Bipolar disorder: an approach to comprehensive management

Bipolar disorder is characterized by a vulnerability to mood instability which is of more intensity and of longer duration than what would be considered normal. The defining mood pole is the manic one, with elated mood, excessive goal-directed motor drive, overabundant energy, racing thoughts and a reduced need to sleep.

There might be associated psychotic features such as grandiose of even messianic delusions and related hallucinosis. According to the US Diagnostic and Statistical Manual of Mental Disorder (DSM-5) there is a distinction between bipolar type I, with defined by mania (the features are severe and endure for at least 7 days unless treated); and bipolar type II, where the intensity of elevated mood is lower and lasts only 4 days (termed ‘hypomania’). Some people with bipolar have only manic/hypomanic episodes but most also suffer depressive episodes which are often prolonged, severe, disabling and associated with substantial risk of suicide.

There is particular interest currently about the extent to which bipolar exists in the population, and also in the lesser forms of mood perturbation which have been called ‘subthreshold’ bipolar and which makes up the tail of the so-called bipolar spectrum. General prevalence figures for bipolar I are around 1%, bipolar II 2-3% and subthreshold 3-5%. The treatment implications for those people considered subthreshold are not yet clear.

Another area of current interest is the notion of ‘mixed states’. Thus, in mania/hypomania people might also experience some depressive symptoms, whilst in the depressive phase various manic-like symptoms (eg racing thoughts) might be seen. A mixed state ‘specifier’ is allowed in DSM-5 for bipolar mania and depression and also for major depressive disorder. Mixed states are usually difficult to treat and have a poor longitudinal course with more comorbid anxiety and substance use and worse functional recovery. Antidepressants are thought to exacerbate mixed states and should be avoided in this context.

A general approach to treating bipolar is outlined here under three headings, namely ‘anchoring’, ‘early warning signs’ and ‘buffering’. Of course psychoeducation and engagement with the individual and, where feasible, their loved ones, is crucial to successful management.

1) Anchoring: I include here a series of strategies that can help tether the patient’s mood to the line of euthymia. Such strategies include mood and sleep monitoring (using a simple diary system); exquisite attention to the sleep-wake cycle (I encourage sleeping with curtains open, thus waking to natural light); regular exercise; regular healthy meals (a Mediterranean style diet seems the best); and generally as much regulation of activities as is feasible.

2) Early warning signs should be customized by the individual and clearly documented for both depressive and manic poles. Sleep disturbance, irritability and overtalkativeness are common harbingers of mania, whilst withdrawal and loss of interest in things around them, signal depressive relapse. Family members can be very helpful in establishing and monitoring early warning signs, as well as play a role in ensuring appropriate actions are taken, including appropriate help-seeking as well as ameliorating risk, such as removing access to credit cards in incipient mania.

3) By ‘buffering’ I refer to the use of mood stabilizing medications to try to reduce the extremes of mood swings. Lithium carbonate remains a mainstay amongst the mood stabilisers, but requires careful titration to ensure it is in the effective and safe dose range; and can have side effects including thyroid and renal problems that require monitoring. The atypical antipsychotics, notably quetiapine and olanzapine, have gained wide use in bipolar disorder but both have sedative properties (which can be helpful initially but can be extreme for some patients) and also metabolic problems including weight gain and (for olanzapine in particular) diabetes. There are various other atypical antipsychotic options, including asenapine (indicated for manic pole only in Australia), ziprasidone (not PBS listed for bipolar but with some data to support use in mixed states) and risperidone. Lurasidone is a newer antipsychotic which has encouraging short-term data for bipolar depression and which is neither overly sedating nor associated with much metabolic signal: we await long-term data in bipolar and again it is not approved for bipolar in Australia.

A number of anticonvulsants are also used in bipolar, notably sodium valproate (mostly effective for manic pole and associated with weight gain, hair loss, polycystic ovarian syndrome and very high rate of tetatogenicity so should be avoided if at all possible in young women wishing to become pregnant), carbamazepine (which can cause sedation, ataxia and dizziness and which has numerous drug-drug interactions) and lamotrigine (which is particularly helpful in buffering depressive relapse but which requires very slow up-titration to avoid the possibility of skin problems which can prove fatal).

Perhaps the most controversial area of treatment in bipolar is the place of antidepressants. Certainly antidepressants should not be used in the absence of a mood stabilizer in bipolar I, and only with great care in bipolar II; and should be avoided altogether in mixed states. ECT remains a viable alternative in severe bipolar depression and TMS is showing some emerging place in bipolar depression.

Overall, bipolar disorder can be effectively managed if a good treatment alliance is established, sufficient information is provided, and the cardinal rules outlined above, followed. Many patients and family members find self help books, reputable online programs, and individual and group psychotherapy programs to be a hugely effective adjunct to excellent medical care.

1200x1500_Prof David CastleProf David Castle is Chair of Psychiatry at St Vincent’s Health and The University of Melbourne. He has broad clinical and research interests, encompassing schizophrenia and related disorders, bipolar disorder, cannabis abuse, OCD spectrum disorders and disorders of body image.

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