The following document was written by Dr. Khalid Ahmed MBBS an Fy2 at Medway Maritime Hospital, UK in May 2008.
You may use the information here for personal use but if you intend to publish or present it, you must clearly credit the author and www.clinicaljunior.com
This site is not intended to be used by people who are not medically trained. Anyone using this site does so at their own risk and he/she assumes any and all liability. ALWAYS ASK YOUR SENIOR IF YOU ARE UNSURE ABOUT A PROCEDURE. NEVER CONDUCT A PROCEDURE YOU ARE UNSURE ABOUT.

---

Bipolar Affective Disorder

Introduction

Bipolar disorder, or manic-depressive illness, has been recognized since the time of Hippocrates, who described such patients as "amic" and "melancholic." In 1899, Emil Kraepelin defined manic-depressive illness and noted that persons with manic-depressive illness lacked deterioration and dementia, which he associated with schizophrenia.

Bipolar affective disorder is a serious mental health condition with a very high suicide rate (25-50% attempted suicide, and 11% completed suicide). It utilises more healthcare service than patients with depression or chronic medical conditions. It’s the 6th leading cause of morbidity worldwide.

Prevalence rate is between 0.3-1.5%. No racial predilection exists. It occurs equally in both sexes; however, rapid cycling of Bipolar Disorder is more common in women than in men.

Definition:

A disorder characterized by two or more episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar.

Pathophysiology:

Still has not been determined but it is believed that there is a genetic component. First-degree relatives of a person with bipolar disorder are 7 times more likely to develop the disease than the general population. Studies are still ongoing with the human genome project.

There are several theories speculated with this disorder. Environmental factors, sleep deprivation and circadian rhythm, hypothalamic-pituitary-adrenal axis abnormalities, thyroid dysfunction, dopaminergic and mitochondrial dysfunction have all been implicated.

Clinical features:

The age of onset of bipolar disorder varies greatly, but the most common age of onset is between 15-19 years of age and the second most common age of onset is 20-24 years. There is a wide spectrum of symptoms of bipolar disorder which include:

Mood symptoms:

• Labile mood


• Euphoria


• Irritability

Cognitive symptoms:

• Poor concentration


• Distractibility


• Confusion

Psychotic symptoms (60% approximately):

• Delusions


• Hallucinations


• Thought disorder

Behavioural symptoms:

• Pressure of speech


• Poor sleep and appetite


• Increased libido/disinhibition


• Aggression


• Religiosity


• Catatonia/stupor


• Hyperactivity

Depressive symptoms:

• Depressed mood


• Displeasure or lack of interest in most activities


• Significant weight loss or gain, increased or decreased appetite


• Hypersomnia or insomnia


• Loss of energy or lack of motivation


• Suicidal thoughts


• Symptoms cause impairment and distress

Manic symptoms are diagnosed by the presence of at least 1 week of profound mood disturbance such as elation, irritability, or expansiveness. On the other hand hypomanic episodes are characterised by the patient having an elevated, expansive, or irritable mood of at least 4 days' duration but to lesser degree than mania.

It is important to rule out organic causes of mania/hypomania and depressive symptoms such as infections, postoperative delirium, Addison’s Disease, Cushing’s disease, thyroid dysfunction, brain tumours (primaries or secondaries), CVA, HIV, epilepsy and drug abuse.

Types:

Bipolar I: major depression contrasting vividly with episodes of mania. It can lead to severe functional impairment.

Bipolar II: milder form of the disease which consists of depression alternating with periods of hypomania which does not involve psychotic symptoms and usually does not cause major impairment of social or occupational function.

Differential Diagnoses:

• Anxiety disorder


• Schizophrenia


• Cushing’s Disease


• Hypo/hyperthyroidism


• Hyperparathyroidism


• Head trauma/brain lesion


• Schizoaffective disorder


• SLE

Investigations:

• Detailed history (concentrate on triggers), physical examination and MSE.


• FBC, UE’s, LFT’s, TFT’s, VDRL, HIV, ECG, EEG, drug screen, Ca, CT/MRI brain if indicated.


• Use Young Mania Scale and Hamilton Depression Scale to assess severity of symptoms.

Management:

• Comprehensive Needs and Risk Assessment will determine whether they will need admission or not.


• Find out about any advanced directives the patient had given in the past and that includes how they want to be treated and preference for medication.


• Be vigilant for antidepressant induced mania. Avoid antidepressants in rapid cycling bipolar disorder.
• CBT for persistent depressive symptoms.

Medications:

1. Lithium - therapeutic range-0.6-1mmol/l, evaluate response after 7 days


2. Sodium Valproate - therapeutic range- 60-120 mg/l, evaluate response after 3 days for semi-sodium valproate. Do not prescribe for women of childbearing age.


3. Carbamazepine – consider risk of drug interaction


4. Lamotrigine (not to be used as single 1st line), Olanzapine, Aripiprazole (recently licensed)

• ECT if treatment fails or if life threatening situation.


• Length of treatment is usually for 2 years and up to 5 years or beyond if high risk of relapse.


• Arrange regular reviews and assess: weight, BMI, BP, lipids, FBC, TFT’s, LFT’s, glucose, prolactin level, ECG, smoking and substance use.


• Consider psychological therapy in chronic cases such as group therapy, family therapy, psycosocial support, CBT etc.

References:

1. www.emedicine.com
2. www.nice.org.uk
3. The ICD-10 Classification of Mental and Behavioural Disorders

Author:
Dr. Khalid Ahmed MBBS

F2 at Medway Maritime Hospital, UK

Disclaimer

The authors of this document have attempted to provide information that is medically sound and up-to-date. The authors nor Clinicaljunior.com cannot take any reponsibility for the accuracy or completeness of this article. The reader should confirm the statements made in this website before using the information outside this website.