Bipolar disorders are a class of Axis I mood disorders with severe physical, social, and psychological consequences to the patient, the patient s friends and family, and society as a whole. According to the Diagnostic and Statistical Manual of Mental Disorders, 4 th ed. , the lifetime prevalence for the three main types of bipolar disorders (bipolar type I, bipolar type II, and cyclothymic disorder) combined is approximately 1-2% percent, and unlike major depressive disorders, bipolar disorder is equally common among both men and women. The disorder appears to be mostly genetic, with a concordance rate of 40% among monozygotic twins and 15-20% among first degree relatives. As the name implies, patients who suffer from bipolar disorder constantly shift between the two poles of the affective spectrum, that is, from depression to mania (or hypomania). There is no specific pattern that allows clinicians to predict what affective state the patient will present next, nor when he or she will cycle into a manic or depressive state.
The fact that many patients can often last in a state of affective normalcy for years and then suddenly lapse into depression or mania makes this disorder horrendously difficult for the patient, clinician, and anyone involved in the patient s life. The category of bipolar disorder is comprised of three distinct disorders, the first and most common of which is bipolar type I disorder. In this disorder, patients experience episodes of both depression and full-blown mania, normally in a somewhat slow cycle. The depressive episodes are similar to those found in major depression, and if left untreated will usually withdraw in 3 to 4 months. Manic episodes are much more difficult to predict, as they are particularly unique to each individual. Because mania is the defining feature of bipolar disorder (i.
e. the differentiating criteria between bipolar and unipolar depression), some time should b spent analyzing the features of a manic episode. A clinical manic state consists of several essential elements. In particular, patients who are experiencing mania suffer from persistent insomnia and often can go several days with little or no sleep. This insomnia is associated with a sense of euphoria or irritability. People in a manic state have highly mercurial moods, and can shift between euphoria and irritability very quickly (very much like mixed episodes where euphoria and depression can be interchanged quite rapidly).
Other symptoms of mania include a fast, pressured speech, a flight of often unrelated ideas, poor insight, and, in rare cases, frank psychosis, assaultive ness, and suicidal ity. This combination of symptoms can have detrimental consequences, such as wild spending sprees and impulsive sexual promiscuity. Hypomanic episodes are distinguished from manic episodes by both their intensity and their duration. Bipolar type II disorder is when the patient alternates between depression and hypomania.
Hypomanic patients often require little sleep for days on end, take on tremendous, creative projects that they normally would not, and often experience a self-described fluidity of thought. Hypomania generally leads to much less severe consequences than mania, and is often described by patients and a pleasurable experience. It is because of this fact that medication compliance among bipolar patients is only about 30%, despite the high efficacy rate of mood stabilizing medications. The third main type of bipolar disorder is cyclothymic disorder, often called rapid cycling bipolar disorder. In this disorder, which accounts for roughly 15% of all bipolar sufferers, patients experience rapidly fluctuation between mania and depression, sometimes even cycling within hours or days. In order to be classified as a rapid cycler, patients must experience four manic, hypomanic, or depressive episodes within one year.
Those with bipolar disorder are fortunate in that, although the disease is seriously debilitating, it is also one of the most treatable mental disorders. Lithium carbonate has been the drug of choice used to treat bipolar disorder for several decades. About 20 years ago, researchers found that several anticonvulsant drugs used to treat epilepsy, including Depakote, Tegretol, and Neurontin, were very effective in treating bipolar disorders, especially for rapid cycles and in the manic and hypomanic phases of bipolar types I and II. In addition, these new drugs had the benefit of fewer side effects and less toxicity.
Lithium poisoning is a very real threat for those taking lithium carbonate. Frequent blood tests must be done to ensure that the blood level of lithium is within the narrow therapeutic range. Lithium also poses the danger of being used by a depressive (or even manic) bipolar patient in a suicide attempt, much like the old tricyclic and MAO inhibitor antidepressants. In addition to these mood stabilizing drugs, some patients benefit from taking an antidepressant as well. This is because lithium and anticonvulsants are much better at preventing manic episodes than depressive episodes.
One must be careful, however, because antidepressants may trigger manic episodes, especially first onset mania. A new category of bipolar disorder, bipolar type III, is being considered for the DSM-V and that category would include patients who were first diagnosed as depressive and given an antidepressant that precipitated their first manic or hypomanic attack. The addition of mood stabilizing drugs is one of the two ways in which bipolar disorder treatment differs from that of major depression. The other way is that, whereas cognitive and interpersonal therapy can be extremely effective in the treatment of depression, these therapies provide little in the way of relief for bipolar patients. The best that one can hope for in therapy with a bipolar patient is to educate them about their disease, try to increase compliance with medication, and help them to deal with the psychosocial impact that the disease has had and will continue to have on their life. One of the most vital elements in effective treatment of bipolar disorder is to make the patient understand that they have a chronic, organic disease, much like diabetes, and that they will require medication for the rest of their lives.
Though the effects of bipolar disorder are horrific for all involved, there is hope. Treatments continue to be improved, and we can only hope that someday gene therapy and modern medicine will unravel the underlying causes of bipolar disorder and be able to eradicate them. Until then, people with bipolar disorder must do their best to accept their disease and take responsibility for their treatment.