Bipolar Disorders

A manic episode is defined as ≥ 1 week of a persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or a noticeable increase of energy plus ≥ 3 additional symptoms:

Manic patients may be inexhaustibly, excessively, and impulsively involved in various pleasurable, high-risk activities (eg, gambling, dangerous sports, promiscuous sexual activity) without insight into possible harm. Symptoms are so severe that they cannot function in their primary role (occupation, school, housekeeping). Unwise investments, spending sprees, and other personal choices may have irreparable consequences.

Patients in a manic episode may be exuberant and flamboyantly or colorfully dressed and often have an authoritative manner with a rapid, unstoppable flow of speech. Patients may make clang associations (new thoughts that are triggered by word sounds rather than meaning). Easily distracted, patients may constantly shift from one theme or endeavor to another. However, they tend to believe they are in their best mental state.

Lack of insight and an increased capacity for activity often lead to intrusive behavior and can be a dangerous combination. Interpersonal friction results and may cause patients to feel that they are being unjustly treated or persecuted. As a result, patients may become a danger to themselves or to other people. Accelerated mental activity is experienced as racing thoughts by patients and is observed as flights of ideas by the physician.

Manic psychosis is a more extreme manifestation, with psychotic symptoms that may be difficult to distinguish from schizophrenia Schizophrenia Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect... read more . Patients may have extreme grandiose or persecutory delusions (eg, of being Jesus or being pursued by the FBI), occasionally with hallucinations. Activity level increases markedly; patients may race about and scream, swear, or sing. Mood lability increases, often with increasing irritability. Full-blown delirium (delirious mania) may appear, with complete loss of coherent thinking and behavior.

A hypomanic episode is a less extreme variant of mania involving a distinct episode that lasts ≥ 4 days with behavior that is distinctly different from the patient’s usual nondepressed self and that includes ≥ 3 of the additional symptoms listed above under mania.

During the hypomanic period, mood brightens, the need for sleep decreases as energy noticeably increases, and psychomotor activity accelerates. For some patients, hypomanic periods are adaptive because they produce high energy, creativity, confidence, and supernormal social functioning. Many do not wish to leave the pleasurable, euphoric state. Some function quite well, and functioning is not markedly impaired. However, in some patients, hypomania manifests as distractibility, irritability, and labile mood, which the patient and others find less attractive.

A depressive episode has features typical of major depression Major depression (unipolar disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ; the episode must include ≥ 5 of the following during the same 2-week period, and one of them must be depressed mood or loss of interest or pleasure and, with the exception of suicidal thoughts or attempts, all symptoms must be present nearly every day:

Psychotic features are more common in bipolar depression than in unipolar depression.

An episode of mania or hypomania is designated as having mixed features if ≥ 3 depressive symptoms are present for most days of the episode. This condition is often difficult to diagnose and may shade into a continuously cycling state; the prognosis is then worse than that in a pure manic or hypomanic state.

Risk of suicide during mixed episodes is particularly high.

Drugs for bipolar disorder Drug Treatment of Bipolar Disorders Choice of drug treatment for bipolar disorders can be difficult because all drugs have significant adverse effects, drug interactions are common, and no drug is universally effective. Selection... read more include

These drugs are used alone or in combination for all phases of treatment, although at different dosages.

Choice of drug treatment Drug Treatment of Bipolar Disorders Choice of drug treatment for bipolar disorders can be difficult because all drugs have significant adverse effects, drug interactions are common, and no drug is universally effective. Selection... read more for bipolar disorder can be difficult because all drugs have significant adverse effects, drug interactions are common, and no drug is universally effective. Selection should be based on what has previously been effective and well-tolerated in a given patient. If the patient has not previously been given drugs to treat bipolar disorder (or drug history is unknown), choice is based on the patient’s medical history (vis-à-vis the adverse effects of the specific mood stabilizer) and the severity of symptoms.

Specific antidepressants Drug Treatment of Depression Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (eg, selective serotonin reuptake inhibitors [SSRIs]) are sometimes added for severe depression, but their effectiveness is controversial; they are not recommended as sole therapy for depressive episodes. Ketamine infusion has also been shown to be effective in the treatment of severe bipolar depression.

Electroconvulsive therapy Electroconvulsive therapy (ECT) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more (ECT) is sometimes used for depression refractory to treatment and is also effective for mania.

Phototherapy Phototherapy Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more can be useful in treating depressive symptoms of seasonal (with autumn-winter depression and spring-summer hypomania) or nonseasonal bipolar I or bipolar II disorder. It is probably most useful as augmentative therapy.

Transcranial magnetic stimulation, which is sometimes used to treat severe, resistant depression, has also proven effective in bipolar depression.

Enlisting the support of loved ones is crucial to preventing major episodes.

Group therapy is often recommended for patients and their partner; there, they learn about bipolar disorder, its social sequelae, and the central role of mood stabilizers in treatment.

Individual psychotherapy may help patients better cope with problems of daily living and adjust to a new way of identifying themselves.

Patients, particularly those with bipolar II disorder, may not adhere to mood-stabilizer regimens because they believe that these drugs make them less alert and creative. The physician can explain that decreased creativity is relatively uncommon because mood stabilizers usually provide opportunity for a more even performance in interpersonal, scholastic, professional, and artistic pursuits.

Patients should be counseled to avoid stimulant drugs and alcohol, to minimize sleep deprivation, and to recognize early signs of relapse.

If patients tend to be financially extravagant, finances should be turned over to a trusted family member. Patients with a tendency to sexual excesses should be given information about conjugal consequences (eg, divorce) and infectious risks of promiscuity, particularly AIDS.

Support groups (eg, the Depression and Bipolar Support Alliance [DBSA] ) can help patients by providing a forum to share their common experiences and feelings.