Article summary of Bipolar Disorder by Grande et al. - Chapter

What is bipolar disorder?

Bipolar disorder is a recurring, chronic disorder that is characterized by fluctuations in mood and energy. It leads to cognitive and functional impairment. A distinction is made between type I and type II bipolar disorder. In bipolar I there must have been at least one manic episode. In bipolar II, there must have been at least one hypomanic and one depressive episode. Bipolar II is more common in women, for bipolar I the prevalence is equal among men and women. It is often diagnosed in young adults. This is the economically active population, which means that the social costs of the disorder are high. 

What are the characteristics of bipolar disorder?

Bipolar disorder is characterized by episodes of mania, hypomania, and depression. Bipolar II is often characterized by psychiatric comorbidity and suicidal behavior.

What are the characteristics of manic and hypomanic episodes?

Manic or hypomanic episodes are characterized by elevated mood and increased motor drive. With a manic episode there is an impairment of functioning, this does not have to be the case with a hypomanic episode. Occupational functioning is sometimes even improved during a hypomanic episode. Psychotic symptoms can occur during a manic episode. A hypomanic episode must last 4 days in a row, a manic episode must last 1 week. Specifiers define clinical features of episodes and the course of bipolar disorder. The rapid-cycling specifier, for example, indicates that there have been at least four episodes of mania, hypomania or depression within 12 months. The mixed specifier states that there are also three characteristics of the opposite spectrum during mania, hypomania or depression. If one of these specifiers is present, the prognosis of the disorder is worse.

What are the characteristics of depressive episodes?

The DSM-5 criteria for a depressive episode are the same for unipolar and bipolar disorders. Yet, there are other differences. Bipolar depression starts at a younger age, has more frequent episodes of shorter duration, has an abrupt beginning and end, is often comorbid with substance abuse, is triggered by stressors at early stages, and has more post-partum risk. Atypical symptoms are also more common. Somatic complaints are more common in unipolar depression.

What is the suicide risk?

The risk of suicide in bipolar disorder is 20 times higher than in the general population. Variables associated with suicide attempts include being a woman, early onset of disorder, depressive polarity of first and most recent episodes, comorbid anxiety and substance abuse disorders, borderline personality disorder, and a family history of suicide. Men succeed more often in their suicide attempts than women.

How fast is bipolar disorder diagnosed after onset?

The time between the onset of the disorder and diagnosis is 5-10 years on average. The most common comorbid disorders are schizophrenia, anxiety disorders, substance abuse, personality disorders and ADHD and ODD in children.

What causes bipolar disorder?

Bipolar disorder is one of the most heritable psychiatric disorders. A multi-factorial model in which both genes and environment interact fits the disorder best. Risk alleles overlap partly with those of schizophrenia.

What is the prognosis?

Bipolar disorder is often chronic and recurrent. Patients with a predominantly depressive polarity are most likely to commit suicide, and are often diagnosed with seasonal bipolar II. With mainly manic polarity, drug abuse and bipolar I are more common. Bipolar disorder is associated with neurocognitive deficits. Cognitive impairments in the areas of executive functions and verbal memory could at least partly explain functional impairments. Bipolar disorder is also often comorbid with cardiovascular diseases, diabetes and obesity.

What are the treatment options?

Various factors influence the choice of treatment, including medical and psychiatric comorbidity, past treatments, and the patient's willingness to be treated. Clinicians must take this into account to make the treatment as effective and efficient as possible. Mood stabilizers and antipsychotics are most commonly prescribed during acute bipolar mania or depression. The evidence for the effectiveness of antidepressants in treating depression is unclear. Electroconvulsive therapy is effective in patients with psychotic or catatonic characteristics. In general, antipsychotics are more effective than mood stabilizers, especially risperidone and olanzapine, because they work faster. A combination treatment of an atypical antipsychotic with a mood stabilizer is the most effective. During a depressive episode in bipolar I, antidepressants may only be prescribed in combination with a mood stabilizer. SSRIs and buproprion can be prescribed for bipolar II.
For long-term treatment, lithium is mainly used to prevent both manic and depressive episodes, whether or not in combination with an antipsychotic or antidepressant. Psychoeducation, cognitive behavior therapy, interpersonal therapy and social rhythm therapy are also effective.

Which are special populations to consider?

Which issues need to be considered during pregnancy?

Advice and guidance for women with bipolar disorder that want to get pregnant is important because some medication is harmful to the unborn baby. Women whose mood is stable sometimes stop taking medication abruptly when they become pregnant, which increases the risk of relapse. The reduction must be gradual. The risk of a relapse is particularly high in the post-partum period.

Which issues need to be considered for adolescents?

Early identification of bipolar disorder in adolescents aged 13-19 is crucial, as the disorder often presents itself before the age of 21. Attention should also be paid to the children of patients, because they have a greater risk of developing the disorder. The verbal expression of symptoms is constricted, because of cognitive and emotional immaturity of young people, making it more difficult to identify certain manic symptoms such as grandiosity and increased targeted activity. Some symptoms also overlap with ADHD, personality disorders and conduct disorders, making diagnostics more difficult.

Which issues need to be considered regarding physical health?

Medical comorbidity is common in bipolar disorder due to the effects of pharmacological treatments, genetic vulnerability and lifestyle factors (smoking, poor diet and lack of exercise). Physical health must therefore be checked upon regularly with these patients. When using lithium or valproate, blood concentrations should be monitored to ensure that they fall within the therapeutic range.

What does future research need to address?

Translational research is needed for a better pathophysiological understanding. This can also improve diagnostic accuracy, especially in young people.