Bipolar disorder

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"Manic depression" redirects here. For other uses, see Manic depression
(disambiguation).
Bipolar disorder
Classification and external resources

Many people involved with the arts, such as Vincent van

Gogh, are believed to have suffered from bipolar disorder
ICD-10 F31.
ICD-9 296.80
OMIM 125480 309200
DiseasesDB 7812
MedlinePlus 001528
eMedicine med/229
MeSH D001714

Bipolar disorder or manic–depressive disorder (also referred to as bipolar affective

disorder or manic depression) is a psychiatric diagnosis that describes a category of mood
disorders defined by the presence of one or more episodes of abnormally elevated mood.
These moods are clinically referred to as mania or, if milder, hypomania. Individuals who
experience manic episodes also commonly experience depressive episodes or symptoms,
or mixed episodes in which features of both mania and depression are present at the same
time.[1] These episodes are usually separated by periods of "normal" mood, but in some
individuals, depression and mania may rapidly alternate, known as rapid cycling.
Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions
and hallucinations. The disorder has been subdivided into bipolar I, bipolar II,
cyclothymia, and other types, based on the nature and severity of mood episodes
experienced; the range is often described as the bipolar spectrum.
Data from the United States on lifetime prevalence varies, but indicates a rate of around
1% for Bipolar I, 0.5–1% for Bipolar II or cyclothymia, and 2–5% for subthreshold cases
meeting some, but not all, criteria. The onset of full symptoms generally occurs in late
adolescence or young adulthood. Diagnosis is based on the person's self-reported
experiences, as well as observed behavior. Episodes of abnormality are associated with
distress and disruption, and an elevated risk of suicide, especially during depressive
episodes. In some cases it can be a devastating long-lasting disorder; in others it has also
been associated with creativity, goal striving and positive achievements; there is
significant evidence to suggest that many people with creative talents have also suffered
from some form of bipolar disorder (for more information, see list of people affected by
bipolar disorder). [2]

Genetic factors contribute substantially to the likelihood of developing bipolar disorder,

and environmental factors are also implicated. Bipolar disorder is often treated with
mood stabilizer medications, and sometimes other psychiatric drugs. Psychotherapy also
has a role, often when there has been some recovery of stability. In serious cases in which
there is a risk of harm to oneself or others involuntary commitment may be used; these
cases generally involve severe manic episodes with dangerous behavior or depressive
episodes with suicidal ideation. There are widespread problems with social stigma,
stereotypes and prejudice against individuals with a diagnosis of bipolar disorder.[3]
People with bipolar disorder exhibiting psychotic symptoms can sometimes be
misdiagnosed as having schizophrenia, another serious mental illness.[4]

The current term "bipolar disorder" is of fairly recent origin and refers to the cycling
between high and low episodes (poles). A relationship between mania and melancholia
had long been observed, although the basis of the current conceptualisation can be traced
back to French psychiatrists in the 1850s. The term "manic-depressive illness" or
psychosis was coined by German psychiatrist Emil Kraepelin in the late nineteenth
century, originally referring to all kinds of mood disorder. German psychiatrist Karl
Leonhard split the classification again in 1957, employing the terms unipolar disorder
(major depressive disorder) and bipolar disorder.

Contents
[hide]

• 1 Signs and symptoms

o 1.1 Depressive episode
o 1.2 Manic episode
o 1.3 Hypomanic episode
o 1.4 Mixed affective episode
o 1.5 Associated features
• 2 Causes
o 2.1 Genetic
o 2.2 Childhood precursors
o 2.3 Life events and experiences
 o 2.4 Neural processes
o 2.5 Melatonin activity
o 2.6 Psychological processes
• 3 Diagnosis
o 3.1 Clinical scales
o 3.2 Criteria and subtypes
 3.2.1 Bipolar I
 3.2.2 Bipolar II
 3.2.3 Cyclothymia
 3.2.4 Bipolar NOS
 3.2.5 Rapid cycling
o 3.3 Challenges
• 4 Management
o 4.1 Psychosocial
o 4.2 Medication
• 5 Prognosis
o 5.1 Functioning
o 5.2 Recovery
o 5.3 Recurrence
o 5.4 Morbidity
• 6 Epidemiology
o 6.1 Children
o 6.2 Older age
• 7 History
• 8 Society and culture
o 8.1 Cultural references
• 9 References
o 9.1 Cited texts
• 10 Further reading

• 11 External links

Signs and symptoms

Bipolar disorder is a condition in which people experience abnormally elevated (manic or
hypomanic) and abnormally depressed states for a period of time in a way that interferes
with functioning. Bipolar disorder has been estimated to afflict more than 5 million
Americans—about 1 out of every 45 adults.[5] It is equally prevalent in men and women,
and is found across all cultures and ethnic groups.[6] Not everyone's symptoms are the
same, and there is no blood test to confirm the disorder. Researchers postulate that
bipolar disorder may be caused by chemical imbalances in the brain. Bipolar disorder can
appear to be unipolar depression. Diagnosing bipolar disorder is often difficult, even for
mental health professionals. What distinguishes bipolar disorder from unipolar depression
is that the affected person experiences states of mania and depression. Often bipolar is
inconsistent among patients because some people feel depressed more often than not and
experience little mania whereas others experience predominantly manic symptoms.

Depressive episode

Main article: Major depressive episode

Signs and symptoms of the depressive phase of bipolar disorder include persistent
feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep
and appetite; fatigue and loss of interest in usually enjoyable activities; problems
concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of
interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or
without a known cause); lack of motivation; and morbid suicidal ideation.[7] In severe
cases, the individual may become psychotic, a condition also known as severe bipolar
depression with psychotic features.

Manic episode

Main article: Mania

Mania is generally characterized by a distinct period of an elevated, expansive, or

irritable mood state. People commonly experience an increase in energy and a decreased
need for sleep. A person's speech may be pressured, with thoughts experienced as racing.
Attention span is low and a person in a manic state may be easily distracted. Judgment
may become impaired; sufferers may go on spending sprees or engage in behavior that is
quite abnormal for them. They may indulge in substance abuse, particularly alcohol or
other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may
become aggressive, intolerant or intrusive. People may feel out of control or unstoppable.
People may feel they have been "chosen," are "on a special mission," or other grandiose
or delusional ideas. Sexual drive may increase. At more extreme phases of bipolar I, a
person in a manic state can begin to experience psychosis, or a break with reality, where
thinking is affected along with mood.[8] Many people in a manic state experience severe
anxiety and are very irritable (to the point of rage), while others are euphoric and
grandiose.

In order to be diagnosed with mania according to the Diagnostic and Statistical Manual of
Mental Disorders (commonly referred to as the DSM) a person must experience this state
of elevated or irritable mood, as well as other symptoms, for at least one week, less if
hospitalization is required. According to the National Institute of Mental Health, "A
manic episode is diagnosed if elevated mood occurs with three or more of the other
symptoms most of the day, nearly every day, for 1 week or longer. If the mood is
irritable, four additional symptoms must be present."[9]

Hypomanic episode

Main article: Hypomanic episode

Hypomania is generally a mild to moderate level of mania, characterized by optimism,
pressure of speech and activity, and decreased need for sleep. Some people have
increased creativity while others demonstrate poor judgment and irritability. Others
experience hypersexuality. These persons generally have increased energy and tend to
become more active than usual. They do not, however, have delusions or hallucinations.
Hypomania can be difficult to diagnose because it may masquerade as mere happiness,
though it carries the same risks as mania.

Hypomania may feel good to the person who experiences it. Thus, even when family and
friends learn to recognize the mood swings, the individual often will deny that anything is
wrong.[10] Mind you, what might be called a "hypomanic event", if it not accompanied by
complementary depressive episodes ("downs", etcetera), is not typically deemed as
problematic whatsoever. The "problem" arises when mood changes are uncontrollable
and, more importantly, volatile or "mercurial". If unaccompanied by depressive
counterpart episodes or otherwise general irritability, this behavior is typically called
hyperthymia, or happiness, which is of course perfectly normal. Indeed, the most
elementary definition of bipolar disorder is an often "violent" or "jarring" state of
essentially uncontrollable oscillation between hyperthymia and dysthymia.

Mixed affective episode

Main article: Mixed state (psychiatry)

In the context of bipolar disorder, a mixed state is a condition during which symptoms of
mania and clinical depression occur simultaneously (for example, agitation, anxiety,
aggressiveness or belligerence, confusion, fatigue, impulsiveness, insomnia, irritability,
morbid and/or suicidal ideation, panic, paranoia, persecutory delusions, pressured speech,
racing thoughts, restlessness, and rage).[11]

Associated features

Associated features are clinical phenomena that often accompany the disorder, but are not
part of the diagnostic criteria for the disorder.

Cognitive functioning

Reviews have indicated that most individuals diagnosed with bipolar disorder but who
are euthymic (not experiencing major depression or mania) do not show
neuropsychological deficits on most tests.[12] Meta-analyses have indicated, by averaging
the variable findings of many studies, cognitive deficits on some measures of sustained
attention, executive function and verbal memory, in terms of group averages. On some
tests functioning is superior, however,[12] and sub-threshold mood states and psychiatric
medications may account for some deficits.[13][14] A 2010 study found that "excellent
performance" at school at age 15-16 was associated in males with a higher rate of
developing bipolar disorder, but so was the poorest performance.[15] A 2005 study of
young adult males found that poor performance on visuospatial tasks was associated with
a higher rate of developing bipolar disorder, but so was high performance in arithmetic
reasoning.[16]

Creativity
Main article: Creativity and mental illness

Bipolar disorder has been associated with people involved in the arts but it is an ongoing
question as to whether many creative geniuses had bipolar disorder.[17][18][19] Some studies
have found a significant association between bipolar disorder and creativity, although it is
unclear in which direction the cause lies or whether both conditions are caused by a third
unknown factor; temperament has been hypothesized to be one such factor.[20][21][22]

Goals

A series of authors have described mania or hypomania as being related to a high

motivation to achieve, ambitious goal-setting, and sometimes high achievement. One
study indicated that the pursuit of goals, encouraged by sometimes achieving them, can
become emotionally dysregulated and involve the development of mania.[23] Individuals
may have low self-esteem and difficulties in social adjustment, however, and by
definition there are periods of depression with difficulty in motivation and functioning.[24]

Causes
The causes of bipolar disorder likely vary between individuals. Twin studies have been
limited by relatively small sample sizes but have indicated a substantial genetic
contribution, as well as environmental influence. For Bipolar I, the (probandwise)
concordance rates in modern studies have been consistently put at around 40% in
monozygotic twins (same genes), compared to 0 to 10% in dizygotic twins.[25] A
combination of bipolar I, II and cyclothymia produced concordance rates of 42% vs 11%,
with a relatively lower ratio for bipolar II that likely reflects heterogeneity. The overall
heritability of the bipolar spectrum has been put at 0.71.[26] There is overlap with unipolar
depression and if this is also counted in the co-twin the concordance with bipolar disorder
rises to 67% (Mz) and 19% (Dz).[27] The relatively low concordance between dizygotic
twins brought up together suggests that shared family environmental effects are limited,
although the ability to detect them has been limited by small sample sizes.[26]

Genetic

Genetic studies have suggested many chromosomal regions and candidate genes
appearing to relate to the development of bipolar disorder, but the results are not
consistent and often not replicated.[28] Although the first genetic linkage finding for mania
was in 1969,[29] the linkage studies have been inconsistent.[30] (Genetic linkage studies
may be followed by fine mapping searching for the phenomenon of linkage
disequilibrium with a single gene, then DNA sequencing; using this approach causative
DNA base pair changes have been reported for the genes P2RX7[31] and TPH1[citation needed]).
Recent meta-analyses of linkage studies detected either no significant genome-wide
findings or, using a different methodology, only two genome-wide significant peaks, on
chromosome 6q and on 8q21. Genome-wide association studies have also not brought a
consistent focus — each has identified new loci, while none of the previously identified
loci were replicated.[30] Findings did include a single-nucleotide polymorphism in DGKH;
[32]
a locus in a gene-rich region of high linkage disequilibrium (LD) on chromosome
16p12;[33] and a single-nucleotide polymorphism in MYO5B.[34] A comparison of these
studies, combined with a new study, suggested an association with ANK3 and
CACNA1C, thought to be related to calcium and sodium voltage-gated ion channels.[35]
Diverse findings point strongly to heterogeneity, with different genes being implicated in
different families.[36] Numerous specific studies find various specific links.[37][38][39][40][41]
Advanced paternal age has been linked to a somewhat increased chance of bipolar
disorder in offspring, consistent with a hypothesis of increased new genetic mutations.[42]
A review seeking to identify the more consistent findings suggested several genes related
to serotonin (SLC6A4 and TPH2), dopamine (DRD4 and SLC6A3), glutamate (DAOA
and DTNBP1), and cell growth and/or maintenance pathways (NRG1, DISC1 and
BDNF), although noting a high risk of false positives in the published literature. It was
also suggested that individual genes are likely to have only a small effect and to be
involved in some aspect related to the disorder (and a broad range of "normal" human
behavior) rather than the disorder per se.[43]

Childhood precursors

Some limited long-term studies indicate that children who later receive a diagnosis of
bipolar disorder may show subtle early traits such as subthreshold cyclical mood
abnormalities, full major depressive episodes, and possibly ADHD with mood
fluctuation. There may be hypersensitivity and irritability. There is some disagreement
whether the experiences are necessarily fluctuating or may be chronic.[44] A history of
stimulant use in childhood is found in high numbers of bipolar patients and has been
found to cause an earlier onset of bipolar disorder and a worse clinical course,
independent of attention deficit hyperactivity disorder.[45][46][47]

Life events and experiences

Evidence suggests that environmental factors play a significant role in the development
and course of bipolar disorder, and that individual psychosocial variables may interact
with genetic dispositions.[43] There is fairly consistent evidence from prospective studies
that recent life events and interpersonal relationships contribute to the likelihood of
onsets and recurrences of bipolar mood episodes, as they do for onsets and recurrences of
unipolar depression.[48] There have been repeated findings that between a third and a half
of adults diagnosed with bipolar disorder report traumatic/abusive experiences in
childhood, which is associated on average with earlier onset, a worse course, and more
co-occurring disorders such as PTSD.[49] The total number of reported stressful events in
childhood is higher in those with an adult diagnosis of bipolar spectrum disorder
compared to those without, particularly events stemming from a harsh environment rather
than from the child's own behavior.[50] Early experiences of adversity and conflict are
likely to make subsequent developmental challenges in adolescence more difficult, and
are likely a potentiating factor in those at risk of developing bipolar disorder.[44]

Neural processes

Hyperintensities (bright areas on MRI scans above) are 2.5 times more likely to occur in
bipolar disorder

Researchers hypothesize that abnormalities in the structure and/or function of certain

brain circuits could underlie bipolar and other mood disorders. Some studies have found
anatomical differences in areas such as the amygdala,[51] prefrontal cortex[52] and
hippocampus. However, despite 25 years of research involving more than 7,000 MRI
scans, studies continue to report conflicting findings and there remains considerable
debate over the neuroscientific findings. Two fairly consistent abnormalities found in a
meta-analysis of 98 MRI or CT neuroimaging studies were that groups with bipolar
disorder had lateral ventricles which were on average 17% larger than control groups, and
were 2.5 times more likely to have deep white matter hyperintensities. Given the size of
the meta-analysis, it was concluded that the relatively small number of significant
findings was perhaps surprising, and that there may be genuinely limited structural
change in bipolar disorder, or perhaps heterogeneity has obscured other differences. In
addition, it was noted that averaged associations found at the level of multiple studies
may not exist for an individual.[53]

The "kindling" theory asserts that people who are genetically predisposed toward bipolar
disorder can experience a series of stressful events,[54] each of which lowers the threshold
at which mood changes occur. Eventually, a mood episode can start (and become
recurrent) by itself. There is evidence of hypothalamic-pituitary-adrenal axis (HPA axis)
abnormalities in bipolar disorder due to stress.[55]

Recent research in Japan hypothesizes that dysfunctional mitochondria in the brain may
play a role [56]

Other recent research implicates issues with a sodium ATPase pump,[57] causing cyclical
periods of poor neuron firing (depression) and hyper sensitive neuron firing (mania). This
may only apply for type one, but type two apparently results from a large confluence of
factors.[citation needed]

Melatonin activity

It has been suggested that a hypersensitivity of the melatonin receptors in the eye could
be a reliable indicator of bipolar disorder, in studies called a trait marker, as it is not
dependent on state (mood, time, etc). In small studies, patients diagnosed as bipolar
reliably showed a melatonin-receptor hypersensitivity to light during sleep, causing a
rapid drop in sleeptime melatonin levels compared to controls.[58] Another study showed
that drug-free, recovered, bipolar patients exhibited no hypersensitivity to light.[59] It has
also been shown in humans that valproic acid, a mood stabilizer, increases transcription
of melatonin receptors[60] and decreases eye melatonin-receptor sensitivity in healthy
volunteers[61] while low-dose lithium, another mood stabilizer, in healthy volunteers,
decreases sensitivity to light when sleeping, but doesn't alter melatonin synthesis.[62] The
extent to which melatonin alterations may be a cause or effect of bipolar disorder are not
fully known.

Psychological processes

Psychological studies of bipolar disorder have examined the development of a wide range
of both the core symptoms of psychomotor activation and related clusterings of
depression/anxiety, increased hedonic tone, irritability/aggression and sometimes
psychosis. The existing evidence has been described as patchy in terms of quality but
converging in a consistent manner. The findings suggest that the period leading up to
mania is often characterized by depression and anxiety at first, with isolated sub-clinical
symptoms of mania such as increased energy and racing thoughts. The latter increase and
lead to increased activity levels, the more so if there is disruption in circadian rhythms or
goal attainment events. There is some indication that once mania has begun to develop,
social stressors, including criticism from significant others, can further contribute. There
are also indications that individuals may hold certain beliefs about themselves, their
internal states, and their social world (including striving to meet high standards despite it
causing distress) that may make them vulnerable during changing mood states in the face
of relevant life events. In addition, subtle frontal-temporal and subcortical difficulties in
some individuals, related to planning, emotional regulation and attentional control, may
play a role. Symptoms are often subthreshold and likely continuous with normal
experience. Once (hypo)mania has developed, there is an overall increase in activation
levels and impulsivity. Negative social reactions or advice may be taken less notice of,
and a person may be more caught up in their own thoughts and interpretations, often
along a theme of feeling criticised. There is some suggestion that the mood variation in
bipolar disorder may not be cyclical as often assumed, nor completely random, but results
from a complex interaction between internal and external variables unfolding over time;
there is mixed evidence as to whether relevant life events are found more often in early
than later episodes.[12] Many sufferers report inexplicably varied cyclical patterns,
however.[63]
Diagnosis
Diagnosis is based on the self-reported experiences of an individual as well as
abnormalities in behavior reported by family members, friends or co-workers, followed
by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist
or other clinician in a clinical assessment. There are lists of criteria for someone to be so
diagnosed. These depend on both the presence and duration of certain signs and
symptoms. Assessment is usually done on an outpatient basis; admission to an inpatient
facility is considered if there is a risk to oneself or others. The most widely used criteria
for diagnosing bipolar disorder are from the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-
IV-TR, and the World Health Organization's International Statistical Classification of
Diseases and Related Health Problems, currently the ICD-10. The latter criteria are
typically used in Europe and other regions while the DSM criteria are used in the USA
and other regions, as well as prevailing in research studies.

An initial assessment may include a physical exam by a physician. Although there are no
biological tests which confirm bipolar disorder, tests may be carried out to exclude
medical illnesses such as hypo- or hyperthyroidism, metabolic disturbance, a systemic
infection or chronic disease, and syphilis or HIV infection. An EEG may be used to
exclude epilepsy, and a CT scan of the head to exclude brain lesions. Investigations are
not generally repeated for relapse unless there is a specific medical indication.

There are several other mental disorders which may involve similar symptoms to bipolar
disorder. These include schizophrenia,[64] schizoaffective disorder, drug intoxication, brief
drug-induced psychosis, schizophreniform disorder and borderline personality disorder.
Both borderline personality and bipolar disorder can involve what are referred to as
"mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and
depressed mood which generally last weeks or months. The term in borderline
personality refers to the marked lability and reactivity of mood, known as emotional
dysregulation, due to response to external psychosocial and intrapsychic stressors; these
may arise or subside suddenly and dramatically and last for seconds, minutes, hours or
days. A bipolar depression is generally more pervasive with sleep, appetite disturbance
and nonreactive mood, whereas the mood in dysthymia of borderline personality remains
markedly reactive and sleep disturbance not acute.[65] Some hold that borderline
personality disorder represents a subthreshold form of mood disorder,[66][67] while others
maintain the distinctness, though noting they often coexist.[68][69]

Clinical scales

The Bipolar Spectrum Diagnostic Scale (BSDS)[70] was developed by Ronald Pies, MD
and was later refined and tested by S. Nassir Ghaemi, MD, MPH and colleagues. The
BSDS arose from Pies's experience as a psychopharmacology consultant, where he was
frequently called on to manage cases of "treatment-resistant depression." There are 19
question items and two sections on the English version of the BSDS. The scale was
validated in its original version and demonstrated a high.[71]
Criteria and subtypes

Main article: Current diagnostic criteria for bipolar disorder

There is no clear consensus as to how many types of bipolar sensitivity disorder exist.[72]
In DSM-IV-TR and ICD-10, bipolar disorder is conceptualized as a spectrum of disorders
occurring on a continuum. The DSM-IV-TR lists four types of mood disorders which fit
into the bipolar categories: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS
(Not Otherwise Specified).

Bipolar I

In Bipolar I disorder, an individual has experienced one or more manic episodes with or
without major depressive episodes. For a diagnosis of Bipolar I disorder according to the
DSM-IV-TR, one or more manic or mixed episodes are required. A depressive episode is
not required for the diagnosis of Bipolar I but it frequently occurs.

Bipolar II

Bipolar II disorder is characterized by hypomanic episodes rather than actual manic

episodes, as well as at least one major depressive episode. Patients with a Bipolar II
diagnosis under the DSM IV criteria cannot, by definition, ever have had a manic episode
prior to their diagnosis. However, a Bipolar II diagnosis is not a guarantee that they will
not eventually suffer from such an episode in the future.[citation needed]

Hypomanic episodes do not go to the full extremes of mania (i.e. do not usually cause
severe social or occupational impairment, and without psychosis), and this can make
Bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as
a period of successful high productivity and is reported less frequently than a distressing,
crippling depression. For both Bipolar I and II, there are a number of specifiers that
indicate the presentation and course of the disorder, including "chronic", "rapid cycling",
"catatonic" and "melancholic".

Cyclothymia

Cyclothymia involves a presence or history of hypomanic episodes with periods of

depression that do not meet criteria for major depressive episodes. A diagnosis of
Cyclothymic Disorder requires the presence of numerous hypomanic episodes,
intermingled with depressive episodes that do not meet full criteria for major depressive
episodes. The main idea here is that there is a low-grade cycling of mood which appears
to the observer as a personality trait, but interferes with functioning.

Bipolar NOS

Bipolar Disorder NOS, sometimes called "sub-threshold" Bipolar Disorder, is a "catch-

all" diagnosis that is used to indicate bipolar illness that does not fit into any of the formal
DSM-IV bipolar diagnostic categories (Bipolar I, Bipolar II, or cyclothymia). If an
individual seems to be suffering from bipolar spectrum symptoms (e.g. some manic and
depressive symptoms) but does not meet the criteria for one of the subtypes mentioned
above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise
Specified). Despite not fully meeting one of the formal diagnostic categories, Bipolar
NOS can still significantly impair and adversely affect the quality of life of the patient.

Rapid cycling

Most people who meet criteria for bipolar disorder experience a number of episodes, on
average 0.4 to 0.7 per year, lasting three to six months.[73][74]

Rapid cycling, however, is a coarse specifier that may be applied to any of the above
subtypes. It is defined as having four or more episodes per year and is found in a
significant fraction of individuals with bipolar disorder. The definition of rapid cycling
most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: at
least four major depressive, manic, hypomanic or mixed episodes are required to have
occurred during a 12-month period.[75] There are references that describe very rapid
(ultra-rapid) or extremely rapid[76] (ultra-ultra or ultradian) cycling. One definition of
ultra-ultra rapid cycling is defining distinct shifts in mood within a 24-to-48-hour period.

Challenges

The experiences and behaviors involved in bipolar disorder are often not understood by
individuals or recognized by mental health professionals, so diagnosis may sometimes be
delayed for 10 years or more.[77] That treatment lag is apparently not decreasing, even
though there is now increased public awareness of this mental health condition in popular
magazines and health websites. Despite this increased focus, individuals are still
commonly misdiagnosed.[78] An individual may appear simply depressed when they are
seen by a health professional. This can result in misdiagnosis of Major Depressive
Disorder and harmful treatments. Screening tools such as the Hypomanic Check List
Questionnaire (HCL-32)[79] have been developed to assist the quite often difficult
detection of Bipolar II disorders.

However, there is also a long-standing issue in the research literature as to whether a

categorical classificatory divide between unipolar and bipolar depression is actually
valid, or whether it is more accurate to talk of a continuum involving dimensions of
depression and mania.[80][81]

It has been noted that the bipolar disorder diagnosis is officially characterised in
historical terms such that, technically, anyone with a history of (hypo)mania and
depression has bipolar disorder whatever their current or future functioning and
vulnerability. This has been described as "an ethical and methodological issue", as it
means no one can be considered as being recovered (only "in remission") from bipolar
disorder according to the official criteria. This is considered especially problematic given
that brief hypomanic episodes are widespread among people generally and not
necessarily associated with dysfunction.[12]

Flux is the fundamental nature of bipolar disorder.[82] Individuals with the illness have
continual changes in energy, mood, thought, sleep, and activity. The diagnostic subtypes
of bipolar disorder are thus static descriptions—snapshots, perhaps—of an illness in
continual flux, with a great diversity of symptoms and varying degrees of severity.
Individuals may stay in one subtype, or change into another, over the course of their
illness.[83] The DSM-V, to be published in 2013, will likely include further and more
accurate sub-typing (Akiskal and Ghaemi, 2006).

The diagnosis of bipolar disorder can be complicated by coexisting psychiatric conditions

such as obsessive-compulsive disorder, social phobia, panic disorder, or attention-
deficit/hyperactivity disorder. Substance abuse may predate the appearance of bipolar
symptoms, further complicating the diagnosis. A careful longitudinal analysis of
symptoms and episodes, enriched if possible by discussions with friends and family
members, is crucial to establishing a valid treatment plan where these comorbidities exist.
[84]

The diagnosis of bipolar disorder in children is particularly challenging, and

controversial. Some who show some bipolar symptoms tend to have a rapid-cycling or
mixed-cycling pattern that may not meet DSM-IV criteria.[85] In addition, it can be
difficult to distinguish between age-appropriate restlessness, the fidgeting of children
with ADHD, and the purposeful busy activity of mania.[86] Further complicating the
diagnosis, is that abused or traumatized children can seem to have bipolar disorder when
they are actually reacting to horrors in their lives.[87]

In the elderly, recognition and treatment of bipolar disorder may be complicated by the
presence of dementia or the side effects of medications being taken for other conditions.
[88]
As yet there is very little evidence-based research to guide management of bipolar in
the elderly as opposed to adults in general.

Management
Main article: Treatment of bipolar disorder

There are a number of pharmacological and psychotherapeutic techniques used to treat

Bipolar Disorder. Individuals may use self-help and pursue a personal recovery journey.

Hospitalization may be required especially with the manic episodes present in bipolar I.
This can be voluntary or (if mental health legislation allows and varying state-to-state
regulations in the USA) involuntary (called civil or involuntary commitment). Long-term
inpatient stays are now less common due to deinstitutionalization, although can still
occur.[89] Following (or in lieu of) a hospital admission, support services available can
include drop-in centers, visits from members of a community mental health team or
Assertive Community Treatment team, supported employment and patient-led support
groups, intensive outpatient programs. These are sometimes referred to partial-inpatient
programs.[90]

Psychosocial

Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers,

reducing negative expressed emotion in relationships, recognizing prodromal symptoms
before full-blown recurrence, and, practicing the factors that lead to maintenance of
remission[91] Cognitive behavioural therapy, family-focused therapy, and psychoeducation
have the most evidence for efficacy in regard to relapse prevention, while interpersonal
and social rhythm therapy and cognitive-behavioural therapy appear the most effective in
regard to residual depressive symptoms. Most studies have been based only on bipolar I,
however, and treatment during the acute phase can be a particular challenge.[92] Some
clinicians emphasize the need to talk with individuals experiencing mania, to develop a
therapeutic alliance in support of recovery.[93]

Medication

Sodium valproate is a common mood stabilizer

The mainstay of treatment is a mood stabilizer medication such as lithium carbonate or

lamotrigine.[94][95] Lamotrigine has been found to be best for preventing depressions, while
lithium is the only drug proven to reduce suicide in bipolar patients. These two drugs
comprise several unrelated compounds which have been shown to be effective in
preventing relapses of manic, or in the one case, depressive episodes. The first known
and "gold standard" mood stabilizer is lithium,[96] while almost as widely used is sodium
valproate,[97] also used as an anticonvulsant. Other anticonvulsants used in bipolar
disorder include carbamazepine, reportedly more effective in rapid cycling bipolar
disorder, and lamotrigine, which is the first anticonvulsant shown to be of benefit in
bipolar depression.[98]

Treatment of the agitation in acute manic episodes has often required the use of atypical
antipsychotic medications, such as quetiapine, olanzapine and chlorpromazine. More
recently, olanzapine and quetiapine have been approved as effective monotherapy for the
maintenance of bipolar disorder.[99] A head-to-head randomized control trial in 2005 has
also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.
[100]
The use of antidepressants in bipolar disorder has been debated, with some studies
reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes,
especially if no mood stabiliser is used. However, most mood stabilizers are of limited
effectiveness in depressive episodes. Rapid cycling can be induced or made worse by
antidepressants, unless there is adjunctive treatment with a mood stabilizer.[101][102] One
large-scale study found that depression in bipolar disorder responds no better to an
antidepressant with mood stabilizer than it does to a mood stabilizer alone.[103] Recent
research indicates that triacetyluridine may help improve symptoms of bipolar disorder.
[104]
Clinical studies have shown that Omega 3 fatty acids may have beneficial effects on
bipolar disorder.[105]

Also, topiramate is an anticonvulsant often prescribed as a mood stabilizer. It is an off-

label use when used to treat bipolar disorder. Unfortunately, its usefulness is likely
minimal and side effects, such as significant cognitive impairment, undermine its efficacy
(Kushner, et al. 2006 Bipolar Disorders 8; Chengappa, et al. 2006 J Clin Psych; 6).

When medication causes a reduction in symptoms or complete remission, it is important

for someone with a bipolar disorder to understand they should continue to take the
medicine. This can be complicated, as effective treatment may result in the reduction of
manic symptoms and/or the medicine can be mood blunting or sedative, resulting in the
person feeling they are stifled or that the medicine isn't working. Either way, relapse is
likely to occur if the medicine is discontinued.

Prognosis
For many individuals with bipolar disorder a good prognosis results from good treatment,
which, in turn, results from an accurate diagnosis. Because bipolar disorder can have a
high rate of both under-diagnosis and misdiagnosis[citation needed], it is often difficult for
individuals with the condition to receive timely and competent treatment.

Bipolar disorder can be a severely disabling medical condition. However, many

individuals with bipolar disorder can live full and satisfying lives. Quite often,
medication is needed to enable this. Persons with bipolar disorder may have periods of
normal or near normal functioning between episodes.[106]

Ultimately one's prognosis depends on many factors, several of which are within the
control of the individual. Such factors may include: the right medicines, with the right
dose of each; comprehensive knowledge of the disease and its effects; a positive
relationship with a competent medical doctor and therapist; and good physical health,
which includes exercise, nutrition, and a regulated stress level.

There are obviously other factors that lead to a good prognosis as well, such as being
very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as
having a plan in conjunction with one's doctor for how to manage subtle changes that
might indicate the beginning of a mood swing. Some people find that keeping a log of
their moods can assist them in predicting changes.[107]
Functioning

A recent 20-year prospective study on bipolar I and II found that functioning varied over
time along a spectrum from good to fair to poor. During periods of major depression or
mania (in BPI), functioning was on average poor, with depression being more persistently
associated with disability than mania. Functioning between episodes was on average
good — more or less normal. Subthreshold symptoms were generally still substantially
impairing, however, except for hypomania (below or above threshold) which was
associated with improved functioning.[108]

Another study confirmed the seriousness of the disorder as "the standardized all-cause
mortality ratio among patients with BD is increased approximately two-fold." Bipolar
disorder is currently regarded "as possibly the most costly category of mental disorders in
the United States." Episodes of abnormality are associated with distress and disruption,
and an elevated risk of suicide, especially during depressive episodes.[109]

Recovery

A naturalistic study from first admission for mania or mixed episode (representing the
hospitalized and therefore most severe cases) found that 50% achieved syndromal
recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within
two years. 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved
functional recovery (regaining of prior occupational and residential status). However,
40% went on to experience a new episode of mania or depression within 2 years of
syndromal recovery, and 19% switched phases without recovery.[110] Many therapists treat
individuals with Bipolar I and II by helping them identify the return of symptoms, and
actions that will prevent symptoms from getting worse.[111]

Recurrence

The following behaviors can lead to depressive or manic recurrence:[citation needed]

• Discontinuing or lowering one's dose of medication.

• Being under- or over-medicated. Generally, taking a lower dosage of a mood
stabilizer can lead to relapse into mania. Taking a lower dosage of an
antidepressant may cause the patient to relapse into depression, while higher
doses can cause destabilization into mixed-states or mania.
• An inconsistent sleep schedule can aggravate symptoms. Too much sleep can be
an indicator that depression is returning. It has been found that too little sleep can
lead to mixed states/mania.
• Caffeine can cause destabilization of mood toward irritability, dysphoria, and
mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can
have effects ranging from anti-depressant to mania-inducing.
• Inadequate stress management and poor lifestyle choices. If unmedicated,
excessive stress can cause the individual to relapse. Medication raises the stress
threshold somewhat, but too much stress still causes relapse.
 • Often bipolar individuals are subject to self-medication, the most common drugs
being alcohol, diazepam/sleeping tablets and marijuana. Studies show that
tobacco smoking induces a calming effect on most bipolar people, and a very high
percentage suffering from the prolonged use.[112]

Recurrence can be managed by the sufferer with the help of a close friend, based on the
occurrence of idiosyncratic prodromal events.[113] This theorizes that a close friend could
notice which moods, activities, behaviours, thinking processes, or thoughts typically
occur at the outset of bipolar episodes. They can then take planned steps to slow or
reverse the onset of illness, or take action to prevent the episode from being damaging.[114]

Morbidity

According to an article in Psychiatric Times by McIntyre et al.,

"Mortality studies have documented an increase in all-cause mortality in patients

with BD (Bipolar Disorder). A newly established and rapidly growing database
indicates that mortality due to chronic medical disorders (eg, cardiovascular
disease) is the single largest cause of premature and excess deaths in BD. The
standardized mortality ratio from suicide in BD is estimated to be approximately
18 to 25, further emphasizing the lethality of the disorder."[115]

Most people with bipolar disorder never attempt suicide or complete it. The annual
average suicide rate in males and females with diagnosed bipolar disorder is 0.4%. This is
10 to more than 20 times that of the general population.[116]

Bipolar disorder can cause suicidal ideation that leads to suicidal, especially during
mixed states such as dysphoric mania and agitated depression.[117] Persons suffering from
Bipolar II have high rates of suicide compared to persons suffering from other mental
health conditions, including Major Depression. Major Depressive episodes are part of the
Bipolar II experience, and there is evidence that sufferers of this disorder spend
proportionally much more of their life in the depressive phase of the illness than their
counterparts with Bipolar I Disorder (Akiskal & Kessler, 2007[which?]).

Epidemiology

Disability-adjusted life year for bipolar disorder per 100,000 inhabitants in 2002.
no data less than 180 180–186 186–190 190–195 195–200 200–205
205–210 210–215 215–220 220–225 225–230 230–235
The lifetime prevalence of bipolar disorder type I, which includes at least a lifetime
manic episode, has generally been estimated at 2%.[118] A reanalysis of data from the
National Epidemiological Catchment Area survey in the United States, however,
suggested that 0.8 percent experience a manic episode at least once (the diagnostic
threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for bipolar
II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two
symptoms over a short time-period, an additional 5.1 percent of the population, adding up
to a total of 6.4 percent, were classed as having a bipolar spectrum disorder.[119] A more
recent analysis of data from a second US National Comorbidity Survey found that 1%
met lifetime prevalence criteria for bipolar 1, 1.1% for bipolar II, and 2.4% for
subthreshold symptoms.[120] There are conceptual and methodological limitations and
variations in the findings. Prevalence studies of bipolar disorder are typically carried out
by lay interviewers who follow fully structured/fixed interview schemes; responses to
single items from such interviews may suffer limited validity. In addition, diagnosis and
prevalence rates are dependent on whether a categorical or spectrum approach is used.
Concerns have arisen about the potential for both underdiagnosis and overdiagnosis.[121]

Late adolescence and early adulthood are peak years for the onset of bipolar disorder.[122]
[123]
These are critical periods in a young adult's social and vocational development, and
they can be severely disrupted.

Major depressive disorder and bipolar disorder are currently classified as separate
disorders. Some researchers increasingly view them as part of an overlapping spectrum
that also includes anxiety and psychosis. According to Hagop Akiskal, M.D., at the one
end of the spectrum is bipolar type schizoaffective disorder, and at the other end is
recurrent unipolar depression, with the anxiety disorders present across the spectrum.
Also included in this view is premenstrual dysphoric disorder, postpartum depression,
and postpartum psychosis. This view helps to explain why many people who have the
illness do not have first-degree relatives with clear-cut "bipolar disorder", but who have
family members with a history of these other disorders.

Children

Main article: Bipolar disorder in children

In professional classifications such as the American Psychiatric Association's Diagnostic

and Statistical Manual (DSM) [124] or the World Health Organization's International
Classification of Diseases (ICD)[125] bipolar disorder is classified with adult onset
disorders. However, as far back as the 1920s, Kraepelin [126] showed in a retrospective
study of 900 manic-depressive adults that 0.4% had onset of symptoms before the age of
ten. In a cohort of bipolar disordered adults, Loranger and Levine [127] retrospectively
evaluated 200 adult bipolar patients and found that 0.5% had onset between the ages of
five and nine. In a study of 898 adults with bipolar disorder, Goodwin and Jamison [128]
found that 0.3% had onset before age 10. This literature supported the existence of
childhood onset mania, but also indicated that it may be rare.
This idea was supported by a review of 28 papers by Anthony and Scott[129], which
suggested that childhood bipolar disorder was uncommon. In these papers, only three of
60 cases (5%) of purported childhood bipolar disorder met their criteria for bipolar
disorder. However, Anthony and Scott's criteria differed from those currently in use, so
the applicability of this work to current views of bipolar disorder is uncertain.

Population and community studies using DSM criteria show that about 1% of youth may
have bipolar disorder [130][131]. Studies in clinics using these criteria show that up to 20% of
youth referred to psychiatric clinics have bipolar disorder [132][133][134]. Many of these
children required hospitalization due to the severity of their disorder [135][136]

Because of these diagnostic uncertainties, the validity of an early-onset form of bipolar

disorder had been debated in the late 20th century. However, since that time, systematic
reviews of diagnostic, genetic, neurobiological, treatment and longitudinal research
studies [137][138][139][140] have concluded that this disorder can be validly diagnosed in
children and adolescents. This consensus of the scientific community is also seen in the
appearance of practice parameters for the disorder from the American Academy of Child
and Adolescent Psychiatry[141]

Findings indicate that the number of American [children] and [adolescents] treated for
bipolar disorder increased 40-fold from 1994 to 2003, and continues to increase. The data
suggest that doctors had been more aggressively applying the diagnosis to children, rather
than that the incidence of the disorder has increased. The study calculated the number of
psychiatric visits increased from 20,000 in 1994 to 800,000 in 2003, or 1% of the
[population] under age 20.[142]

The reasons for this increase in diagnosis are unclear. On the one hand, the recent
consensus from the scientific community (see above) will have educated clinicians about
the nature of the disorder and the methods for diagnosis and treatment in children. That,
in turn, should increase the rate of diagnosis. On the other hand, assumptions regarding
behavior, particularly in regard to the differential diagnosis of bipolar disorder, ADHD,
and conduct disorder in children and adolescents, may also play a role.

Another factor is that the "consensus" regarding the diagnosis in the pediatric age group
seems to apply only to the USA. The British National Institute on Health and Clinical
Excellence (NICE) guidelines on bipolar disorder in 2006 [143] specifically described the
broadened criteria used in the USA to diagnose bipolar disorder in children as suitable
"only for research" and "were not convinced that evidence currently exists to support the
everyday clinical use of (pediatric bipolar phenotype) diagnoses" which increase the "risk
that medicines may be used to inappropriately treat a bipolar diathesis that does not
exist."(p526). A 2002 German survey [144] of 251 child and adolescent psychiatrists
(average 15 years clinical experience) found only 8% had ever diagnosed a pre-pubertal
case of bipolar disorder in their careers. A similar survey of 199 child & adolescent
psychiatrists (av 15 years clinical experience) in Australia and New Zealand [145] also
found much lower rates of diagnosis than in the USA and a consensus that bipolar
disorder was overdiagnosed in children and youth in the USA. Concerns about
overdiagnosis in the USA have also been expressed by American child & adolescent
psychiatrists [146][147][148][149] and a series of essays in the book "Bipolar children: Cutting-
edge controversy, insights and research" [150] highlight several controversies and suggest
the science still lacks consensus with regard to bipolar disorder diagnosis in the pediatric
age group.

Although accurately diagnosing all disorders in children is important, for bipolar

disorder, it is critical. On the one hand, the antipsychotic drugs sometimes prescribed for
the treatment of bipolar disorder may increase risk to health including heart problems,
diabetes, liver failure, and death.[151] On the other hand, bipolar disorder is a very
disabling disorder which leads to many impairments in children, including cognitive
impairment[152][153][154], psychiatric hospitalization[133][134][155][156][157], psychosis [133][134][156][157]
and suicide.[158] Thus, physicians, parents and patients need to weight the potential risks
and benefits when treating this disorder.[159]

Older age

There is a relative lack of knowledge about bipolar disorder in late life. There is evidence
that it becomes less prevalent with age but nevertheless accounts for a similar percentage
of psychiatric admissions; that older bipolar patients had first experienced symptoms at a
later age; that later onset of mania is associated with more neurologic impairment; that
substance abuse is considerably less common in older groups; and that there is probably a
greater degree of variation in presentation and course, for instance individuals may
develop new-onset mania associated with vascular changes, or become manic only after
recurrent depressive episodes, or may have been diagnosed with bipolar disorder at an
early age and still meet criteria. There is also some weak evidence that mania is less
intense and there is a higher prevalence of mixed episodes, although there may be a
reduced response to treatment. Overall there are likely more similarities than differences
from younger adults.[160]

History
Main article: History of bipolar disorder

Varying moods and energy levels have been a part of the human experience since time
immemorial. The words "melancholia" (an old word for depression) and "mania" have
their etymologies in Ancient Greek. The word melancholia is derived from melas/μελας,
meaning "black", and chole/χολη, meaning "bile" or "gall",[161] indicative of the term's
origins in pre-Hippocratic humoral theories. Within the humoral theories, mania was
viewed as arising from an excess of yellow bile, or a mixture of black and yellow bile.
The linguistic origins of mania, however, are not so clear-cut. Several etymologies are
proposed by the Roman physician Caelius Aurelianus, including the Greek word ‘ania’,
meaning to produce great mental anguish, and ‘manos’, meaning relaxed or loose, which
would contextually approximate to an excessive relaxing of the mind or soul (Angst and
Marneros 2001). There are at least five other candidates, and part of the confusion
surrounding the exact etymology of the word mania is its varied usage in the pre-
Hippocratic poetry and mythologies (Angst and Marneros 2001).

Society and culture

Cultural references

See also: List of people affected by bipolar disorder

Kay Redfield Jamison is a clinical psychologist and Professor of Psychiatry at the Johns
Hopkins University School of Medicine, who profiled her own bipolar disorder in her
1995 memoir An Unquiet Mind,[162] and argued for a connection between bipolar disorder
and artistic creativity in her 1993 book, Touched with Fire.[163]

Several films portrayed characters with traits suggestive of the diagnosis which have been
the subject of discussion by psychiatrists and film experts alike. The 1993 film Mr. Jones
is a notable example, with Richard Gere playing a person who swings from a manic
episode into a depressive phase and back again, spending time in a psychiatric hospital
and displaying many of the features of the syndrome.[164] Allie Fox, the character played
by Harrison Ford in the 1986 movie The Mosquito Coast, displays some features
including recklessness, grandiosity, increased goal-directed activity and mood lability, as
well as some paranoia.[165]

In the progressive metal band Dream Theater song Six Degrees of Inner Turbulence from
the album of the same name, the lyrics of the first movement, About to Crash, describes a
girl with bipolar disorder.

Tom Wilkinson portrayed a manic depressive lawyer in Tony Gilroy's film Michael
Clayton. Matt Damon portrays a manic depressive whistleblower and FBI informant in
the Steven Soderbergh film The Informant!. In the film, Mark Whitacre, the character
played by Matt Damon, displays bizarre behavior including recklessness and grandiosity.

Next to Normal, a rock musical debuted off-Broadway in 2008 before going on to play in
Arlington, VA and eventually, in April 2009, on Broadway. Its story concerns a mother
who struggles with worsening bipolar disorder and the effect that her illness has on her
family.

In the Australian TV drama Stingers, Gary Sweet played the role of Detective Luke
Harris from season six, portraying him as having bipolar disorder and showing how his
paranoia interfered with his work. As research for the role Sweet visited a psychiatrist to
learn about manic depressive illness. He said that he left the sessions convinced he had
the condition.

TV specials, for example the BBC's The Secret Life of the Manic Depressive,[166] MTV's
True Life: I'm Bipolar, talk shows, and public radio shows, and the greater willingness of
public figures to discuss their own bipolar disorder, have focused on psychiatric
conditions thereby raising public awareness.

On April 7, 2009, the nighttime drama 90210 on the CW network, aired a special episode
where one of the characters, Silver, was diagnosed with bipolar disorder. A PSA aired
after the episode, directing teens and young adults with questions or concerns about mood
disorders to the Child and Adolescent Bipolar Foundation website for information, and to
chat with other teens [167].

Recently Stacey Slater from the popular BBC soap EastEnders has begun to show signs
of bipolar disorder; her mother Jean Slater also has bipolar disorder.[168]

In Law & Order: Special Victims Unit, Elliot Stabler's daughter, Kathleen Stabler, is
diagnosed with bipolar disorder. It is later revealed that his mother, Bernadette, also
suffered the same disorder, but chose not to take medication for it.

http://en.wikipedia.org/wiki/Bipolar_disorder

BIPOLAR I DISORDER

SYNOPSIS
 Summary Pathophysiology

Bipolar I Disorder is one of the most severe forms The pathophysiology of Bipolar I Disorder is
of mental illness and is characterized by recurrent poorly understood. However, a variety of imaging
episodes of mania and (more often) depression. studies suggests the involvement of structural
The condition has a high rate of recurrence and if abnormalities in the amygdala, basal ganglia and
untreated, it has an approximately 15% risk of prefrontal cortex. Research is now showing that
death by suicide. It is the third leading cause of this disorder is associated with abnormal brain
death among people aged 15-24 years, and is the levels of serotonin, norepinephrine, and
6th leading cause of disability (lost years of dopamine.
healthy life) for people aged 15-44 years in the
developed world. Prevalence

Causation Bipolar I Disorder affects both sexes equally in all

age groups and its worldwide prevalence is
Bipolar I Disorder is a life-long disease and runs approximately 3-5%. It can even present in
in families but has a complex mode of preschoolers. There are no significant differences
inheritance. Family, twin and adoption studies among racial groups in the prevalence of this
suggest genetic factors. The concordance rate for disorder.
monozygotic (identical) twins is 43%; whereas it
is only 6% for dizygotic (nonidentical) twins. Course
About half of all patients with Bipolar I Disorder
have one parent who also has a mood disorder, The first episode may occur at any age from
usually Major Depressive Disorder. If one parent childhood to old age. The average age at onset is
has Bipolar I Disorder, the child will have a 25% 21. More than 90% of individuals who have a
chance of developing a mood disorder (about half single Manic Episode go on to have future
of these will have Bipolar I or II Disorder, while episodes. Untreated patients with Bipolar I
the other half will have Major Depressive Disorder typically have 8 to 10 episodes of mania
Disorder). If both parents have Bipolar I Disorder, and depression in their lifetime. Often 5 years or
the child has a 50%-75% chance of developing a more may elapse between the first and second
mood disorder. First-degree biological relatives of episode, but thereafter the episodes become more
individuals with Bipolar I Disorder have elevated frequent and more severe.
rates of Bipolar I Disorder (4%-24%), Bipolar II
Disorder (1%-5%), and Major Depressive There is significant symptom reduction between
Disorder (4%-24%). episodes, but 25% of patients continue to display
mood instability or mild depression. As many as
The finding that the concordance rate for 60% of patients experience chronic interpersonal
monozygotic twins isn't 100% suggests that or occupational difficulties between acute
environmental or psychological factors likely play episodes. Bipolar I Disorder may develop
a role in causation. Certain environmental factors psychotic symptoms. The psychotic symptoms in
(e.g., antidepressant medication, antipsychotic Bipolar I Disorder only occur during severe
medication, electroconvulsive therapy, stimulants) manic, mixed or depressive episodes. In contrast,
or certain illnesses (e.g., multiple sclerosis, brain the psychotic symptoms in Schizophrenia can
tumor, hyperthyroidism) can trigger mania. Mania occur when there is no mania or depression. Poor
can be triggered by giving birth, sleep
 deprivation, and major stressful life events. recovery is more common after psychosis.

Symptoms Manic episodes usually begin abruptly and last for

between 2 weeks and 4-5 months (median
In adults, mania is usually episodic with an duration about 4 months). Depressive episodes
elevation of mood and increased energy and tend to last longer (median length about 6
activity. In children, mania is commonly chronic months), though rarely for more than a year,
rather than episodic, and usually presents in except in the elderly.
mixed states with irritability, anxiety and
depression. In adults and children, during Treatment And Outcome
depression there is lowering of mood and
decreased energy and activity. During a mixed The usual treatment for Bipolar I Disorder is
episode both mania and depression can occur on lifelong therapy with a mood-stabilizer (either
the same day. lithium, carbamazepine, or divalproex / valproic
acid) often in combination with an antipsychotic
Comorbidity medication. Usually treatment results in a
dramatic decrease in suffering, and causes an 8-
Comorbidity is the rule, not the exception, in fold reduction in suicide risk. In mania, an
bipolar disorder. The most common mental antipsychotic medication and/or a benzodiazepine
disorders that co-occur with bipolar disorder are medication is often added to the mood-stabilizer.
anxiety, substance use, and conduct disorders. In depression, quetiapine, olanzapine, or
Disorders of eating, sexual behavior, attention- lamotrigine is often added to the mood-stabilizer.
deficit/hyperactivity, and impulse control, as well Alternatively, in depression, the mood-stabilizer
as autism spectrum disorders and Tourette's can be switched to another mood-stabilizer, or
disorder, co-occur with bipolar disorder. The most two mood-stabilizers can be used together.
common general medical comorbidities are Sometimes, in depression, antidepressant
migraine, thyroid illness, obesity, type II diabetes, medication is used. Since antidepressant
and cardiovascular disease. medication can trigger mania, antidepressant
medication should always be combined with a
Associated Mental Disorders mood-stablizer or antipsychotic medication to
prevent mania.
Bipolar I Disorder is often associated with:
alcoholism, drug addiction, Anorexia Nervosa, Research has shown that the most effective
Bulimia Nervosa, Attention-Deficit Hyperactivity treatment is a combination of supportive
Disorder, Panic Disorder, and Social Phobia. psychotherapy, psychoeducation, and the use of a
mood-stabilizer (often combined with an
Diagnostic Tests antipsychotic medication). There is no research
showing that any form of psychotherapy is an
There are no diagnostic laboratory tests for effective substitute for medication. Likewise there
Bipolar I Disorder. Thus diagnosis is arrived at by is no research showing that any "health food store
using standardized diagnostic criteria to rate the nutritional supplement" (e.g., vitamin, amino
patient's behavior. Onset of mania after age 40 acid) is effective for Bipolar I Disorder.
could signify that the mania may be due to a
general medical condition or substance use. Since a Manic Episode can quickly escalate and
 Current or past hypothyroidism (or even mild destroy a patient's career or reputation, a therapist
thyroid hypofunction) may be associated with must be prepared to hospitalize out-of-control
Rapid Cycling. Hyperthyroidism may precipitate manic patients before they "lose everything".
or worsen mania in individuals with a preexisting Likewise, severely depressed, suicidal bipolar
Mood Disorder. However, hyperthyroidism in patients often require hospitalization to save their
individuals without preexisting Mood Disorder lives.
does not typically cause manic symptoms.
Although the medication therapy for Bipolar I
Differential Diagnosis Disorder usually must be lifelong, the majority of
bipolar patients are noncompliant and stop their
Bipolar I Disorder must be distinguished from: medication after one year. At 4-year follow-up of
bipolar patients, 41% have a good overall
• Mood Disorder Due to a General Medical outcome and 4% have died. Women with bipolar
Condition (e.g., due to multiple sclerosis, disorder lose, on average, 9 years in life
stroke, hypothyroidism, or brain tumor) expectancy, 14 years of lost productivity and 12
• Substance-Induced Mood Disorder (e.g., years of normal health
due to drug abuse, antidepressant
medication, or electroconvulsive therapy) Best Recoveries
• Other Mood Disorders (e.g., Major
Depressive Disorder; Dysthymia; Bipolar The best recoveries are achieved when individuals
II Disorder; Cyclothymic Disorder) with Bipolar I Disorder:
• Psychotic Disorders (e.g., Schizoaffective
Disorder, Schizophrenia, or Delusional 1. Get the correct diagnosis (since many are
Disorder) misdiagnosed as having schizophrenia or
"just borderline personality")
• Since this disorder may be associated with 2. Get effective treatment and faithfully stay
hyperactivity, recklessness, impulsivity, on it for a lifetime (most individuals
and antisocial behavior; the diagnosis of require the combination of a mood-
Bipolar I Disorder must be carefully stabilizer plus an antipsychotic
differentiated from Attention Deficit medication)
Hyperactivity Disorder, Conduct Disorder, 3. Adopt a healthy lifestyle (regular sleep
Antisocial Personality Disorder, and and exercise; no alcohol or drug abuse;
Borderline Personality Disorder low stress)
4. Regularly see a supportive physician who
is knowledgeable about the psychiatric
management of this disorder
5. Learn which symptoms predict the return
of this illness, and what additional
"rescue" medication should be taken
6. Learn to trust the warnings given by
family and friends when they see early
signs of relapse

7. Learn as much as possible about this


TREATMENT
Depressive Episode
Proven (Better Than Placebo) Proven (Better Than Placebo) Treatments
Treatments for Bipolar Depression for Mania
• Lithium and anticonvulsants prevent
suicide [ 1, 2, 3, 4 ]
• Lithium (for prevention of future
depression and suicide)
• Carbamazepine (for prevention of future
depression)
• Lamotrigine (for depression)
• Olanzapine (for suicidal ideation in
bipolar I manic or mixed-episode patients)
• Quetiapine (for depression)
• Fluoxetine (for depression)
• Imipramine (for depression but not
prevention of future depression)
• Tranylcypromine (for depression)
illness from therapists, the Internet, books,
or self-help groups
Manic Episode
• Monotherapy (treatment with just one
medication) for Bipolar Disorder is usually
inadequate, and most patients require a
combination of a mood-stabilizer and
antipsychotic medication
• Lithium (for mania & prevention of future
mania (59% success rate), but increases
risk of diabetes insipidus and
hypothyroidism)
• Carbamazepine (for mania & prevention of
future mania)
• Divalproex sodium (for mania but not
prevention of future mania, but increases
risk of polycystic ovaries and
hyperinsulinemia)
• No difference between in generic valproic
acid and divalproex sodium in
hospitalization
• Olanzapine (for mania but increases risk of
weight gain & diabetes)
• Olanzapine (for suicidal ideation in bipolar
I manic or mixed episodes)
• Quetiapine (for mania)
• Risperidone (for mania)
• Haloperidol (for mania)
• Caution: is the increased use of atypical
antipsychotic medication (e.g., olanzapine)
causing an increased risk of stroke, heart

Promising (But Unproven) Treatments
for Bipolar Depression
• Amitriptyline (with mood-stabilizer)
• Cognitive Therapy (with mood-stabilizer)
• Electroconvulsive Therapy (no placebo-
controlled trials)
• Family Psychoeducation (with mood-
stabilizer)
• Group Psychoeducation (with mood-
stabilizer)
• L-Sulpiride (with mood-stabilizer)
• Moclobemide (with mood-stabilizer)
• Paroxetine (with mood-stabilizer)
• Psychotherapy (with mood-stabilizer)
• Venlafaxine (with mood-stabilizer)
Ineffective Treatments for Depression
• No additional benefit of adding
antidepressant medication to a mood
stabilizer
• Do certain medications for Bipolar
Disorder increase suicidal risk? [ 1, 2, 3,
4, 5, 6, 7 ]
Illness Course for Depression
• Bipolar Disorder and severe Major
Depressive Disorder are episodic, life-
long illnesses that need life-long
prophylactic treatment
• Untreated depressive episodes usually last
11 weeks
• Usually there are multiple episodes of
depression if untreated
• Suicide rate for bipolar patients is 15-22
times the national average
• Suicide rate in first year off lithium
therapy is 20 times the rate when on
disease and hypertension?
Promising (But Unproven) Treatments
for Mania
• Clozapine (but increases risk of diabetes
and agranulocytosis)
• Electroconvulsive Therapy
• Lamotrigine (for prevention of future
rapid-cycling)
• Phenytoin (with neuroleptic for mania}
Ineffective Treatments for Mania
• Gabapentin
• Verapamil
• Topiramate monotherapy or adjunctive
therapy with Topiramate (and has serious
side-effects)
Illness Course for Mania
• Untreated pure manic episodes usually last
6 weeks
• Untreated mixed (manic+depressive)
episodes usually last 17 weeks
• Usually there are multiple episodes of
mania if untreated
• Mania usually returns 5 months after
stopping lithium therapy
• Within 2-4 years of first lifetime
hospitalization for mania, 43% achieved
functional recovery, and 57% switched or
had new illness episodes
 lithium

Description

• American Description
• European Description
• Excellent Depression Animation
• Practice Guideline For The Treatment Of Patients With Bipolar Disorder (Second Edition
2002) - (for description of this disorder read Part B: pages 26-31) American Psychiatric
Association
• A Report on Mental Illnesses in Canada - Public Health Agency of Canada 2002
• A Story of Bipolar Disorder: Does This Sound Like You? - National Institute of Mental
Health
• The Secret Life of Manic Depression: Everything You Need to Know About Bipolar Disorder
- BBC.CO.UK
• Bipolar Disorder - National Institute of Mental Health
• Young And Bipolar - Time Magazine
• What Is Bipolar Disorder? - WHO Guide To Mental Health In Primary Care
• Mood Disorders - U.S. Surgeon General
• Bipolar Disorder - New York Times Heath Guide
• Bipolar Affective Disorder - emedicine.com
• What is Bipolar Disorder? - BipolarHelp.org (excellent videos)
• Keeping Kids Healthy: Bipolar Disorder In Children Google video
• Gay White Male In Search For Hope An extremely honest Google video

Diagnosis

Rating Scales

• Depressive Phase
o 7-Item Hamilton Rating Scale for Depression (HAMD-7)
o Geriatric Depression Scale (Short Form)
o Hospital Anxiety and Depression (HAD) Scale
o Behaviors seen in a major depressive episode of Bipolar Disorder - Internet Mental
Health Quality of Life Scale
• Manic Phase
o Altman Self-Rating Mania Scale and Scale Guidelines
o Clinician-Administered Rating Scale For Mania and Scale Guidelines
 o Young Mania Rating Scale
o Behaviors seen in a manic episode of Bipolar Disorder - Internet Mental Health
Quality of Life Scale
• Mood Chart
o Mood Calendar (requires Adobe Acrobat Reader)
• History Form
o Questionnaire
o Public Forum Survey Results

Web Community

• Bipolar Disorder Support Community - Free internet support community for those living with
Bipolar Disorder

Treatment

• Treatment Synopsis
o Childhood Bipolar Disorder - Massachusetts General Mospital
o Treatment of Bipolar Disorder: A Guide For Patients And Families 2004 - Expert
Consensus Guidelines
• Treatment Guidelines
o Guidelines For The Treatment Of Patients With Bipolar Disorder - Canadian Network
For Mood And Anxiety Treatments: Update 2007
o Bipolar Disorder: National Institute for Health and Clinical Excellence guideline -
National Health Service, UK 2006
o Treatment of Bipolar Disorder Manuals and Algorithms - Texas Medication
Algorithm Project (TMAP) 2005
o Treatment of Bipolar Disorder 2004 - Expert Consensus Guidelines
o Algorithm for the Pharmacotherapy of Depression - Mental Health Connections 2003
o Treatment of Patients With Bipolar Disorder, Second Edition - American Psychiatric
Association 2002
o Psychopharmacologic Treatment Strategies for Depression, Bipolar Disorder, and
Schizophrenia - Annuals of Internal Medicine 2 January 2001
o Management of Bipolar Disorder - American Family Physician 2000
o Treatment of Mood Disorders - U.S. Surgeon General 1999
o Specific Treatments for Episodes of Depression and Mania - U.S. Surgeon General
1999
o Bipolar Disorder: A Summary of Clinical Issues and Treatment Options - CANMAT
1997
Research

• All Recent Research

• Cochrane Reviews (the best evidence-based, standardized reviews available)
• Amitriptyline
• Aripiprazole
• Bupropion
• Carbamazepine, Oxcarbazepine
o depression
o mania
o rapid-cycling
o suicide
• Citalopram
• Clozapine
• Cognitive Behaviorial Therapy
• Complications
• Combination Therapy
• Desipramine
• Diagnosis
• Diagnostic Criteria
• Doxepin
• Drug Therapy
• Drug Therapy: randomized controlled trial
• Drug Therapy: multicenter randomized controlled trial
• Drug Therapy: placebo-controlled randomized controlled trial
• Economic Impact
• Education
• Electroconvulsive Therapy
• Embryology
• Enzymology
• Epidemiology
• Escitalopram
• Etiology
• Family History
• Fluoxetine
• Fluvoxamine
• Genetics
• Haloperidol
• Imipramine
• Immunology
• Lamotrigine
• Lithium
o depression
 o mania
o rapid-cycling
o suicide
• Metabolism
• Microbiology
• Mirtazapine
• Mortality
• Nortriptyline
• Olanzapine
• Paroxetine
• Pathology
• Phenytoin
• Physiology
• Psychoeducation
• Psychology
• Quetiapine
• Quality of Life
• Radiography
• Rehabilitation
• Review
• Risperidone
• Sertraline
• Sulpiride
• Therapy
• Tranylcypromine
• Trazodone
• Valproate, Valproic Acid, Divalproex Sodium
• Venlafaxine
• Virology
• Ziprasidone

Research Review Articles On Treatment

• 2009 Research Review Articles

o A review of valproate in psychiatric practice.
o Lithium: updated human knowledge using an evidence-based approach: Part I:
Clinical efficacy in bipolar disorder.
o Development of evidence-based performance measures for bipolar disorder: overview
of methodology.
o An update on the treatment of bipolar depression.
o An analysis of the efficacy of treatments for bipolar depression.
o Specific aspects of treatment for women with bipolar affliction.
o New understanding of mechanisms of action of bipolar medications.
 o Antidepressant-associated mood elevations in bipolar II disorder compared with
bipolar I disorder and major depressive disorder: a systematic review and meta-
analysis.
o Olanzapine in long-term treatment for bipolar disorder. [Editor: Found that lithium is
the best maintenance treatment for bipolar disorder.]
o Lamotrigine for treatment of bipolar depression: independent meta-analysis and meta-
regression of individual patient data from five randomised trials.
o Pharmacotherapy in bipolar disorders during childhood and adolescence.
o Comparison of carbamazepine and lithium in treatment of bipolar disorder: a
systematic review of randomized controlled trials.
o Gabapentin in the treatment of mental illness: the echo chamber of the case series.
• 2008 Research Review Articles
o Trichotillomania and comorbidity--lamotrigine in a new perspective.
o Effectiveness of antiepileptic drugs for the treatment of bipolar disorder: findings from
a systematic review.
o Polycystic ovary syndrome in women using valproate: a review.
o Effectiveness and safety of adjunctive antidepressants in the treatment of bipolar
depression: a review.
o Adjunctive use of modafinil in bipolar patients: just another stimulant or not?
o Predictors of prophylactic response to lithium.
o Adjunctive psychotherapy for bipolar disorder: state of the evidence.
o The primacy of mania: a reconsideration of mood disorders.
o Pediatric bipolar disorder: recognition in primary care.
o Are antidepressants safe in the treatment of bipolar depression? A critical evaluation
of their potential risk to induce switch into mania or cycle acceleration.
o Treatment of bipolar disorder: a systematic review of available data and clinical
perspectives.
o Current issues: women and bipolar disorder.
o The use of antidepressants in bipolar disorder.
o Reporting outcomes in clinical trials for bipolar disorder: a commentary and
suggestions for change.
o Prevention of bipolar disorder in at-risk children: theoretical assumptions and
empirical foundations..
o Optimizing treatment outcomes in bipolar disorder under ordinary conditions.
o Neuroleptic malignant syndrome associated with atypical antipsychotics in pediatric
patients: a review of published cases.
o Comorbid anxiety in bipolar disorder alters treatment and prognosis.
o Compelling or irrelevant? Using number needed to treat can help decide.
o Advances in the treatment of mania: aripiprazole.
o Complementary and alternative medicine in the treatment of bipolar disorder--a
review of the evidence.
o Omega-3 fatty acids for bipolar disorder.
o Burden of bipolar depression: impact of disorder and medications on quality of life.
o Infant safety with antipsychotic therapy in breast-feeding: a systematic review.
 o Update on the treatment and management of schizophrenia and bipolar disorder.
o Antipsychotic-induced extrapyramidal side effects in bipolar disorder and
schizophrenia: a systematic review.
o Management of comorbid bipolar disorder and alcohol dependence.
o The changing face of bipolar disorder: adolescence to adulthood.
o What is the optimal serum lithium level in the long-term treatment of bipolar
disorder--a review?
o Oxcarbazepine in the maintenance treatment of bipolar disorder.
o Update on pediatric bipolar disorder.
o Olanzapine for the treatment of bipolar disorder in children and adolescents.
o A review of sensitivity and tolerability of antipsychotics in patients with bipolar
disorder or schizophrenia: focus on somnolence.
o Allostatic load in bipolar disorder: implications for pathophysiology and treatment..
o Electroconvulsive therapy in the treatment of mixed states in bipolar disorder.
o Psychosocial interventions for the prevention of relapse in bipolar disorder: systematic
review of controlled trials.
o New understanding of mechanisms of action of bipolar medications.
o Monotherapy versus combined treatment with second-generation antipsychotics in
bipolar disorder.
o An analysis of the efficacy of treatments for bipolar depression.
• 2007 Research Review Articles
o Are there substantial reasons for contraindicating antidepressants in bipolar disorder?
Part III. The alternatives
o Magnitude of effect of lithium in short-term efficacy studies of moderate to severe
manic episode
o Differentiating bipolar disorders from major depressive disorders: treatment
implications
o Treatment of bipolar disorder: the evolving role of atypical antipsychotics
o Valproate and neuroendocrine changes in relation to women treated for epilepsy and
bipolar disorder: a review
o Early intervention in bipolar disorders: opportunities and pitfalls
o Valproate use in children and adolescents with bipolar disorder
o Clinical implications of antipsychotic-induced hyperprolactinemia in patients with
schizophrenia spectrum or bipolar spectrum disorders: recent developments and
current perspectives.
o Pharmacological suicide prevention under special consideration of lithium salts
o The use of antipsychotics in children and adolescents with bipolar disorders
o Family interventions for bipolar disorder.
o Adjunctive treatment of acute mania: a clinical overview.
o Depot antipsychotic medications in bipolar disorder: a review of the literature.
o Recent understandings in geriatric affective disorder.
o Cellular plasticity cascades in the pathophysiology and treatment of bipolar disorder.
o A systematic review and economic model of the clinical effectiveness and cost-
effectiveness of interventions for preventing relapse in people with bipolar disorder
 o A systematic review of placebo response in studies of bipolar mania
o Pharmacological interventions for acute bipolar mania: a systematic review of
randomized placebo-controlled trials
o Atypical antipsychotics in bipolar disorder: systematic review of randomised trials
o Pharmacotherapeutic strategies for pediatric bipolar disorder
o Bipolar II disorder : epidemiology, diagnosis and management
o Are there substantial reasons for contraindicating antidepressants in bipolar disorder?
o Lithium and bipolar disorder--a renaissance?
o Epidemiology, diagnosis and management of mixed mania
o Psychotherapy for bipolar disorder : a systematic review of controlled studies
o Effectiveness of mood stabilizers and antipsychotics in the maintenance phase of
bipolar disorder: a systematic review of randomized controlled trials
o Bipolar disorder: how far are we from a rigorous definition and effective
management?
o Atypical antipsychotics for the treatment of bipolar disorder: more shadows than
lights.
o Medication adherence and the use of long-acting antipsychotics in bipolar disorder
o Disability and its treatment in bipolar disorder patients
o Collaborative management of women with bipolar disorder during pregnancy and
postpartum: pharmacologic considerations
o Acute bipolar mania: a systematic review and meta-analysis of co-therapy vs.
monotherapy
o Thirty years of clinical experience with carbamazepine in the treatment of bipolar
illness: principles and practice
o Spectrum of effectiveness of valproate in neuropsychiatry
• 2006 Research Review Articles
o The safety of medications for the treatment of bipolar disorder during pregnancy and
the puerperium.

Legislation

• Guide to the Mental Health Act (British Columbia)

Stories of Recovery & Personal Experiences

• My Journey Back to Sanity - Susan Dime-Meenan

• Marja's Story - Olanzapine vs. Flupenthixol
• Mark's Story - Recovering from Manic-Depression and Alcoholism
• External Links
o Margaret Trudeau says quitting marijuana helped - Former Prime Minister's wife tells
of her recovery from Bipolar Disorder
 o Coping with a Major Mental Illness - Robert Lundin
o The Legal Guardian Angel (A Story of the Struggles and Success of a Bipolar and His
Wife) - Morgan Claire
o Medication - the Foundation of Recovery - Edward G. Francell, Jr. (from Treatment
Advocacy Center)
o Personal Story Of A Psychiatrist With Bipolar Disorder - Mental Health
Infosource/li>

Famous Women With Bipolar Disorder

Dr. Kay Redfield Jamison, Professor of Psychiatry,

mental health advocate, author

• Patty Duke, actress

• Carrie Fisher, actress
• Connie Francis, actress, musician
• Linda Hamilton, actress
• Vivien Leigh, actress

Famous Men With Bipolar Disorder

 Kurt Cobain, musician,
leader of the band Nirvana

• Dick Cavett, writer, TV personality

• Vincent Van Gogh, artist
• Charley Pride, musician
• Jean-Claude Van Damme, actor
• Jonathan Winters, comedian, actor

Booklets

• External Links
o Bipolar Disorder (Manic Depression) (Revised 1999) - APA
o Bipolar Disorder - Decade of the Brain - NIMH
o Bipolar Disorder Research at the NIMH
o Child and Adolescent Bipolar Disorder: An Update from the NIMH
o Going to Extremes: Manic-Depressive Illness - NIMH

Medical

• External Links (Introductory)

o 3-D Brain Anatomy - Public Broadcasting System (pbs.org)
o The Human Brain - The Virtual Body
o Brain Tours: Where Are Mental Health Problems Located? - PsychEducation.org
o Is Your Brain Really Necessary? - Dr. Enid Reed
• External Links (Advanced)
o Neuroscience Tutorial - Washington University School of Medicine
o Digital Anatomist: Interactive Brain Atlas - University of Washington
Inspiration

• External Links
o Friendship An Essential Ingredient For Recovery - Terri McPherson
(WiseHearts.com)
o I Am Not Gone (Overcoming Grief) - Terri McPherson (WiseHearts.com)
o Imagine (Overcoming Hatred) - Terri McPherson (WiseHearts.com)

o You Are A Miracle (Overcoming Hopelessness) - Terri McPherson (WiseHearts.com)

General Articles

• Highlights of the First International Conference on Bipolar Disorder (June 23-24, 1994)
• External Links
o The Burden of Bipolar Illness - Mental Health Infosource
o Cognitive Impairment - Why Some People With Schizophrenia And Manic-
Depressive Illness Cannot Think Clearly - Treatment Advocacy Center
o Collaborative Care for Patients With Bipolar Disorder - Mental Health Infosource
o Is There a Biochemical Test That Diagnoses Bipolar Disorder? - Scientific American:
Ask the Experts
o Personality Disorder Worsens Bipolar Disorder - Mental Health Infosource
o Psychosocial Treatments in Bipolar Disorder - Mental Health Infosource
o Rapid-Loading Divalproex Shown Safe, Effective in Double-Blind, Multicenter Trial -
Mental Health Infosource
o Schizophrenia and Manic-Depressive Disorder Are Diseases of the Brain - Treatment
Advocacy Center
o Substance Use, Bipolar Disorder and Suicide - Mental Health Infosource
o Treatment of Bipolar Disorder During Pregnancy - Mental Health Infosource
• Journal Abstracts
o Neuroleptic exposure in bipolar outpatients in a research setting - Compr Psychiatry
2000 (Editor: found 64% of manic patients needed antipsychotic medication)

Articles on Lithium

• (Editor: Lithium is licenced for the treatment of manic episodes associated with bipolar
disorder, and for maintenance therapy to prevent recurrences of mania or depression in
bipolar disorder.)
• External Links
o Antisuicidal Effects of Lithium - McLean Hospital
o Lithium - Proving Its Mettle For 50 Years - JAMA
o Lithium Toxicity - WHO Guide To Mental Health In Primary Care
 • Journal Abstracts
o Lithium for maintenance treatment of mood disorders - Cochrane Review 2001
(Editor: reviewed all research and concluded that lithium is an effective maintenance
treatment for bipolar disorder)
o Treating the suicidal patient with bipolar disorder. Reducing suicide risk with lithium.
- Ann N Y Acad Sci 2001
o Mood stabilizers during breastfeeding: a review. - J Clin Psychiatry 2000
o Does lithium treatment still work? Evidence of stable responses over three decades. -
Arch Gen Psychiatry 2000
o Drug-induced diabetes insipidus: incidence, prevention and management. - Drug Saf
1999
o Avoidance of lithium intoxication - Pharmacopsychiatry 1999
o Lithium-induced subclinical hypothyroidism - J Clin Psychiatry 1999
o Mood stabilizer combinations: a review of safety and efficacy. - Am J Psychiatry
o Irreversible lithium neurotoxicity: an overview. - Clin Neuropharmacol 1997
o Forty years of lithium treatment - Arch Gen Psychiatry 1997
o P . 29, 1996

o Trapped Between Law and Madness - Insight Magazine, Sept. 14, 1998
o Uncivil Liberties - Vancouver Sun, Jul. 22, 1993
o Victimization: One of the Consequences of Failure to Treat - Treatment Advocacy
Center
o We Need to Ask Again: Why Do Severely Mentally Ill Go Untreated? - Boston Globe,
Aug. 1, 1998

Articles on Deinstitutionalization

• External Links
o Deinstitutionalization Hasn't Worked - The Washington Post, July 9, 1999
o The Devil in Deinstitutionalizing - Insight Magazine, Sept. 14, 1998
o Why Deinstitutionalization Turned Deadly - Wall Street Journal, Aug. 4, 1998

Articles on Violence

• External Links
o Approximately 1,000 Homicides per Year in the United States are Committed by
Individuals With Severe Mental Illnesses - where Does This Number Come From? -
Treatment Advocacy Center
o Homelessness, Incarceration, Episodes of Violence: Way of Life for Almost Half of
 Americans with Untreated Severe Mental Illness - Treatment Advocacy Center
o Stigma and Violence - Treatment Advocacy Center
o Violence and Untreated Severe Mental Illness - Treatment Advocacy Center
o Violence: Unfortunate and All too Often Tragic Side-Effect of Untreated Severe
Mental Illness - Treatment Advocacy Center

Articles on Medication Causing Weight Gain

• External Links
o Fighting the Weight Gain of Psychiatric Drugs - The Bipolar Child Newsletter 2002
(Editor: found Axid [nizatidine] ineffective for weight loss in bipolar children, but
exercise and low-sugar diet helped)
• Journal Abstracts
o Correlates of overweight and obesity in 644 patients with bipolar disorder - J Clin
Psychiatry 2002 (Editor: found 58% of patients with bipolar disorder were
overweight, 21% were obese, and 5% were extremely obese; this obesity increased
risk for hypertension and arthitis)
o Prevalence of overweight and obesity in bipolar patients - J Clin Psychiatry 2000
(Editor: found obesity was clearly related to the administration of antipsychotic drugs)
o Lithium-induced changes in the body mass index - Acta Psychiatr Scand 1989 (Editor:
over 4.7 years of therapy, found lithium did not increase obesity [body mass index])
o Prospective studies on a lithium cohort. 3. Tremor, weight gain, diarrhea,
psychological complaints. - Acta Psychiatr Scand 1988 (Editor: over 7 years of
therapy, found lithium caused 4 kg. weight gain, and weight gain was related to use of
antidepressant drugs)
o Does long-term lithium treatment induce diabetes mellitus? - Neuropsychobiology
1987 (Editor: over 6 years of therapy, found lithium did not increase risk of diabetes
mellitus)

Internet Links to Mood Disorders Sites

Internet Mental Health © 1995-2005 Phillip W. Long, M.D.

http://www.mentalhealth.com/dis/p20-md02.html

hat are the risk factors and causes of bipolar disorder?

Genetic or hereditary factors contribute to the risk of bipolar disorder. Studies have
demonstrated that the prevalence of bipolar disorder is higher among the parents of
bipolar patients. However, hereditary factors are not the only cause of bipolar disorder.

Studies of identical twins suggest that both genes and other factors play a role in the
cause of bipolar disorder. Identical twins share all the same genes. If bipolar disorder
were caused entirely by genes, then the identical twin of a patient with the illness would
always develop the illness, which is not the case. However, if one twin has bipolar
disorder, the other twin is more likely to develop the illness. There is a slightly greater
risk of developing the disease among siblings as well.

Other than genetic factors, there are no other known risk factors for bipolar disorder.
Lack of sleep may predispose individual patients to a recurrence of symptoms.
Psychological and hormonal factors are suspected of playing a role as well. Some
medications and illnesses cause symptoms that mimic bipolar disorder. It is important for
these to be ruled out before a diagnosis of bipolar disorder is made.

What are the treatments and drugs used to treat bipolar

disorder?

Bipolar disorder treatment includes medication and non-drug therapy. The good news is
that most patients respond to treatment and are able to control their illness.

Psychotherapy helps patients cope with the cyclical nature of the disease and can lead to
better compliance with bipolar disorder medication. In addition to psychotherapy, some
doctors prescribe bright-light therapy as a bipolar disorder treatment. In a recent study,
this treatment was found to help with bouts of winter depression experienced by many
bipolar disorder patients. Bipolar disorder patients experience seasonal affective disorder-
an illness that causes depression during winter months.

Bipolar disorder medications are used two ways. The first way is to control symptoms
that are out-of-control and need immediate attention. These medications are known as
acute phase medications. They are used to treat severe depression or suicidal behavior
during depressive episodes and they help control dangerous, psychotic behavior that
accompanies some manic episodes. First line medications for the acute phase of bipolar
disorder include lithium, valproate, carbamazepine, lamotrigine, and olanzapine. The
medications function to stabilize mood and are also known as "mood stabilizers."

The second way bipolar disorder medication is used is to prevent future episodes of
mania or depression. When used for this purpose, these medications are known as chronic
phase or preventative medications. The top three medications for this purpose are lithium,
valproate, and carbamazepine. These are often the same medications that are given during
acute or severe episodes of bipolar disorder, but they are given in smaller doses. Bipolar
disorder in children and adolescents is generally treated with lithium, but valproate and
carbamazepine also are used.

Some patients take antidepressants, but antidepressant medications should be used with
caution among bipolar patients. Several antidepressant medications, and in particular
SSRIs--such as Prozac, Zoloft or Paxil, have been shown to cause manic episodes in
some bipolar disorder patients.
With proper medication and treatment, patients with bipolar disorder can lead normal,
productive lives.

Bipolar disorder symptoms are cyclic. Patient's cycle into manic episodes, then return to
normal before cycling into a depressive episode. This cycling makes it possible to divide
bipolar disorder symptoms into two different types: depressive symptoms and manic
symptoms.

A patient does not need to have all the following symptoms to be considered bipolar, but
should demonstrate a number of the manic symptoms.
Bipolar Depression Symptom List - Depressive Symptoms

• Low self-esteem or self-loathing

• Fatigue, lethargy, or feeling slowed down
• Increased need for sleep or the ability to sleep as many as 18 hours without
feeling refreshed
• Social withdrawal
• Loss of emotional control; cries easily or for no reason
• Headaches, backaches or digestive problems
• Unable to concentrate, make decisions, or remember details
• Suicidal thoughts
• Inability to feel pleasure or happiness

Bipolar Depression Symptom List - Manic Symptoms

• Delusions of grandeur or inflated self-esteem

• Increased performance of goal directed activities
• Alcohol or drug abuse
• Irritable or angry
• Irresponsible spending
• Engaged in dangerous, unprotected sexual activity, or other dangerous acts
• Hyperactive
• Flight of ideas, racing thoughts
• No need or little need for sleep
• Rapid, pressurize speech that others can't understand

How is bipolar disorder diagnosed or evaluated?

At present, there is no definitive diagnostic test that leads to a bipolar disorder diagnosis.
Bipolar disorder is not visible on brain scans or discovered through blood tests.

Bipolar disorder diagnosis is made on the basis of symptoms, the course of illness (manic
versus depressive states), and family history. In order to be diagnosed with bipolar
disorder, a patient must have experienced at least one manic episode.

Reports of symptoms from family and friends appear to help with diagnosis-even more so
than reports from the patient. In a recent study of bipolar disorder in child patients, a
parental report of bipolar disorder symptoms was more useful in making a bipolar
disorder diagnosis than a report on symptoms from teachers or even the child in question.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV), a patient with a bipolar disorder could be diagnosed with one of four types of
bipolar disorder: bipolar I disorder, bipolar II disorder, cyclothymia, and bipolar disorder
not otherwise specified. These bipolar disorder diagnosis are very similar in nature. A
patient is classified with one of these types of bipolar disorder based on the severity and
frequency of their bipolar disorder symptoms.