolar – a new classification, where there are >4 episodes/year of mania + depression. Important because the treatment is different from other types of bipolar disorder
It is important to distinguish bipolar disorder from unipolar depression, as the treatments are different. In depression, mania does not occur. In all types of bipolar disorder, then it is possible for mania to occur at any time, or when under antidepressant medication.

Epidemiology

  • Prevalence of 1-1.5%
    • 1% is bipolar 1
    • 0.5% is bipolar 2
  • More common in women
  • Usual onset in teenage years
  • First incidence is usually before at the age of 30
  • If first incidence is after 45, suspect organic cause
  • The first presentation can involve any/all of the following; depression, hypomania, mania
In my personal experience, many cases of bipolar which present with a depressive episode are typically diagnosed and treated as depression, and it may not be truly diagnosed as bipolar disorder for many years – Dr Tom Leach

Aetiology

  • Genetic factors
    • 5-10% ↑ risk if family member has depression / bipolar
    • The exact genes not determined – it is thought that there are many. One particular gene that has been identified is the COMT gene associated with rapid cycling bipolar disorder.
  • ↑ risk in those with a tendency to have rapid mood changes (cyclothymia) or unusual periods of elated feelings (hyperthymia)

Factors than can precipitate an event include:

  • Life factors that lead to early morning waking – can precipitate a manic episode. This can include anything that causes early morning waking, such as working in shift patterns, or even a one off event, such as having to get up early in the morning to e.g. go on a long journey.
  • Positive life events – can also precipitate mania
  • Negative life events – can precipitate both mania depression, although depression is more likely
  • Pregnancy, CVA (or anything that affects frontal lobe or cortical structures) steroids and stimulants can aso precipitate mania
  • Thyroid disease, antidepressants, steroids, alcohol, cannabis – can all cause rapid cycling mood in patients with bipolar disorder.
Patients with any of these factors in their life are likely to have improvement in symptoms if the factors are addressed

Clinical Features

  • Elated mood:
    • Mania – this is an elated mood lasting 1-2 weeks (or more), with psychotic symptoms. Affects social functioning.
    • Hypomania – there are no psychotic symptoms, and generally, it does not last as long. Must last >4 days to be classed as hypomania
  • Irritable mood
    • This can occur between periods of elation, and may be expressed as inappropriate anger. The general mood in mania can be very variable, with periods of elation lasting anywhere between minutes and days. This variable mood is known as a Labile Mood.
  • Feelings of ↑ self worth
  • Inappropriate social behaviour – may include sexual behaviour, often includes compulsive actions, such as gambling, spending lots of money, dangerous driving
  • General increase in activity
    • Also often includes lack of sleep – patients only feel they need a couple of hours of sleep
    • Patients will often switch from one activity to another, without finishing any of them. This is sometimes known as distractability – which shows poor attention and concentration.
  • Heighten sense of one’s abilities / prestige. They may believe they are a rich, famous, important person.
  • Delusions and Hallucinations may occur during periods of mania, but can occur at any time. They often represent the current mood, e.g. an elated patient will have a pleasant hallucination, whilst a depressed patient may have an unpleasant hallucination.
  • Auditory hallucinations – these are usually second person – i.e. they talk to the patient.
  • Very fast speech – the patient’s thoughts are often excessively fast, and their speech may not be able to ‘keep up’. This makes them difficult to interrupt.
  • Altered perceptions – the patient may perceive colours as brighter, and sounds as louder
Questions to ask when taking a history
  • Have you ever felt especially happy or cheerful? How long does it last? How often does it occur?
  • Do you feel you lose your temper more easily than usual?
  • Do you feel you have more energy than usual?
  • If the patient answers yes to any of these, ask about sleep patterns, restlessness, opinion of the self, libido (↑↑), spending habits.

Mental State

  • Appearance – bright coloured clothes, eccentric
  • Behaviour – over friendly, perhaps inappropriate
  • Speech – fast, and difficult to interrupt
  • Mood – elated/irritable
  • Thought – fast, sentences may be logical, but linked by puns and similar sounding words, and not by ideas, patient may be very self important and have grandiose ideas.
  • Perception – Hallucinations – usually occur with elated mood
  • Cognition – distractability

Diagnosis

The diagnosis is typically based on the manic episodes. DSM-V critter for mania include:
  • Elated or irritable mood for at least one week, PLUS at least three of:
    • Inflated self esteem
    • Decreased need for sleep
    • Accelerated speech
    • Racing thoughts / flight of ideas
    • Distractibility (reported or observed)
    • Increased goal directed activity or psychomotor agitations
    • Excessive activity
  • Impaired social or occupational functioning
  • Episode not due to substance misuse or other organic cause
 

Differential diagnosis

  • Unipolar depression (i.e. ‘regular’ depression)
  • Schizophrenia
  • Borderline personality disorder
    • Can mimic the cycling moods of bipolar disorder. However, bipolar disorder tends to episodic, which BPD tends to be chronic
  • Organic causes of mania:
    • Endocrine – thyroid, pituitary or adrenal disorders
    • Neurological – MS, CVA, Epilepsy, tumour – particularly those things that affect the frontal and subcortical areas.
    • Drugs – steroids, stimulants, anti-depressives

Risk Management

Factors that increase risk:
  • Reckless behaviour
  • Aggression
  • Promiscuous sexual behaviour (STI’s, pregnancy)
  • Lack of self care (can be a big risk e.g. in diabetes)
Some patients may need to be sectioned for inpatient care – particularly as during manic episodes, patients feel ‘very healthy’!

Investigations

There are no diagnostic tests for bipolar disorder – the diagnosis is clinical. However investigations are typically used to rule out an organic cause at the first presentation. These might include:

Blood tests

  • FBC
  • UEC
  • LFTs
  • TSH
  • Urinary drug screen
Neurochemistry, Neuroimaging and Neuropathology
  • PET scan – excessive post synaptic dopamine 2 activity in mania
  • Increased serotonin and noradrenaline levels – during episodes of mania – but the evidence is not conclusive
  • Inositol phosphate – a chemical that increases the metabolism of lithium is increased in mania
  • Cortisol – in mania, there is increase cortisol release/response to stress
  • White-matter hyper-intesities- the presence of these is related to poor prognosis, increased frequency of manic episodes, and cognitive impairment

Management

Acute Manic Episode
  • First line – Atypical antipsychotice.g. Olanzapine, risperidone, quetiapine, Clozapine (Be weary of Agranulocytosis!)
  • Second line –try Valporate, lamotrigine (anticonvulsants), or Lithium
Depressive Episode
  • AVOID ANTIDEPRESSANTS!these can cause rapid cycling mood
  • Try an atypical antipsychotic – such as quetiapine or olanzapine. If this doesn’t work, try adding the anticonvulsant lamotrigine or possible lithium adjunct
  • In some cases, SSRI may be suitable, but be very careful
General Maintenance

Try to avoid acute changes in medication regimens, and assess the effectiveness of current treatments over months.

  • Consider a mood diary. As the patient to rate their mood (e.g. out of 10) everyday – it is most effective when part of the bedtime routine. You can then use this to assess the patients mood over a long period – e.g. 12-18 months.
  • Consider education/therapy to encourage a proper diurnal pattern.
  • First line – Lithium (mood stabiliser)
  • In cases of manic or depressive episodes, first add an atypical antipsychotic, and if response is poor, consider anticonvulsants.
Psychological treatments
These are less effective than in unipolar depression. There are still some useful techniques, however. For example, patients can be taught to recognise the early warning signs of a manic episode, and then it is possible to avoid the episode completely. Similar techniques can be used for depressive episodes. It is also important to involve family (and perhaps friends), not only for support, but also because they can help recognise some of these signs.
General principles
Don’t change medications too soon. May take months for drugs to be effect. Psychological treatments (e.g. CBT), are not as effective as unipolar depression.

Prognosis

  • It is very unusual for a person to only ever have one manic episode. Therefore if a patient has experienced one, they are very likely to experience others in the future:
    • 50% chance in the next year
    • 80% chance in the next 4 years

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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