Treatment for Bipolar Disorder

Treatment of Bipolar Disorder. Introduction

Bipolar disorder, or manic-depressive illness (MDI), is a severe and usually persistent mental disorder characterized by mood fluctuation between two opposite extremes.

There are four types of mood episodes in bipolar disorder: mania, hypomania, depression, and mixed episodes. Manic phases with elevated mood, drive and restlessness alternate with severe depressive episodes with sadness, lethargy, and loss of self-esteem. The episodes can appear few times per year, rarely once in few years.

The in-depth diagnosis is the key element in the treatment of bipolar disorder allowing the differentiation from other psychiatric conditions.

Treatment of bipolar disorder, especially in cases with rare episodes, might lead to a full cure without the need of ongoing medication. However, in most of the cases bipolar disorder requires life-long psychiatric treatment with medication and complementary treatment with psychotherapy and sociotherapy.

Our Psychiatric Clinic offers comprehensive diagnostics and treatment for Bipolar Disorder in Dubai.

Types of Bipolar Disorder

The current psychiatric diagnostic manuals, ICD 10 and DSM V, describe two types of bipolar disorder

Bipolar I Disorder

is the classic manic-depressive form of the illness characterized by episodes of mania and depression

Bipolar II Disorder

shows episodes of hypomania and milder depression

Mixed Episode in BD

A mixed episode of bipolar disorder is characterized by the coexistence of manic and depressive symptoms. The patient experiencing a mixed episode might be hyperactive, being unable to sleep or concentrate, feeling at the same time very anxious and depressed. This combination of high energy and low mood increases the risk of suicide.

Mixed bipolar episodes can resemble ADD or ADHD. Although BD II is a full recognized diagnostic entity, it is less reliably diagnosed than Bipolar I. The main reason is that the symptoms are less obvious than those of bipolar disorder I.

Criteria of Manic Episode in Bipolar Disorder I

The most precise criteria for identifying the BP disorder diagnosis have been outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-V).

The periods of abnormally and persistently elevated mood abnormally increased goal-directed activity or energy must last at least 1 week. The symptoms have to be present most of the day, nearly every day. In the phase of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms should be present to a significant degree and represent a noticeable change from usual behaviour.

Additional Symptoms

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in activities that have a high potential for painful consequences
• The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization
• The episode is not attributable to the physiological effects of a substance or to another medical condition.

Criteria of Depressive Episode in Bipolar Disorder I

Five (or more) of the following symptoms have been present during the same 2-week period:

• Depressed mood most of the day, nearly every day
• Markedly diminished interest or pleasure in all, or almost all, activities
• Significant weight loss
• Insomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
• Significant distress or impairment in social, occupational, or other important areas of functioning
• The episode is not attributable to the physiological effects of a substance or another medical condition.

Criteria of Bipolar Disorder II

The diagnostic criteria for Bipolar Disorder II are:

Criteria of Hypomanic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

Additional Symptoms

During the above-described period, three (or more) of the following symptoms have persisted:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity or psychomotor agitation
• Excessive involvement in activities that have a high potential for painful consequences

The episode is:

• associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
• not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
• not attributable to the physiological effects of a drug abuse or a medication

Rapid Cycling in Bipolar Disorder

The course of bipolar disorder with four or more episodes withing 12 months is called rapid cycling. The other criteria for the diagnosis of rapid cycling is the demarcation between the episodes either by period of remission or switch to the opposite polarity. Mood switches in rapid cycling can last from days to months.

Rapid cycling is more commonly observed in women. Furthermore, women tend to have a higher frequency of depressive and mixed episodes compared to men. Interestingly, men often have their initial encounter with bipolar disorder during a manic state, whereas women tend to experience their first episode in a depressive state.

Diagnosis of Bipolar Disorder at CHMC in Dubai

The first step in properly treated bipolar disorder is getting the correct diagnosis. A thorough diagnostic approach is important because bipolar disorder can resemble other serious psychiatric conditions. Diagnoses such as schizophrenia, schizoaffective disorder, ADHD, or depression can be misdiagnosed as BD.

It is important to see an experienced psychiatrist trained in diagnosing and treating bipolar disorder. A psychiatric evaluation includes the patient’s medical and personal history collected from his relatives and friends.

The international medical standard for securing the diagnosis of BD also includes physical examination, a set of laboratory tests, EEG and CT or MRT brain scans. Those tests can help rule out other contributing factors, especially physical illnesses such as metabolic and hormonal diseases and changes on the central nervous system.

Untreated manic or depressive episodes can last for months. Ignoring the problem won`t make it go away. Bipolar disorder tends to worsen if it is not treated. Once the disorder is activated, it typically persists, and untreated first episodes rarely remain dormant.

Treatment for Bipolar Disorder

Untreated bipolar disorder leads usually to more frequent and more severe episodes, than when the illness first appeared. In the worst-case scenario, the condition can evolve in developing the rapid cycling. Also, delays in getting the correct diagnosis and treatment make the patient more likely to experience personal, social, and work-related problems.

People with bipolar disorder need an ongoing treatment due to the chronic nature of the illness. If left untreated, the symptoms of BD worsen, thus early diagnosis and treatment are crucial.

Proper diagnosis and treatment help people with bipolar disorder to control their symptoms. In most cases, treatment helps reduce the frequency and severity of episodes, and in the best-case scenario the illness can be lifelong completely suppressed.

There is no one-size-fits-all approach for treatment of bipolar disorder because the symptoms of bipolar disorder vary in different people. The symptoms diverge widely in their pattern, severity, and frequency. Each type of bipolar disorder mood episode has a unique set of symptoms.

Depending on the phase of Bipolar disorder the patient can be treated, in manic phase and severe depression in one of the psychiatric hospitals in Dubai; patients with hypomania or moderate depression ca be treated the out-patient setting at our clinic in Dubai.

Below we describe and treatment options for different phases of Bipolar Disorder.

Treatment of Mania

The term “mania” describes a state of extreme euphoria, unjustified optimism, and hyperactivity. Both, mania and hypomania are combined with increased speed of thinking, talking as well as increased motor activities. The patient may stay awake for several nights not feeling tired. His sexual drive can be increased, and the inhibition (conscious control of his actions) decreased. His judgment will be always impaired.

Some of the patients will develop delusions and sometimes even hallucinations. Delusions are irrational thoughts; in mania this is usually the delusion of grandeur. The existence of delusional (psychotic) symptoms can be confusing and lead to misdiagnosis of schizophrenia.

Treatment of mania requires hospitalization. In Dubai Al Amal Hospital and The Psychiatric Department of Rashid Hospital can accommodate patients in acute manic state. The hospitalization is needed due to patient’s irrational, sometimes aggressive behaviour. In the hospital the medication can be adjusted instantly depending on the symptoms.

Treatment of Hypomania

A hypomanic episode is different from full mania. Its symptoms are less severe. The person can experience such state as very productive, being optimistic and feeling happy. The hypomania doesn`t include psychotic symptoms (i.e. delusions) and the patient is able to keep some level of control.

Under the condition of a close support of patient’s family and our CHMC Clinic in Dubai can treat hypomanic patients in the outpatient-setting. The patients can stay at home under the supervision of their families visiting more frequently our clinic until their full stabilization.

Treatment of Bipolar Depression

In the past, bipolar depression was not differentiated from regular depression. The results of research suggest that there are significant differences between the two. For example, certain symptoms are more common in bipolar depression than in regular depression. Bipolar depression is more likely to involve irritability, unpredictable mood swings, and feelings of restlessness.

The patients suffering from bipolar depression are more likely to develop psychotic symptoms with delusional thoughts and/or delusions. The depressive phase of bipolar disorder can be also more severe including risk of suicide. In fact, people suffering from bipolar disorder are more likely to attempt suicide than those suffering from regular depression. Furthermore, their suicide attempts tend to be more lethal.

In case of severe depression with suicidal tendencies the patient should be admitted to the psychiatric hospital in Dubai (Al Amal or Rashid Hospital). In less severe cases we can treat the patient in out-patient setting at CHMC in Dubai.

Long Term Treatment of Bipolar Disorder

Bipolar disorder is a complex psychological condition. Diagnosis can be tricky, and treatment is often difficult.

Patient suffering of BP, which is a lifelong and recurrent illness, need long-term treatment to maintain control of symptoms. Therefore, psychiatrists should closely monitor the mental health of their patients and adjust medication accordingly. Psychologists should address their patients’ concerns openly, thereby improving their insight and coping skills.

Since bipolar disorder is a chronic, relapsing illness, it`s important to continue treatment with medication even when the patient feels better. The appearance of two manic episodes makes life-long medication treatment necessary.

However, medication alone is not enough to prevent the relapses. The most effective treatment strategy involves a combination of medication, therapy, lifestyle changes, and social support.

Treatment of Bipolar Disorder with Medication

Some people believe that bipolar disorder can be healed with psychotherapy. The question that arises though is how a person can benefit from psychotherapy (counselling/talk therapy) if they are in a state of confusion, are irrational and possibly aggressive. During a manic episode, patients are often in denial about their condition and have no ability to gain insight. The only way to treat patients during acute mania is to use medication. In most of such cases, the psychiatrist must initially hospitalize the patient. After the patient is discharged from the hospital, the psychiatrist can continue the treatment in an out-patient setting. The treatment providers should not add psychotherapy until the patient gains his psychological stability. At that point, the combination of medication and psychotherapy is the best treatment for individuals with bipolar disorder.

The medication treatment of bipolar disorder is one of the biggest challenges in the field of psychiatry. The patient with bipolar disorder can be compared with someone balancing on a tight rope between mania and depression. Adding too much weight on one side can lead to a collapse. Effective treatment of bipolar disorder requires profound knowledge, experience, and dedication from the psychiatrist and psychologist involved in the process. A large percentage of patients suffering from bipolar disorder need lifelong treatment.

Treatment with medication in different phases of bipolar disorder

As the word “bipolar” suggests, the symptoms of bipolar disorder swing between two opposite emotional and mental states. In one phase, the patient experiences the symptoms of emotional “low,” i.e., depression. On the other side of the spectrum, he develops symptoms of an emotional “high”, i.e. mania or hypomania. The common dynamic for bipolar disorder is that once “unlashed,” the illness tends to persist. Only in rare cases an untreated first episode of bipolar disorder come to a standstill and will not appear again.  

The objective of the treatment in the acute state, regardless mania, or depression, is to suppress the symptoms as fast as possible. The long-term treatment goal is to stabilize the patient between these two extremes, which means keeping his mood and energy on a normal level.

In the acute phase of bipolar disorder, regardless mania or depression, the treatment requires a higher dosage of medication and often a combination of two or three different substances. The goal is to silence quickly the symptoms and to avoid a disaster to patient’s private and professional life.

Classes of medication used in bipolar treatment

The untreated acute phase of bipolar disorder can last for several months. The manic episodes tend to last 3-6 months; the untreated depressive episodes are longer up to one year. The treatment with medication significantly reduces the duration of the episodes. The goal of the treatment between the episodes is to extend stable periods, and in the best-case scenario to keep the patient symptom free lifelong. After two manic phases of bipolar disorder psychiatrists will frame it as a chronic illness, thus the patient needs an ongoing treatment. Untreated bipolar disorder might end in frequently appearing manic episodes, followed by depressive phases. Psychiatrists use the term “rapid cycling” for this type of presentation. Patients who develop rapid cycling are not able to participate in social and professional life. Therefore, fast diagnosing and early beginning of treatment are crucial for the therapeutic success.

Psychiatrists treat bipolar disorder with medication belonging to three main categories: mood stabilizers, antipsychotics, and antidepressants. Treatment of bipolar depression entails a combination of at least two, sometimes three drugs including antidepressants.

Antipsychotics

Antipsychotics such as risperidone, olanzapine, and quetiapine are well established in the treatment of acute manic phase. They are mostly used in combination with a mood stabilizer. Among them only quetiapine has an approval for relapse prevention and is effective even in bipolar depression.

The side effect profiles of atypical antipsychotics such as drowsiness and weight gain must be taken into account.

Sedatives

e.g., Diazepam, Lorazepam, Alprazolam can be used temporarily for agitation, aggressive impulses, and anxiety.

Antidepressants

antidepressants, e.g. escitalopram can be used in treatment of the bipolar depression.

Mood stabilizers

The mood stabilizers are psychiatric medications used for treatment in bipolar disorder. Mood stabilizers can be used alone or in combination with antipsychotics. They can be used throughout all treatment phases, stabilizing mood swings during both manic and depressive episodes. Some mood stabilizers are effective only for treatment of mania, the others for bipolar depression. Few of them protect the patients “on both sides”: from mania and from depression. They stabilize prevailing mood without inducing opposite episodes, which is crucial in preventing relapse even during stable phases. The most frequently applied mood stabilizers are lithium, valproate, lamotrigine and carbamazepine.

Lithium

Lithium became the first effective medication in the field of psychiatry and remains until today the “golden standard” for treatment of bipolar disorder. Psychiatrists use the medication lithium in the long-term treatment of bipolar disorder stabilizing mood and preventing the extreme highs and lows. Lithium protects the patients from both, manic and depressive episodes. In most of the patients lithium does not cause any side effects.

Lithium, history

The therapeutic effect of lithium as a mood stabilizer in treatment of bipolar disorder was discovered 1948 by an Australian psychiatrist John Cade. Cade published his findings in Medical Journal of Australia in a paper “Lithium salts in the treatment of psychotic excitement”. Cade was a pioneer and father of psychiatric research. His discovery, similar to Fleming’s discovery of penicillin, in later years changed in the fate of millions of people. The portrait of Cade and the story of his research is presented in the movie “Troubled minds, the lithium revolution”.

Cade himself did not recognize the importance of his discovery. It was the the Danish psychiatrist Mogens Schou who first introduced lithium into psychiatric treatment. He fought for years to lithium accepted for treatment of bipolar disorder. Schou knew the condition very well as his brother suffered from bipolar disorder. Beginning in 1950ties, Schou and his fellow psychiatrist Poul Baastrup conducted experiments on lithium. In 1970 they published, in The Lancet , the result of a double-blind, placebo-controlled clinical trial (evidence based scientific method) proving beyond doubt the healing effect of lithium and establishing lithium as an effective medication for most people with bipolar disorder, including Schou’s brother (P. C. Baastrup et al. Lancet 296, 326–330; 1970).

Treatment with lithium

Lithium is not metabolized in the body and eliminated through the kidneys. The lithium plasma level variates individually. Therefore, the psychiatrist must adjust the lithium dosage in each patient to achieve the full therapeutic effect. Lithium can be used in the phase prophylaxis protecting the patient from mood swings as well as in acute manic phase. In acute mania, lithium intake can also begin immediately. The necessary tests are then carried out in parallel. In the acute phase of mania, a higher plasma level of lithium.

Diagnostic before starting lithium therapy

When starting lithium treatment as a long-term mood stabilizer, initially more frequent monitoring of lithium plasma level is necessary. To keep the plasma level stable, lithium level controls should be performed every three months in younger individuals and every two months in older persons. Additionally, the lithium level should be measured with every dose change or when other medications are added.

Avoiding side effects of lithium

Despite so many years since its beneficiary effect in bipolar disorder has been discovered, lithium remains still the “golden standard”. In most of the patients lithium does not cause any side effects and is not limiting the life quality of the patients. Apart of that Lithium protects patients not only from manic mood swing but also from depressive episodes.

Lithium is eliminated only through the kidneys and not metabolized in the body. The psychiatrist must adjust the lithium dosage individually in each patient not only to achieve the full therapeutic effect but also to avoid side effects. To allow the patient to “sleep through” any potential side effects, a single evening dose of lithium can be used.

One of the side effects of lithium therapy is tremor. Hand tremor is usually observed at the beginning of treatment and is often caused by rapid dose increase or a high serum lithium level. In the majority of the cases tremor can be avoided by gradual increase of the dosage any by keeping the plasma level low, but still therapeutically effective. It would be incorrect to discontinue lithium immediately upon the first occurrence of tremor.

A small percentage of patients treated with lithium might experience interactions with the thyroid gland. People with a predisposition to hypothyroidism or a family history need a closer monitoring during the first year of treatment.

Anticonvulsants with mood stabilizing effect

For decades, lithium salts were the sole option for relapse prevention in bipolar disorder. However, since the early 90s, additional pharmacological therapies, particularly anticonvulsants, have been developed, expanding treatment options.

Valproic acid

It is a mood stabilizer that helps control symptoms during the manic or mixed phases of bipolar disorder. The positive effect of valproic acid on mood swings was already known in the 1960s but then fall into oblivion. Only in the early 1990s, studies were conducted in the United States, and valproic acid has since been used in the treatment of bipolar disorder.

Valproate works by increasing the level of a neurotransmitter called GABA in the brain, which helps to calm the overactive circuits that contribute to bipolar symptoms.

Valproate is mostly used in treatment of acute manic episodes. Some studies also demonstrate its relapse-preventing effect for both manic and depressive episodes. Valproic acid is only approved for the treatment of manic episodes but can be used off label for the treatment of bipolar depression. Recently published research data suggested that Valproate might be more effective than lithium for treatment of mixed states and rapid cycling in bipolar disorder.

Valproic acid is often used in combination with other mood stabilizers or antipsychotics to reduce the risk of relapse. Valproic acid is generally safe and effective. However, regular monitoring with blood tests and clinical assessments excludes potential side effects.

The most common side effects of valproic acid might be weight gain.

Lamotrigine

Similar to other mood stabilizers, except Lithium, Lamotrigine is a newer generation antiepileptic drug. It is used for years as a mood stabilizer in bipolar I and II, especially in the prophylaxis. It received regulatory approval for the treatment and prevention of bipolar depression in over 30 countries. The recent studies have shown that Lamotrigine is exceptionally effective in the treatment of bipolar I depression.

Lamotrigine inhibits sodium channels in the central nervous system, leading to the release of glutamate. It exerts a positive effect on the corticolimbic network function, which is a resultant of abnormal activities of the circuits in bipolar depression. Further research is needed to confirm its efficacy in treating bipolar II disorder and rapid cycling.

Experience suggests that only a higher dose of 200-400 mg/day effectively prevents relapse. It is necessary to start with a low dose of 25 mg and gradually increase it in weekly intervals. Lamotrigine is usually well tolerated by the patient without major side effects. It can be used also during the pregnancy in women with bipolar disorder. In rare cases Lamotrigine can cause an allergic reaction of the skin. Therefore, the dosage of lamotrigine should be slowly increased over few weeks. Because of this limitation Lamotrigine can’t be used immediately in sufficient dosage in treatment of acute mania.

Carbamazepine

The anticonvulsant effect of Carbamazepine is known for 30 years but its use as a mood stabilizer in bipolar disorder began in the mid-nineties. Carbamazepine works by blocking sodium channels in nerve cells. In 1980, it was discovered in Japan that Carbamazepine also has an anti-manic and relapse-preventing effect in bipolar disorder. Carbamazepine is generally well tolerated creating occasional side effects such as allergic skin reactions. Its main problem is the negative pharmacokinetic interactions with other medication which can lead to a sudden drop of their efficacy. The results of double-blind studies comparing the efficacy of carbamazepine with lithium demonstrated a clear superiority of the latter. For these reasons, carbamazepine is being used less frequently and only as a second-line option for relapse prevention in bipolar disorder.

Choosing the right mood stabilizer in distinct phases of bipolar disorder

Choosing the optimal mood stabilizer is crucial for treating bipolar disorder effectively. It’s important to consider the specific symptoms and needs of the individual patient, as well as the potential side effects and interactions with other medications. The goal is to find a medication that provides effective symptom control without causing additional problems or complications.

The following classification of mood stabilizing medication was proposed by Ketter & Calabrese (adapted by Simhandl):

• Type A: lithium, valproic acid, carbamazepine, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole

• Type B: lithium, lamotrigine, quetiapine

The above classification is helpful to select the proper medication. The key roles for choosing mood stabilizer are:

Type A mood stabilizers work against manic, hypomanic, and mixed episodes, while Type B stabilizers work against depressive and sub-depressive episodes. Apart of that they don’t cause a shift to another phase or to rapid cycling.

Treatment with medication in manic phase

During the manic phase the patient’s irrational behaviour can severely affect his social and economic status. The patient can overspend, buying useless but expensive items, gambling or even donating money which can end in a financial catastrophe, or even in a total impoverishment. In the manic state the person’s “moral brakes” are out of control. This can lead to oversexualized or aggressive behaviour causing irreparable damages to him and his family. Therefore, in most of the cases the patients require hospitalization. The medication used in the acute phase must be administered quickly and in sufficient dosage. The most frequent medication used in the acute phase is a combination of atypical antipsychotics (Quetiapine, Olanzapine, Risperidone) and a mood stabilizer, preferably Valproic acid.

Treatment with medication in depressive phase

In the depressive phase the problems are different. The patient suffers of lack on energy, low mood, sleeplessness, and often develops suicidal ideation. Depressive episodes in bipolar disorder are far more common than mania and have more detrimental effect on patient’s live.

In some patients mood stabilizers may be sufficient to modulate the depressed mood. However, the standard treatment for bipolar depression is the combination of an antidepressant and a mood stabilizer. The mood-stabilizing medication improves mood, social interactions and patient’s level of functioning. The sole use of antidepressants in bipolar depression carries the risk of transitioning into a hypomanic or manic phase. The mood stabilizer of choice in treatment of bipolar depression is lithium because of its anti-suicidal properties,

Only one of the atypical antipsychotics, Quetiapine is worth mentioning, as it can achieve good antidepressant effects at doses of 300-600 mg in bipolar depression.

Prophylaxis in the treatment of bipolar disorder

For the prophylaxis phase, it is recommended to continue prescribing the substances that have successfully stabilized the patient during the maintenance phase. At this stage of the illness, the patient typically feels much better or is even symptom-free, which often leads to a decrease in motivation to take daily medication. It is important to emphasize to the patient that discontinuing the medication causes a significant risk of relapse.

Treatment roles at a glance

• Motivation: Medication needs to be thoroughly discussed with the patient. Many people with bipolar disorder struggle to accept that they need to take medication long-term or even permanently. Comprehensive conversations can help build acceptance and improve compliance, which leads to treatment success.

• Individualized therapy adjustment: It may take some time to find the right medication. Individual symptoms and side effects need to be considered in the medication treatment plan.

• Regular monitoring: The effect of maintenance and prophylactic phases needs to be regularly monitored.

• Acute mania in bipolar disorder: Mood stabilizers such as lithium, valproic acid, carbamazepine, and lamotrigine, as well as atypical antipsychotics such as olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, are used. Combinations of both is usually more effective.

• Acute depression in bipolar disorder: Only combinations of mood stabilizers and antidepressants make sense, and antidepressants should not be used alone in bipolar disorder. Quetiapine is an alternative as monotherapy.

Psychotherapy of Bipolar Disorder

The treatment for bipolar disorder, once primarily managed with medication, evolved to a more complex, comprehensive approach involving a combination of medication and psychotherapeutic and psychosocial interventions. However, psychotherapy alone can’t cure bipolar disorder. For instance, manic patients need medication since they lack insight and act irrationally. The same counts for severe depressive phases. The pharmacological intervention is necessary, especially in suicidal patients. Even during stable periods, relapses are highly probable.

The essential part of the treatment with psychotherapy is therapy during the stable phases of BD.

Psychotherapy approaches in treatment for bipolar disorder

Multiple psychotherapeutic and psychosocial treatment approaches have proven effective. These include family-oriented therapy, cognitive-behavioral therapy, interpersonal and social rhythm therapy, and group psychoeducation. These approaches facilitate quicker recovery from depressive or manic phases, and between the phases reduce the likelihood of experiencing another episode.

One critical therapeutic objective is relapse prevention. This entails educating patients and their families. All involved parties need to understand the nature of the illness. There is an emphasis on ensuring patients consistently take their prescribed medications. Patients also learn improved stress management, early identification of episode warning signs, and the application of suitable coping strategies.  

In the case of depressive episodes, psychotherapy closely resembles the treatment for unipolar depression. The goal is to establish a structured daily routine, motivate increased activity and enjoyable activities, and encourage the social interactions. An important distinction in bipolar disorder is the therapist’s constant vigilance for potential shifts into hypomania or mania.

During acute manic or mixed episodes or severe depressive phases, psychotherapy is scarcely feasible. In these instances, medication is the most effective treatment method. Such phases require often patient’s hospitalization.

While a hypomanic episode also necessitates appropriate medication, hospitalization is usually unnecessary. In such cases, continuing psychotherapy contributes to stabilizing the patient.

Cognitive-Behavioral Therapy (CBT) in bipolar treatment

This therapy has also proven effective in managing bipolar disorder. Therapists and patients collaboratively identify contributing factors to the disorder and specific risk factors for manic and depressive episodes. Therapists work with patients to underscore the importance of consistent medication adherence and encourage balanced daily routines.

In cognitive-behavioral therapy, patients also acquire general psychological skills, such as better expressing their emotions and needs, managing conflicts, and dealing openly with the illness. The therapy also focuses on identifying individual warning signs that may indicate the onset of mania, hypomania, or depression. For example, patients learn to differentiate between ordinary mood fluctuations in response to specific situations, such as irritation from criticism, joy from passing an exam, and emotional states that may serve as early indicators of mania or depression. Additionally, the therapy aims to help patients identify and address thought patterns that may precipitate manic or depressive episodes, such thoughts like “I can do anything” or “My unique abilities are not properly recognized.”

Patients are often encouraging to maintain mood diaries to retrospectively identify mood fluctuations and their triggers. In cases of worsening symptoms, patients and therapists collaborate to establish a crisis plan outlining appropriate responses to early warning signs. These plans typically include multiple steps, such as finding tranquility through relaxation exercises and early bedtime for mild symptoms. For more severe symptoms, patients may be advised to visit the psychiatrist. In cases of pronounced symptoms, patients may be instructed to contact an emergency clinic.

Interpersonal and social rhythm therapy of bipolar disorder

This approach operates on the premise that irregular sleep-wake cycles primarily trigger manic and depressive mood swings. Thus, therapy focuses on establishing regular sleep-wake patterns and relatively consistent daily routines. Simultaneously, patients receive support in resolving individual and interpersonal problems.

Couple and family therapy of bipolar disorder

This therapy is particularly valuable because bipolar disorder often triggers conflicts within families or partnerships. These conflicts can trigger mood swings in patients, raising the likelihood of slipping into mania or depression. Couple and family therapy can prove highly beneficial in managing bipolar disorder and significantly reduce the risk of relapse. Key aspects of this approach include educating families about the disorder and its causes (psychoeducation), assisting in resolving everyday problems (problem-solving training), improving communication skills, and providing guidance for the patient and his family. Over time, the patient and his family gain a better understanding of each other’s viewpoints, potentially leading to mutually satisfactory solutions.

For example, family members may often notice the patient’s changing moods and become concerned while the patient may not perceive their state as problematic. When family members attempt to intervene, suggesting, “You’re behaving differently; you should see a doctor,” the patient may feel patronized. Conversely, family members also bear the burden of the patient’s condition.

Other approaches

Psychoeducational and socio-therapeutic approaches have also proven beneficial for managing bipolar disorder. Patients receive information about the origins of their condition and learn better coping strategies. Additionally, self-help groups can be valuable, enabling patients to share difficulties with others and obtain helpful insights into managing their condition.

Family support in treatment of bipolar patients

Like other serious illnesses, dealing with bipolar disorder is difficult for spouses, family members and friends. Relatives and friends must cope with the person`s serious behavioral problems. Patients in manic state tend to go to wild spending sprees or other irrational behaviours, often breaching the social norms. Patient in the depressive phase goes to the other extreme. He withdraws socially and, in some cases, can get suicidal. Such extreme mood swings can end for the patient in total social and professional disaster. That’s why the involvement of family and friends into the treatment is crucial in the recovery process.

Bipolar Disorder and Pregnancy

The choice of medication in women with bipolar disorder should presume the future pregnancy. Ideally the medication used in treatment of bipolar disorder in young women should ‘t have any teratogenic effects on the baby.

If a woman with bipolar disorder gets pregnant while being on medication, it’s recommendable to continue the medication with low spectrum of side effects on the embryo than stopping its intake. Therefore, discontinuing the medication during pregnancy contains the risk of manic or depressive episode and in consequence the use of higher dosage of medication to control the symptoms.

Bipolar Disorder and Substance Abuse

Another risk factors of bipolar disorder are, and abuse of alcohol or drugs. Studies show that about 50% of people with bipolar disorder have a substance abuse or alcohol problem. Also, people suffering of bipolar disorder tend to use alcohol or drugs, especially during the depressive periods trying to enhance their mood. Conversely, manic episodes’ recklessness leads to substance misuse.

Treatment Prognosis of Bipolar Disorder

Factors suggesting a worse prognosis include such attributes as poor job history, alcohol abuse, psychotic features, depressive features between periods of mania and depression, male sex, poor general health condition, inconsistent psychiatric treatment, or no treatment at all.

Factors correlating with positive outcome of the treatment are short duration of the episodes, late age of onset, few psychotic symptoms, good general health and consistent psychiatric monitoring.

The prerequisite for successful treatment of bipolar disorder without relapses is the consistent psychiatric monitoring by experienced psychiatrist.

Prevalence of Bipolar Disorder

The age of onset of bipolar disorder varies. For both BP I and BP II, the age range is from childhood to about 50 years, with a mean age of about 21 years. Individuals are between 15-19 years when bipolar disorder emerges. The second most frequent age range of onset is 20-24 years. At least half of all cases start before age 25. The lifelong prevalence of bipolar disorder in the United States ranges from 1% to 1.6%. International statistics: lifelong prevalence rate according to the World Health Organization Composite International Diagnostic Interview, determined the aggregate lifetime prevalence for bipolar I disorder: 0.6%. However, the prevalence estimates variate based on the criteria used for diagnosis and the studied population.

Causes of Bipolar Disorder

Bipolar disorder typically emerging near age 25, it impacts various demographics, including genders, races, and socioeconomic groups.

The root causes of BD disorder are multifactorial, with genetics being the strongest. Identical twins have a 50% correlation. However, genetic predisposition does not guarantee the onset of the disorder.

The genetic predisposition can be compared to someone walking on ice; in some cases, the ice may be thin but won’t break if the person moves smoothly. On the other hand, people without genetic predisposition but with triggering physical illnesses and/or stressful life events can develop BD.

Influence of genetics on onset of bipolar disorder

The current research shows that genetic component of bipolar appears to be complex. Multiple genes appear to underlie the disorder. Those studies suggest complex gene interaction and genetic heterogeneity, with different genes being implicated in the onset of bipolar disorder in different families.

Scientists have shown that some people are genetically predisposed to develop bipolar disorder. However, not everyone with an inherited vulnerability develops the illness.

Bipolar tends to run in families. Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness in comparison with the general population.

Genetics are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a patient with bipolar illness does not always develop the disorder; only 50 % of the twins will develop the illness.

Twin studies

Scientists know the role of genetic factors. Twin, family, and adoption studies all show that bipolar disorder has a genetic component. In fact, first-degree relatives of a person with bipolar disorder are approximately 7 times more likely to develop this disorder than the rest of the population.

Environmental Factors

The external factors can set off the onset of bipolar disorder. Psychiatrists call these factors triggers. Triggers can set off new episodes of mania or depression or make existing symptoms worse. Such triggering factors like stressful life events, sleep deprivation, and substance abuse can set off the onset of bipolar disorder in someone with a genetic vulnerability. These events tend to involve drastic or sudden life changes exposing an individual to a high level of emotional tension. Psychiatrists also say that the events could be such as seasonal changes, sleep deprivation, use of drugs, getting married or losing a partner or loved one, losing a job, etc.

Race-related differences in incidence: no racial predilection exists.

Psychological Factors

Psychodynamic factors possess also an important role in bipolar disorder. The psychoanalytical observations suggest that the mania serves as a defence against the feelings of depression. Melanie Klein was one of the major proponents of this formulation. Other psychodynamic based studies found by bipolar patients personality disturbances and higher level of neuroticism.

Physical Factors

Some organic diseases, for example, hyperthyroidism, illnesses of the central nervous system, and intoxication, can lead to similar symptoms as bipolar disorder. The diagnosis of the bipolar disorder includes a profound anamnesis, physical examination, a battery of tests, EEG, as well as a brain scan to exclude an organic cause.

History of Bipolar Disorder

The history of bipolar disorder can be traced back to ancient times. In antiquity, people differentiate between depression and mania. First in the XX century, both conditions appearing in the same person were classified as bipolar disorder.

Ancient Greece

The word “mania” derives from the Greek “μανία” (mania), “madness, frenzy” and that from the verb “μαίνομαι” (mainomai), “to be mad, to rage, to be furious”.

The relationship between melancholy (modern depression) and mania can be traced back to the ancient Greeks. The earliest written descriptions of a relationship between mania and melancholia are attributed to Aretaeus of Cappadocia. Aretaeus was an eclectic medical philosopher who lived in Alexandria somewhere between 30 and 150 AD (Roccatagliata 1986; Akiskal 199^]). Aretaeus is recognized as having authored most of the surviving texts referring to a unified concept of manic-depressive illness, referring melancholia to overweight of black bile and mania as the effect of overproduction of yellow bile. He described the behaviour of people with what we call today bipolar disorder: ” they laughed, played, danced day and night, and sometimes appeared openly in the marketplace, wearing their crowns like winners in the contest of prowess.” There were “dull, boring and sad” at other times.

Another Greek philosopher Soranus of Ephesus (98–177 AD) described mania and melancholia as distinct diseases with separate etiologies. He acknowledged that “many others consider melancholia a form of the disease of mania”.

Ancient Rome

Several etymologies are proposed by the Roman physician Caelius Aurelianus. He introduced into the medical nomenclature the Greek word “ania”, meaning to produce great mental anguish. The other term coined by him was “manos”, meaning relaxed or loose.

Bipolar Disorder history in XIX century

The modern psychiatric concept of bipolar disorder has its origins in the 19th century. In 1854, two French physicians, Jules Baillarger (1809–1890) and Jean-Pierre Falret (1794–1870), independently described the disorder. On January 31, 1854, Jules Baillarger of the French Imperial Academy of Medicine described a biphasic mental illness that causes recurrent oscillations between mania and depression, which he called “folie à double” (“dual-form insanity”). On February 14, 1854, Jean-Pierre Falret  presented the Academy with a description of the same disorder, which he called his “folie circular” (“circular insanity”). He also observed that the disorder was more common among members of the same family, concluding that the disease was hereditary.

Bipolar Disorder history in XX century

In the early 1900s, German psychiatrist Emil Kraepelin (1856–1926) investigated and classified the natural course of patients with untreated bipolar disorder and identified relatively asymptomatic intervals between episodes that allowed patients to function normally.

Kraepelin called the disease “manic-depressive psychosis” and observed that it has less harmful course than dementia praecox (today`s schizophrenia). Despite his diagnostic versatility, he didn`t notice the difference between patients with monopolar depression and those showing both manic and depressive episodes.

The terms “manic–depressive illness” and “bipolar disorder” are relatively new. The term “manic-depressive reaction” appeared in the first diagnostic manual published by the American Psychiatric Association in 1952. A sub-classification of bipolar disorder was first proposed in 1957 by the German psychiatrist Karl Leonhardt. He also introduced the terms bipolar (for patients with mania and depression) and unipolar (for those with depression only).

Bipolar Disorder. FAQ

In the below text, we summarize the facts about bipolar disorder in the form of FAQ:

What is bipolar disorder?

Bipolar disorder is a mental health disorder that causes changes in a person’s mood, energy, and functioning. People with bipolar disorder alternate between intense and conflicting emotional states. These mood swings are classified as manic or hypomanic (abnormally happy or irritable mood) or depressive (sad mood) with periods of neutral mood in-between. The mood swings called mood episodes can last weeks to months. One of such extremes is depressed mood, also called bipolar depression, the other is mania or hypomania.

Under the condition of a proper diagnosis and professional treatment, people with bipolar disorder can be stabilized on the “baseline” mood level, allowing them to live a normal life without limitations.

What are the types of bipolar disorder?

Bipolar disorder is a category that includes three different diagnoses: Bipolar I, Bipolar II, and cyclothymic disorder.

Bipolar I disorder: In this type, periods of manic “ups” last at least a week, or they are severe enough, reaching the level of mania and require medical attention. In this type also the depressive periods are more severe and last longer. The risk of suicide is significantly higher in people with bipolar I disorder than in the general population and even higher than in major depressive disorder.

Bipolar II disorder: This type is characterized by recurring episodes of depression and hypomania. Hypomania is a milder form of mania, with less severe symptoms, but still noticeable changes in mood, and energy levels. People with bipolar II often experience more episodes of depression than hypomania.

Cyclothymic disorder: Cyclothymic disorder, also known as cyclothymia, is a type of mood disorder characterized by cyclic mood swings over a period of at least two years, including periods of hypomania and periods of mild depression. The symptoms are less severe than those of bipolar I and II.

Who can develop bipolar disorder?

Bipolar disorder can affect people of any age, ethnicity, or gender. However, it typically develops in late adolescence or early adulthood and is usually diagnosed in late teens or early twenties. The genetic predisposition doesn’t result by default in the onset of bipolar disorder. Environmental factors such as stress, sleep disturbances, drugs and alcohol can provoke the onset of the illness in at-risk individuals.

Despite high genetic predisposition people can manage to avoid the onset of bipolar disorder by avoiding stressful events, creating proper life-work balance and by avoiding drugs and alcohol. On the other side people with no genetic predisposition, but being exposed to traumatizing life circumstances, physical illnesses or to usage of drugs and alcohol are at high risk to develop the illness.  

How to recognize the normal mood fluctuation from bipolar episodes?

Even people without bipolar disorder have mood swings. However, these mood swings usually last for hours, maximum few days instead of weeks or months. Moreover, the “normal” mood swings are usually triggered by external circumstances, and they are not accompanied by an extreme degree of behavioral changes. During the mood swings people without bipolar are still fully functional. In contrary a person affected by bipolar disorder exhibits during depressive or manic episodes difficulties in daily living and social interactions. Depressive as well as manic episodes can disrupt relationships, creating severe social and professional consequences.

What is rapid cycling?

Rapid cycling is not a type of bipolar disorder, but is a term used to describe the course of illness in people with bipolar I or II disorder. In rapid cycling the mood episodes occur four or more times in a year. Women are more likely to experience rapid cycling than man.

What is the prevalence of bipolar disorder?

The prevalence of bipolar disorder is estimated to be about 2% of the global population. However, the actual prevalence may be higher due to underdiagnosis and lack of access to mental health resources. It is more commonly diagnosed in high-income countries, but the illness can occur anywhere in the world. Prevalence estimates can vary based on the criteria used for diagnosis and the population studied.

Can bipolar disorder be healed?

Bipolar disorder can’t be “cured” in proper sense. Bipolar disorder is a long-term mood disorder. The difference between Bipolar I and II types is the range of severity of the mood swings. Each of bipolar episodes is time-limited, which means people will typically return to their baseline of functioning. The treatment objective is to stabilize the patients on their baseline of functioning without switching to one of the extremes. Keeping the symptoms under control, allows the individual a normal life. Without treatment, bipolar disorder tends to become chronic with more frequent and more severe episodes.

How to diagnose bipolar disorder?

People with bipolar disorder are often misdiagnosed, changing frequently the therapists along with the medication. Sometimes they are luckier and will get an accurate diagnosis and effective treatment. The diagnosis of bipolar disorder can be secured by an experienced psychiatrist. Recognizing bipolar disorder II or cyclothymia is more difficult due to the less pronounced symptoms.

What are the proper treatment of bipolar disorder?

The first step in the treatment of bipolar disorder is the correct diagnosis. In the second step, the psychiatrist should find a balanced medication keeping the symptoms at bay. The most effective treatment is the combination of medication, psychotherapy, and lifestyle changes. The key role is patient’s education about the disorder. Establishing the therapeutic alliance with the psychiatrist and psychologist is the prerequisite of an effective treatment. Early recognition of bipolar warning signs can prevent the escalation of the illness, which makes it easier to control its dynamics.

Famous people who suffered from bipolar disorder

• Ernest Hemingway, American writer
• Graham Greene, English writer
• Jack Irons, drummer, formerly of Red Hot Chili Peppers and Pearl Jam
• Vivien Leigh, actress
• Jack London, American writer
• Edvard Munch, artist
• Edgar Allan Poe, poet and writer
• Jackson Pollock, American artist
• Robert Schumann, German composer
• Kurt Cobain, musician
• Vincent Van Gogh, artist
• Amy Winehouse, musician
• Virginia Woolf, writer

Useful links

International Society for Bipolar Disorders

International Society for Bipolar Disorders (ISBD) is a non-profit organization. The society sponsors research and education for bipolar disorders. ISBD members are mental health professionals as well as patients and their families. ISBD and has branches in fifty countries.