Bipolar Disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Description

In the United States alone, more than two million people are diagnosed with bipolar disorder. Research shows that as many as 10 million people might be affected by bipolar disorder, which is the sixth-leading cause of disability worldwide. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (MDMDA), one-half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of ten years or more before they were correctly diagnosed.

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A person with bipolar disorder experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently; at least four times in 12 months; to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sort of layer or sheath around nerve fibers.) Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

KEY TERMS

Affective disorder— An emotional disorder involving abnormal highs and/or lows in mood. Now termed mood disorder.

Anticonvulsant medication— A drug used to prevent convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication— A drug used to treat psychotic symptoms, such as delusions or hallucinations, in which patients are unable to distinguish fantasy from reality.

Benzodiazpines— A group of tranquilizers having sedative, hypnotic, antianxiety, amnestic, anticonvulsant, and muscle relaxant effects.

DSM-IV— Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

ECT— Electroconvulsive therapy sometimes is used to treat depression or mania when pharmaceutical treatment fails.

Hypomania— A milder form of mania which is characteristic of bipolar II disorder.

Mixed mania/mixed state— A mental state in which symptoms of both depression and mania occur simultaneously.

Mania— An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder.

Neurotransmitter— A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation— Slowed mental and physical processes characteristic of a bipolar depressive episode.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnosis.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose illusions.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD ). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Treatment of bipolar disorder is usually achieved with medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder:

• Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use also may cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)
• Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug often is used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.
• Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. Note: valproate also is approved for the treatment of mania. A 2003 study found that the risk of death from suicide is about two and one-half times higher in people with bipolar disorder taking divalproex than those taking lithium.

Treating the depression associated with bipolar disorder has proven more challenging. In early 2004, the first drug to treat bipolar administration was approved by the U.S. Food and Drug Administration (FDA). It is called Symbyax, a combination of olanzipine and fluoxetine, the active ingredient in Prozac.

Because antidepressants may stimulate manic episodes in some bipolar patients, their use typically is short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

• SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
• MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.
• Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.
• ECT, or electroconvulsive therapy, has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

• Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
• Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) also are used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
• Psychotherapy and counseling. Because bipolar disorder is thought to be biological in nature, therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family. In fact, a 2003 report revealed that people on medication for bipolar disorder had better results if they also participated in family-focused therapy.

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an atypical antipsychotic medication that has been successful in controlling mania when low doses were administered. In early 2004, the FDA approved its use for treating bipolar mania. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

Olanzapine (Zyprexa) is another atypical antipsychotic approved in 2003 for use in combination with lithium or valproate for treatment of acute manic episodes associated with bipolar disorder. Side effects include hypotension (low blood pressure) associated with dizziness, rapid heartbeat, and syncope, or low blood pressure to the point of fainting.

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, was found to alleviate manic symptoms in a 1997 trial of 75 bipolar patients. The drug was used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise, and proper diet. Chinese herbs may soften mood swings. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

A surprising study in 2004 found that a rarely used combination of magnetic fields used in magnetic resonance imaging (MRI) scanning improved the moods of subjects with bipolar disorder. The discovery was made while scientists were using MRI to investigate effectiveness of certain medications. However, they found that a particular type of echo-planar magnetic field led to reports of mood improvement. Further studies may one day lead to a smaller, more convenient use of magnetic treatment.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Resources

PERIODICALS

"Family-focused Therapy May Reduce Relapse Rate." Health & Medicine Week (September 29, 2003): 70.

"FDA Approves Medication for Bipolar Depression." Drug Week (January 23, 2004): 320.

"FDA Approves Risperidone for Bipolar Mania." Psychopharmacology Update (January 2004): 8.

"Lithium and Risk of Suicide." The Lancet (September 20, 2003): 969.

Rossiter, Brian. "Bipolar Disorder." Med Ad News (March 2004): 82.

"Schizophrenia and Bipolar Disorder Could Have Similar Genetic Causes." Genomics & Genetics Weekly (September 26, 2003): 85.

Sherman, Carl. "Bipolar's Clinical, Financial Impact Widely Missed. (Prevalence May be Greater Than Expected)." Clinical Psychiatry News (August 2002): 6.

"Unique Type of MRI Scan Shows Promise in Treating Bipolar Disorder." AScribe Health News Service (January 1, 2004).

"Zyprexa." Formulary 9 (September 2003): 513.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. 〈http://www.nami.org〉.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. 〈http://www.ndmda.org〉.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. 〈http://www.nimh.nih.gov〉.

Bipolar disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Description

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV ), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not-otherwise-specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A person with bipolar disorder experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep . Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia, a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One third of patients with cyclothymia develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20 percent of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently, at least four times in 12 months, to meet the diagnostic definition. In some cases of "ultra-rapid cycling" the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Demographics

According to the American Academy of Child and Adolescent Psychiatry, up to one third of American children and adolescents diagnosed with depression develop early onset bipolar disorder. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (MDMDA), one half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one third reported waiting ten years or more before they were correctly diagnosed.

Causes and symptoms

The cause of bipolar disorder had not as of 2004 been clearly defined. Because two thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sheath around nerve fibers.) Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder, and these are under investigation as well.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse, which may be an issue in adolescent patients. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30 percent of abusers meet the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions.

When to call the doctor

When symptoms of bipolar disorder are present, a child should be taken to a qualified medical healthcare professional as soon as possible for evaluation. If a child or teen diagnosed with bipolar disorder reveals at any time that they have had recent thoughts of self-injury or suicide , or if they demonstrate behavior that compromises their safety or the safety of others, professional assistance from a mental healthcare provider or care facility should be sought immediately.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist. In addition to an interview with the child and her parents, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Children's Global Assessment Scale (C-GAS), General Behavior Inventory (GBI), Beck Depression Inventory (BDI), Minnesota Multiphasic Personality Inventory Adolescent (MMPI-A), the Youth Inventory (YI-4), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend to demonstrate irritability and aggressiveness instead of the elation of mania in adults. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD). Their aggression can lead to violence, which may be misdiagnosed as a conduct disorder .

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV ) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem , decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization , and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Substance abuse can mask or mimic the presence of bipolar disorder and can make diagnosis more difficult in adolescents. When substance abuse or addiction is present, a patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder can be accurately diagnosed.

Treatment

The manic and depressive symptoms of bipolar disorder are usually controlled by a combination of prescription medications, including lithium, antipsychotics, anticonvulsants, and antidepressants .

Lithium

Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of adult bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea , and hand tremors. Prolonged lithium use also may cause hyperthyroidism .

Antipsychotics

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in adult patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation , and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is another atypical antipsychotic that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea , dry mouth, headache , heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat , fatigue, and weight gain).

Olanzapine (Zyprexa) was approved in 2003 for use in combination with lithium or valproate for treatment of acute manic episodes associated with bipolar disorder. In 2004 it received additional approval for long-term maintenance of bipolar disorder. Possible side effects include drowsiness, dizziness , weight gain, dry mouth, rapid heartbeat, nausea, and muscle weakness.

Quetiapine (Seroquel) was approved by the FDA in 2004 for the treatment of acute mania associated with bipolar disorder. Potential side effects of the drug include dizziness, sleepiness, dry mouth, weight gain, and constipation.

Ziprasidone (Geodon) is a schizophrenia drug that is often prescribed to treat bipolar mania. Common side effects associated with ziprasidone include dizziness, fatigue, constipation, and rash. Unlike the other antipsychotic drugs, however, it does not promote weight gain.

Atypical antipsychotics have been associated with hyperglycemia (high blood sugar) and diabetes in some patients. Their use may be contraindicated (i.e., not recommended) in children and teens with type 1 or type 2 diabetes.

Anticonvulsants

Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. It is also approved for the treatment of mania. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. A 2003 study found that the risk of suicide from death is about two and one half times higher in people with bipolar disorder taking divalproex than those taking lithium.

Gabapentin (Neurontin) has been prescribed by some physicians for the treatment of bipolar disorder, although there is no conclusive clinical evidence as to its effectiveness.

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug often is used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. Clinical trials continue as of 2004 in an attempt to obtain FDA approval of carbamazepine for use in bipolar treatment.

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, is often used in patients with a history of rapid cycling and antidepressant-induced mania. A University of Cincinnati one-year study of the drug in patients with bipolar I disorder found that it provided sustained relief of depressive symptoms. Lamotrigine may be used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting .

Antidepressants

Because antidepressants may stimulate manic episodes in some bipolar children and teens, their use is typically short-term. Some researchers have hypothesized that the use of antidepressants for depression may even trigger bipolar disorder in children who are genetically predisposed.

When antidepressants are prescribed for episodes of bipolar depression, they are usually selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors). Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety , diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.

MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

In 2004, 10 antidepressant drugs (including fluoxetine, sertraline, paroxetine, and bupropion) came under scrutiny when the FDA issued a public health advisory and announced it was requesting the addition of a warning statement in drug labeling that outlined the possibility of worsening depression and increased suicide risk. These developments were the result of several clinical studies that found that some children taking these antidepressants had an increased risk of suicidal thoughts and actions. The FDA announced at the time that the agency would embark on a more extensive analysis of the data from these clinical trials and decide if further regulatory action was necessary.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) has a high success rate for treating both unipolar and bipolar depression and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia, and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct therapies

Other drugs that may be use as adjunct therapies (i.e., in addition to regular treatment) to treat manic episodes include the following:

• Calcium channel blockers: Nimodipine (Nimotop, Admon) and verapamil (Calan, Covera, Isoptin), typically used to treat angina and hypotension, have been found effective in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium build up in cells that is thought to be a cause of bipolar disorder. They usually are used in conjunction with other drug therapies such as carbamazepine or lithium.
• Long-acting benzodiazepines: Lorazepam (Ativan), clonazepam (Klonapin), and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
• Neuroleptics: Chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because the side effects of these drugs can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms , severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

Because bipolar disorder is thought to be biological in nature, therapy and/or counseling is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. A 2003 report revealed that people on medication for bipolar disorder had better results if they also participated in family-focused therapy.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise , and proper diet. Biofeedback may be effective in helping some children and adolescents control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Repeated transcranial magnetic stimulation (rTMS) is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Prognosis

While most children show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90 percent of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15 to 25 percent and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by 10 years.

According to the American Psychiatric Association, bipolar children and adolescents experiencing a manic episode have a one-year recovery rate of 37.1 percent and a relapse rate of 38.3 percent. Discontinuing lithium treatment too early may increase the risk of relapse in adolescents with bipolar disorder. In one 1990 study, 92 percent of adolescents hospitalized for mania who stopped taking the drug experienced a relapse of symptoms within 18 months of discharge, compared to 37 percent of those who stayed on lithium therapy.

Children and teens with bipolar disorder are at a greater risk for substance abuse than their non-bipolar peers, and substance abuse can worsen or complicate bipolar treatment. In a 1999 two-year follow-up study of adolescents hospitalized for manic episodes, patients who had ongoing drug or alcohol abuse problems had more manic episodes and poorer functioning than those patients who were not substance abusers. In addition, some studies have indicated that children who develop bipolar disorder in adolescence are more likely to develop a substance abuse problem than those who have early-onset of bipolar disorder in childhood.

Prevention

The ongoing medical management of bipolar disorder is critical for preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Education in the form of psychotherapy or self-help groups is crucial for training bipolar patients and their caregivers to recognize signs of mania and depression and to take an active part in their treatment program.

Parental concerns

Children with bipolar disorder may require special accommodations in the classroom. Section 504 of the Rehabilitation Act of 1973 enables parents to develop both a Section 504 plan (which describes a child's medical needs) and an individualized education plan (IEP), which describes what special accommodations a child requires to address those needs. The IEP may cover issues such as allowing extra time on tests, modifying assignments, and providing home tutoring or a classroom aide when necessary.

Children who are diagnosed with bipolar disorder should be reassured that the condition is due to factors beyond their control (i.e., genetics, neurochemical imbalance) rather than any fault of their own. For those children and teens who feel stigmatized or self-conscious about their diagnosis, arranging psychotherapy sessions outside school hours may lessen their burden. Any child on prescription medication for bipolar disorder should be carefully monitored for any sign of side effects, and these should be reported to their physician when they do occur. A dosage adjustment or medication change may be warranted if side effects are disruptive or potentially dangerous.

See also Depressive disorders; Minnesota Multiphasic Personality Inventory.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Press Inc., 2000.

Papolos, Demitri, and Janice Papolos. The Bipolar Child, 2nd ed. New York: Broadway Books, 2002.

PERIODICALS

American Psychiatric Association. "Practice Guideline for the Treatment of Patients with Bipolar Disorder (Revision)." American Journal of Psychiatry 149, no.4.(April2002):1–50.

"Education and Your Bipolar Child." Brown University Child and Adolescent Behavior Letter 20, no. 7 (July 2004): 9.

"Lithium and Risk of Suicide." The Lancet (September 20, 2003): 969.

"Schizophrenia and Bipolar Disorder Could Have Similar Genetic Causes." Genomics & Genetics Weekly (September 26, 2003): 85.

Sherman, Carl. "Bipolar's Clinical, Financial Impact Widely Missed. (Prevalence May Be Greater than Expected)." Clinical Psychiatry News (August 2002): 6.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Web site: <www.psych.org>.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002–4242. Web site: <www.apa.org>.

Child and Adolescent Bipolar Foundation (CABF). 1187 Wilmette Ave., PMB #331, Wilmette, IL 60091. Web site: <www.bpkids.org>.

Depression and Bipolar Support Alliance (DBSA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. Web site: <www.dbsalliance.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201–3042. Web site: <www.nami.org>.

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892–9663. Web site: <www.nimh.nih.gov>.

WEB SITES

U.S. Food and Drug Administration. "Antidepressant Use in Children, Adolescents, and Adults." Available online at <www.fda.gov/cder/drug/antidepressants/default.htm> (accessed November 9, 2004).

Paula Ford-Martin Teresa Odle

KEY TERMS

Affective disorder —An emotional disorder involving abnormal highs and/or lows in mood. Now termed mood disorder.

Anticonvulsant —Drugs used to prevent convulsions or seizures. They often are prescribed in the treatment of epilepsy.

Antipsychotic drug —A class of drugs used to control psychotic symptoms in patients with psychotic disorders such as schizophrenia and delusional disorder. Antipsychotics include risperidone (Risperdal), haloperidol (Haldol), and chlorpromazine (Thorazine).

Benzodiazepine —One of a class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety. Diazepam (Valium), alprazolam (Xanax), and chlordiazepoxide (Librium) are all benzodiazepines.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) —This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

Electroconvulsive therapy (ECT) —A psychological treatment in which a series of controlled electrical impulses are delivered to the brain in order to induce a seizure within the brain. This type of therapy is used to treat major depression and severe mental illness that does not respond to medications.

Hyperthyroidism —A condition characterized by abnormal over-functioning of the thyroid glands. Patients are hypermetabolic, lose weight, are nervous, have muscular weakness and fatigue, sweat more, and have increased urination and bowel movements. Also called thyrotoxicosis.

Hypomania —A milder form of mania that is characteristic of bipolar II disorder.

Mania —An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyperactivity, disorganization of behavior, and inappropriate elevation of mood.

Mixed mania —A mental state in which symptoms of both depression and mania occur simultaneously. Also called mixed state.

Neurotransmitter —A chemical messenger that transmits an impulse from one nerve cell to the next.

Psychomotor retardation —Slowed mental and physical processes characteristic of a bipolar depressive episode.

Bipolar Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Bipolar, or manic-depressive, disorder is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania (an elevated or euphoric mood or irritable state) and depression.

Description

In the United States alone, bipolar disorder afflicts an estimated 5% of the general population, or almost 15 million people. According to a 2006 study, bipolar disorder costs the U.S. workplace as much as $14 billion a year, lost to the average 65.5 workdays each worker with bipolar disorder missed annually. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. There also has been a new recognition of newonset bipolar disorder in later life, which occurs among the elderly at rates of about 1% and appears to be more prevalent among elderly men than elderly women.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised (DSM-IV-TR), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified (NOS).

Bipolar I disorder is characterized by manic episodes, the “high” of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, in which both manic or hypomanic symptoms and depressive symptoms occur at the same time, also frequently occur with bipolar I patients (for example, depression with the racing thoughts of mania). In addition, dysphoric mania (mania characterized by anger and irritability) is common.

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from unipolar depression (depression without mania, as found in major depressive disorder ). Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia—a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than people with unipolar depression.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in twelve months—to meet the diagnostic definition. In some cases of “ultra-rapid cycling,” the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

Causes

The root causes of bipolar disorder have not been clearly defined, but studies suggest a strong heritable component. The most recent research has identified areas on four different chromosomes (6, 13, 18, and 22) that may carry genes whose protein products confer susceptibility to bipolar disorder. A study from 2006 suggests that inclusion of symptoms of common comorbidities of bipolar disorder and a measurement of social functioning might help researchers pinpoint more closely the genes involved in the development of these disorders.

Studies of the underlying genetics of bipolar disorders also have closely focused on genes related to the regulation of dopamine, a neurotransmitter (nerve-signaling molecule) that is involved generally in mood disorders. Recent studies examining the genes expressed in dopamine neurons (nerve cells) in different parts of the brain have shown that the parts of the brain known to be involved in mood disorders such as bipolar disorder exhibit different patterns of gene expression from other neurons. The area of the brain most closely associated with dopamine’s involvement in bipolar disorders is the ventral tegmental area, which plays a role in the brain’s dopamine-based reward system and in regulation of addictive or emotional behaviors.

Symptoms

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions (ideas that the person affected is extremely important or has some unrecognized talent or insight).

Comorbidities

A large percentage of people diagnosed with bipolar disorder also experience comorbidities, with one study finding that 67% of patients with bipolar disorder had a comorbidity and 76% who had bipolar II disorder also had a comorbidity. Overall, 65% of all bipolar patients will have a comorbidity, including anxiety disorders, attention deficit/hyperactivity disorder, and substance and alcohol abuse. Suicidal ideation (thinking seriously about attempting suicide ) and suicide are relatively common. The type of comorbidity can vary based on sex; women are more likely to have an eating disorder comorbidity or post-traumatic stress disorder (PTSD) as a comorbidity.

Demographics

The disorder is more common among women than men. Women have been observed at increased risk of developing subsequent episodes in the period immediately following childbirth, the postpartum period. The average age at onset in a recent large study was the same for men and women: 17.2 years. Men with bipolar disorder are more likely than women to have a history of violence and to have experienced legal problems, and women are more likely than men to have made a suicide attempt. In the survey of U.S. workers from 2006, twice as many women as men met the criteria for bipolar disorder, but there were no distinctions based on ethnicity.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient’s mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multi-axial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the DSM-IV-TR as a guideline for diagnosis of bipolar disorder and other mental illnesses. The DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that, unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features (no delusions or hallucinations). In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often manifest differently in children and adolescents than they appear in adults. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of ADHD. Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatments

Bipolar disorder is usually treated with both medical and psychosocial interventions. Psychosocial therapies address both psychological and social issues.

Medical interventions

A combination of mood-stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

MOOD-STABILIZING AGENTS

Mood-stabilizing agents such as lithium, carbamazepine, and valproic acid (valproate) are prescribed to regulate the manic highs and lows of bipolar disorder:

• Lithium (lithium carbonate, Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics (other psychiatric drugs) and/or benzodiazepines (medications that ease tension by slowing down the central nervous system) to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but it is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thyroid marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms).
• Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug (a drug to treat seizures) usually prescribed in conjunction with other mood-stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. It may also result in a reduction in red blood cells (anemia), which if left untreated can be life threatening (as in aplastic anemia). Signs to watch for and report immediately to a doctor include easy bruising, tiny purple dots or spots on the skin, or mouth sores.
• Valproic acid (divalproex sodium, or Depakote; valproate, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed-states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. This drug can cause severe damage to the liver and pancreas, with the greatest risk of liver damage in children under age two years and in people taking two or more medications to prevent seizures or people with certain metabolic disorders. Warning signs that warrant an immediate call to the doctor include severe fatigue, nausea, vomiting, facial swelling, or loss of appetite.

ANTIDEPRESSANTS

Although mania receives more attention, the reality is that people with bipolar disorder spend more time in depressive episodes, making antidepressant treatment seem like a logical choice. However, research indicates that antidepressants, including selective serotonin reuptake inhibitors (SSRIs ) and tricyclic antidepressants, may stimulate manic episodes in some bipolar patients. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression. Antidepressants that may be used to treat bipolar depression include:

• SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
• Monoamine oxidase inhibitors (also called MAOIs), such as tranylcypromine (Parnate) and phenelzine (Nardil), block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking certain kinds of MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diets, although use of a newer, more selective form of MAOI, selegiline, delivered via a low-dose transdermal patch, does not generally require dietary adjustment.
• Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia. It now comes with a warning about its use in teenagers and children because some research indicates an increased risk of suicidal ideation and suicide attempts in young people taking this type of antidepressant. Its use in people under age 18 is not recommended.
• Lamotrigine is an antiepileptic that has shown some promise in treating bipolar I depression. Its dosage will vary based on whether or not the person is also taking other drugs, such as valproic acid. This drug is associated with a rare incidence of the development of a serious rash, and the risk of the rash increases if the person is also taking valproic acid. Children are more susceptible to this adverse, possibly life-threatening rash. Women who are pregnant should discuss carefully with their doctor whether or not to use lamotrigine. Studies have shown that fetal exposure in the first trimester of pregnancy increases the chances of cleft lip or cleft palate.

ADJUNCT TREATMENTS

These adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

• Long-acting benzodiazepines (medications that ease tension by slowing the central nervous system) such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood-stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
• Neuroleptics (antipsychotic medications) such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
• Electroconvulsive therapy (ECT) has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient’s head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.
• Calcium channel blockers (nimodipine, or Nimotop), typically used to treat angina and hypotension (low blood pressure), have been found effective, in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium buildup in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an antipsychotic medication used to control manic episodes in patients who have not responded to typical mood-stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an antipsychotic medication that has been successful in controlling mania. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain). However, because of a risk of death in older people with dementia who take antipsychotics, risperidone is not approved by the FDA for treatment of behavioral disorders in older adults with dementia.

Repeated transcranial magnetic stimulation (rTMS) is a newer treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient’s head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Psychosocial interventions

Because bipolar disorder is thought to be biological in nature, psychological therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family.

In educative counseling, patients (and their families) learn of the high rates of social dysfunction and marital discord associated with this disorder. Patients also learn how their treatment will progress, which factors can affect treatment, and what kind of follow-up after treatment will be implemented. Genetic counseling should be a part of family education programs because this disorder is more prevalent among first-degree relatives of individuals with the disorder.

Social support for individuals with bipolar disorder is also important. Some people with the disorder, as well as their families, may find support groups helpful.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding over-stimulation, getting plenty of rest, exercising regularly, and maintaining a proper diet. Some Chinese herbs may soften mood swings, but care must be taken (and good communication with the physician is essential) when combining herbal therapies with medications. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to complete unresponsiveness to all drugs and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient increases by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse (recurrence) of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

KEY TERMS

Anticonvulsant medication —A medication that prevents convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication —A medication used to treat psychotic symptoms of schizophrenia such as hallucinations, delusions, and delirium. May be used to treat symptoms in other disorders as well.

Benzodiazepines —A group of central nervous system depressants used to relieve anxiety or to induce sleep.

ECT —Electroconvulsive therapy is sometimes used to treat depression or mania when pharmaceutical treatment fails.

Hypomania —A milder form of mania that is characteristic of bipolar II disorder.

Mania —An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyperactivity, disorganization of behavior, and inappropriate elevation of mood.

Mixed mania/mixed state —A mental state in which symptoms of both depression and mania occur simultaneously.

Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation —Slowed mental and physical processes characteristic of a bipolar depressive episode.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Maxmen, Jerrold S., and Nicholas G. Ward. “Mood Disorders.” In Essential Psychopathology and Its Treatment. 2nd ed. New York: W. W. Norton, 1995.

Tasman, Allan, Jerald Kay, MD, and Jeffrey A. Lieberman, MD, eds. Psychiatry, 1st ed. Philadelphia: W. B. Saunders, 1997.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Greene, James G. “Gene Expression Profiles of Brain Dopamine Neurons and Relevance to Neuropsychatric Disease.” Journal of Physiology 575 (2006): 411–16.

Hoblyn, Jennifer. “Bipolar Disorder in Later Life.” Geriatrics 59 (2004): 41–44.

Keck, P., S. McElroy, and L. Arnold. “Advances in the Pathophysiology and Treatment of Psychiatric Disorders: Implications for Internal Medicine.” Medical clinics of North America 85.3 (2001).

Kilzieh, N., and H. Akiskal. “Rapid-cycling Bipolar Disorder: An Overview of Research and Clinical Experience.” Psychiatric Clinics of North America 22.3 (1999).

Nierenberg, Andrew A., and others “Systematic Treatment Enhancement Program for Bipolar Disorder (STEPBD): A Clinical View.” Journal of Clinical Psychiatry 67.11 (2006).

Schulze, Thomas G., and others. “What Is Familial about Familial Bipolar Disorder?” Archives of General Psychiatry 63 (2006): 1368–76.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. <http://www.psych.org>.

Child and Adolescent Bipolar Foundation. 1000 Skokie Boulevard, Suite 570, Wilmette, IL 60091. E-mail: [email protected]. <http://www.bpkids.org/site/PageServer>.

Depression and Bipolar Support Alliance. 730 N. Franklin Street, Suite 501, Chicago, IL 60610-7224. Telephone: (800) 826-3632. Fax: (312) 642-7243. <http://www.dbsalliance.org/site/PageServer?pagename=home>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201-3042. Telephone: (800) 950-6264. <http://www.nami.org>.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. Telephone: (800) 826-3632. <http://www.ndmda.org>.

National Institute of Mental Health, Mental Health Public Inquiries. 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. Telephone: (888) 826-9438. <http://www.nimh.nih.gov>.

OTHER

“Bipolar Disorder.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/bipolardisorder.html>.

“Bupropion.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a695033.html>.

“Drug Information: Carbamazepine.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/print/druginfo/medmaster/a682237.html>.

“Lamotrigine.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a695007.html>.

“Patient Information Sheet: Lamotrigine (marketed as Lamictal).” U.S. Food and Drug Administration. <http://www.fda.gov/cder/drug/InfoSheets/patient/lamotriginePIS.htm>.

“Patient Information Sheet: Risperidone Tablets (marketed as Risperdal).” U.S. Food and Drug Administration. <http://www.fda.gov/cder/drug/InfoSheets/patient/risperidonePIS.htm>.

“Risperidone.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a694015.html>.

“Valproic Acid.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682412.html>.

Paula Anne Ford-Martin, MA
Laith Farid Gulli, MD
Nicole Mallory, MS, PA-C
Emily Jane Willingham, PhD

Bipolar Disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression. The switch between highs and lows often comes without warning. For instance, a "high" mood can quickly deteriorate into a "low," causing the sufferer exceptional stress.

Description

An estimate by the National Institute of Mental Health states that more than two million American adults—about 1% of the population age 18 and over in any given year—have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, while others develop them late in life. Very often, bipolar disorder is not recognized as an illness. Many people suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

An even grimmer survey by the National Depressive and Manic Depressive Association (NDMDA) estimates that over 17.4 million adults in the United States suffer with an affective disorder each year (one in seven people). Women are twice as likely as men to experience major depression, while manic depression occurs on an even percentage between the sexes. Onset of major or manic depression can occur at any age, however it most commonly develops between the ages of 25 and 44.

The problem is compounded by inaccurate or no diagnoses in the early stages. A survey taken by the NDMDA reports that half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of 10 years or more before they were correctly diagnosed.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not-otherwise-specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. However, these individuals are usually characterized as mild, moderate, or severe without psychotic features. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability). Catatonic features occasionally occur. Two of the following must be present for the bipolar I diagnosis to move into bipolar I with catatonic features: motor immobility; excessive, purposeless motor activity that is not caused by external stimuli; extreme negativity or mutism; inappropriate or bizarre postures, movements, mannerisms, or grimaces; and repetitive or echoing speech patterns.

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. At least one hypomanic instance must occur before the bipolar II criteria are met. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives. Catatonic features may also be present in bipolar II disorder.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. For this diagnosis, symptoms must be present for at least two years for adults and one year for children and adolescents. During the one and two year diagnosis-gathering period, patients may not be symptom-free for more than a two-month consecutive period. After the initial diagnostic periods, there may be superimposed mixed or manic episodes. In these instances, bipolar I and cyclothymic disorder may be diagnosed simultaneously. A third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in 12 months—to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses. Examples include:

• Very rapid transitions (a matter of days) between manic and depressed symptoms;
• Recurrent hypomanic episodes without depressive symptoms;
• Manic or mixed episodes that are superimposed on delusional disorder, residual schizophrenia, or psychotic disorder NOS;
• Hypomanic episodes that alternate with depression, but are not frequent enough to qualify for a diagnosis of cyclothymia;
• Situations where it has been assumed that a bipolar condition exists, but a determination cannot be made as to whether it is the primary diagnosis, is substance-induced, or comes from another medical condition.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

Over half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown that up to 30% of abusers meet the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose illusions.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as a guideline for diagnosing this disorder and other mental illnesses. DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Treatment of bipolar disorder is usually involves medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder. Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes 4-10 days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. As of early 1998, carbamazepine did not have an FDA-approved indication for mania.

Valproate (divalproex sodium or Depakote; valproic acid or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. (Note: valproate is also approved for the treatment of mania.)

Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), treat depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.

MAOIs, such as tranylcypromine (Parnate) and phenelzine (Nardil), block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

ECT, or electroconvulsive therapy, has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan. Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.

Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

Because bipolar disorder is thought to be biological in nature, therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family.

Calcium channel blockers (nimodipine or Nimotop), typically used to treat angina and hypotension, have been found effective in a few small studies for treating rapid cyclers. Calcium channel blockers stop the excess calcium build up in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is another atypical antipsychotic medication that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, was found to alleviate manic symptoms in a 1997 trial of 75 bipolar patients. The drug was used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting.

rTMS, or repeated transcranial magnetic stimulation is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise, and proper diet. Chinese herbs may soften mood swings. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years, with work productivity increasing by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical in preventing relapse or recurrence of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Health care team roles

The health care team roles are crucial to the proper treatment of bipolar disorder. Bipolar disorder requires lifelong care, and regular monitoring is essential so that the optimum treatment goals are achieved. A treatment team comprised of family members and caregivers, as well as professional staff, is advised to meet regularly to discuss progress and assess new needs. The treatment plan is based on input from a psychological or psychiatric evaluation, as well as input from the caregivers and the patient. This plan of care should be regularly updated and personalized to fit the patient's individual needs. Periodic assessment will track the patient's progress/regression and will make use of current research.

KEY TERMS

Affective disorder— An emotional disorder involving abnormal highs and/or lows in mood. Now termed mood disorder.

Anticonvulsant medication— A drug used to prevent convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication— A drug used to treat psychotic symptoms, such as delusions or hallucinations, in which patients are unable to distinguish fantasy from reality.

Benzodiazepines— A group of tranquilizers having sedative, hypnotic, antianxiety, amnestic, anticonvulsant, and muscle relaxant effects.

DSM-IV— Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

ECT— Electroconvulsive therapy is sometimes used to treat depression or mania when pharmaceutical treatment fails.

Hypomania— A milder form of mania which is characteristic of bipolar II disorder.

Mixed mania/mixed state— A mental state in which symptoms of both depression and mania occur simultaneously.

Mania— An elevated or euphoric mood, or irritable state that is characteristic of bipolar I disorder.

Neurotransmitter— A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation— Slowed mental and physical processes characteristic of a bipolar depressive episode.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association Press, Inc., 2000.

Maxmen, Jerrold S., and Nicholas G. Ward. "Mood Disorders." In Essential Psychopathology and Its Treatment, 2nd ed. New York: W.W. Norton, 1995, pp. 206-43.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Biederman, Joseph A. "Is There a Childhood Form of Bipolar Disorder?" Harvard Mental Health Letter vol. 13, no. 9 (March 1997): 8.

Bowden, Charles L. "Choosing the Appropriate Therapy for Bipolar Disorder." Medscape Mental Health, vol. 2, no. 8 (1997). 〈http://www.medscape.com〉.

Bowden, Charles L. "Update on Bipolar Disorder: Epidemiology, Etiology, Diagnosis, and Prognosis." Medscape Mental Health, vol. 2, no. 6 (1997). 〈http://www.medscape.com〉.

ORGANIZATIONS

American Psychiatric Association (APA). Office of Public Affairs. 1400 K Street NW, Washington, DC 20005. (202) 682-6119. 〈http://www.psych.org/〉.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754. (800) 950-6264. 〈http://www.nami.org〉.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. 〈http://www.ndmda.org〉.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02, Bethesda, MD 20857. (301) 443-4513. 〈http://www.nimh.nih.gov/〉.

Bipolar disorder

Definition

Bipolar, or manic-depressive, disorder is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania (an elevated or euphoric mood or irritable state) and depression.

Description

In the United States alone, bipolar disorder afflicts an estimated three million people. According to a report by the National Institutes of Mental Health, the disorder costs over $45 billion annually. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised (DSM-IV-TR ), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from unipolar depression (depression without mania, as found in major depressive disorder ). Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia—a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than people with unipolar depression.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. A third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in 12 months—to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. There is significant evidence that correlates bipolar II with genetic causes. Studies have shown that identical twins have an 80% concordance rate (presence of the same disorder). Additionally, studies have demonstrated that the disorder is transmitted to children by autosomal dominant inheritance. This means that either affected parent (father or mother) has a 50% chance of having a child (regardless if the child is male or female) with the disorder.

Further studies concerning the genetic correlations have revealed specific chromosomes (the structures that contain genes) that contain mutated genes. Susceptible genes are located in specific regions of chromosomes 13, 18, and 21. The building blocks of genes, called nucleotides, are normally arranged in a specific order and quantity. If these nucleotides are repeated, a genetic abnormality usually results. Recent evidence suggests that a special type of nucleotide repeat is observed in persons with bipolar II on chromosome 18. However, the presence of this sequence does not worsen the disorder or change the age of onset. It is currently thought that expression of bipolar II involves multiple mutated genes. Further research is ongoing to discover precise mechanisms and to develop genetic markers (gene tags) that would predict which individuals are at higher risk.

Another possible biological cause for bipolar disorder under investigation is the presence of an excessive calcium buildup in the cells. Also, dopamine and other neurochemical transmitters (the chemicals that transmit messages from nerve cell to nerve cell) appear to be implicated in bipolar disorder and these are under intense investigation.

Over half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions (ideas that the person affected is extremely important or has some unrecognized talent or insight).

Demographics

Manic-depression is a common psychological disorder that is difficult to detect. As stated, it is estimated that about three million people in the United States are affected. The disorder is more common among women than men. Women have been observed at increased risk of developing subsequent episodes in the period immediately following childbirth.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the DSM-IV-TR as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization , and do not have psychotic features (no delusions or hallucinations). In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often appear differently in children and adolescents than they appear in adults. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia . Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention-deficit/hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder .

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Bipolar disorder is usually treated with both medical and psychosocial interventions. Psychosocial therapies address both psychological and social issues.

Medical interventions

A combination of mood-stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

MOOD-STABILIZING AGENTS. Mood-stabilizing agents such as lithium, carbamazepine , and valproic acid (valproate) are prescribed to regulate the manic highs and lows of bipolar disorder:

• Lithium (lithium carbonate , Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics (other psychiatric drugs) and/or benzodiazepines (medications that ease tension by slowing down the central nervous system) to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)
• Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug (a drug to treat seizures ) usually prescribed in conjunction with other mood-stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.
• Valproic acid (divalproex sodium , or Depakote; valproate, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate.

ANTIDEPRESSANTS. Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

• SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
• MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet.
• Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

ADJUNCT TREATMENTS. Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

• Long-acting benzodiazepines (medications that ease tension by slowing the central nervous system) such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood-stabilizing agents can take effect. Sedation is a common effect, and clumsiness, light-headedness, and slurred speech are other possible side effects of benzodiazepines.
• Neuroleptics (antipsychotic medications) such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
• ECT, or electroconvulsive therapy , has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Calcium channel blockers (nimodipine, or Nimotop), typically used to treat angina and hypotension (low blood pressure), have been found effective, in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium buildup in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an antipsychotic medication used to control manic episodes in patients who have not responded to typical mood-stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an antipsychotic medication that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

A new potential treatment for bipolar II disorder may be gabapentin , an anticonvulsant that may help treat mania. Recent reports indicate that gabapentin is effective for treating sudden onset bipolar II. Very recent evidence suggests, however, that gabapentin can potentially induce aggressive and disruptive behavior in children treated with this drug for seizures.

rTMS, or repeated transcranial magnetic stimulation is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Psychosocial interventions

Because bipolar disorder is thought to be biological in nature, psychological therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy , such as cognitive-behavioral therapy , can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide . Also, educative counseling is recommended for the patient and family.

In educative counseling, patients (and their families) learn of the high rates of social dysfunction and marital discord associated with this disorder. Patients also learn how their treatment will progress, which factors can affect treatment, and what kind of follow-up after treatment will be implemented. Genetic counseling should be a part of family education programs since this disorder is more prevalent among first-degree relatives of individuals with the disorder.

Social support for individuals with bipolar disorder is also important. Some people with the disorder, as well as their families, may find support groups helpful.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding over-stimulation, getting plenty of rest, regular exercise, and proper diet. Some Chinese herbs may soften mood swings, but care must be taken (and good communication with the physician is essential) when combining herbal therapies with medications. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drugs and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient increases by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse (recurrence) of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revised. Washington, DC: American Psychiatric Press, Inc., 2000.

Maxmen, Jerrold S. and Nicholas G. Ward. "Mood Disorders." In Essential Psychopathology and Its Treatment. 2nd ed. New York: W. W. Norton, 1995.

Tasman, Allan, Jerald Kay MD, and Jeffrey A. Lieberman MD, eds. Psychiatry. 1st edition. Philadelphia: W. B. Saunders, Co., 1997.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Keck, P., S. McElroy, L. Arnold. "Advances in the pathophysiology and treatment of psychiatric disorders: implications for internal medicine." Medical clinics of North America 85, no. 3 (May 2001).

Kilzieh, N., and H. Akiskal. "Rapid-cycling bipolar disorder: an overview of research and clinical experience." Psychiatric Clinics of North America 22, no. 3 (September 1999).

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. <http://www.psych.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. <http://www.nami.org>.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. <http://www.ndmda.org>.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. <http://www.nimh.nih.gov>.

Paula Anne Ford-Martin, M.A. Laith Farid Gulli, M.D. Nicole Mallory, M.S., PA-C