Bipolar Disorder is a Lifelong Condition
by Mauricio Tohen, M.D., Dr. P.H.
Bipolar disorder, also known as manic-depressive illness, has been recognized as a mental illness for the last 2,000 years. It affects 1 percent to 1.5 percent of the world population, occurring equally in men and women across all ethnic groups and socioeconomic strata. It is estimated that 4 million Americans will suffer from bipolar illness at one point in their lifetime. At any give time, 1.5 million Americans are being treated for a manic episode.
Bipolar disorder is a lifelong condition with an age of onset corresponding to an individual's years of peak productivity. Two decades ago the average age of onset was the late 20s or early 30s. Recently, however, the average age when symptoms become apparent has been the late teens and early 20s. Some investigators argue that this finding represents a genetic phenomenon, while others point out a correlation with the widespread use of illicit drugs in the general population. Those who support this position suggest such drug use could account for the early appearance of manic-depressive illness in vulnerable individuals who otherwise would have experienced the onset of their condition a decade later.
Manic-depressive illness is an episodic condition characterized by the presence of manic and depressive episodes which alternate with periods of well-being. Changes occur in the person's mood, thinking and behavior. Irritability and anger without provocation are common during an episode of mania. There may be shifts from euphoria, when the individual is gregarious, joking and laughing inappropriately, to irritability or depression. Moods can change within minutes and in some cases shift constantly from one to another.
During periods of mania, there is an increased sense of physical energy, and the individual may exhibit constant activity. Speech tends to be so fast that other people are unable to interrupt. The flow of the conversation may have no logic, shifting from one topic to the next. The individual has a decreased need for sleep, sometimes not sleeping for days. There may also be changes in sexual behavior. This may include hypersexuality, possibly indiscriminatory, which could lead to obviously risky behaviors.
The individual with bipolar disorder may be engaged in "seeking adventure" and starting new projects. Delusions are present in 75 percent of patients who are hospitalized with a manic episode. In addition to grandiose delusions, paranoid thinking can occur. The person may imagine he or she is in the midst of a conspiracy, hear voices or see things that are not there. In a small percentage of individuals, threatening and violent behavior toward others may arise, especially when paranoid thinking and irritable moods are present. Fortunately, this situation is rare.
In contrast to the increased energy level of mania, during depressive episodes the individual has low energy and low motivation, at times not getting out of bed for days. The mood is predominately depressed and, in severe cases, accompanied by suicidal thoughts. Successful suicides occur in 10 to 15 percent of these cases. There are changes in sleep pattern, with trouble falling asleep and waking up in the early hours of the morning. There is a constant sense of tiredness, in addition to trouble with memory and concentration. At times the individual may have feelings of hopelessness, desperation or guilt for no clear reason. The person may be convinced that he or she is suffering from a terminal illness or has committed a major crime and needs to be punished, although there is no evidence of any such crime.
Mixed episodes, in which the symptoms of mania and depression may both be present, appear more frequently than was previously thought. During mixed episodes, the individual shifts from one state to another within hours or days.
The interdependence of manic-depressive illness and use of illicit drugs has been the focus of many investigations. In addition to possibly lowering the age of onset, the use of illicit drugs has been associated with a poor outcome. Studies conducted at McLean Hospital, a teaching hospital of Harvard Medical School, have found that individuals with manic-depressive illness who have abused illicit drugs take longer to recover and are more likely to suffer recurrences.
How the use of drugs affects the outcome of manic-depressive illness is not clear. The self-medication theory suggests that individuals utilize drugs in order to relieve the symptoms of the manic-depressive illness. Recent studies have shown, however, that in the manic phase patients tend to abuse cocaine, which further aggravates their condition. It is also possible that manic-depressive illness and substance abuse disorders have a similar origin. Therefore, the same biological and psychosocial pathology would lead to development of both conditions. The concurrence of two conditions, otherwise known as comorbidity, may represent a more severe form of the same underlying condition. It has also been well documented that individuals who abuse illicit drugs are noncompliant with medical treatment, which cold explain the poorer outcome of individuals who suffer from both conditions.
Treatments for Bipolar Disorder
In the early 1970s the Food and Drug Administration approved lithium as the first pharmacological treatment for mania. For 25 years lithium was the sole FDA approved antimanic drug. In 1995 the FDA approved valproate or divalproex as an antimanic drug. It had been approved as an anticonvulsant since 1978 and utilized to treat mania since the mid-'80s.
Although lithium remains the most commonly prescribed treatment for bipolar disorder, studies have shown its limitations, especially with severe presentations. It is estimated that 30 to 40 percent of patients are lithium nonresponders. Patients who commonly do not respond to lithium carbonate include those who present with episodes of mania accompanied by symptoms of depression, those who have experienced three or more episodes and those with accompanying comorbid substance abuse disorder. Those with severe forms of mania presenting with psychotic features also tend to respond better to valproate. In addition to having a broader efficacy, valproate has been found to be better tolerated.
Among the most common side effects of lithium include increased thirst and urination, weight gain, acne, tiredness and impaired memory. Some of these side effects, not surprisingly, lead to abrupt discontinuation which is followed by an increased risk of relapse. Although better tolerated, valproate is not free of adverse effects, the most common being weight gain and drowsiness. Another major advantage of valproate over lithium is its faster onset of action, which has led to shorter hospitalizations and faster recovery.
Other drugs that have been utilized to treat mania include the anticonvulsant carbamazepine, which has an onset of action between lithium and valproate. Unfortunately, it also has side effects including neurocognitive impairment. However, in patients where weight gain is a major concern, carbamazepine may represent a good choice. A number of other drugs have also been utilized to treat mania, including neuroleptics such as haloperidol or chlorpromazine. Closapine, commonly used in schizophrenia, appears to be a good treatment when patients have failed to respond to lithium, valproate or carbamazepine. It is, however, not an ideal choice as it requires weekly blood testing. The new antipsychotic drug, resperidone, also appears to have antimanic properties. Anecdotal reports have suggested antimanic properties in other anticonvulsants, such as gabapentin. A number of other atypical, antipsychotic drugs currently in clinical trials may also have antimanic properties.
The depressive phase of bipolar disorder remains a treatment challenge. Although commonly used antidepressants relieve symptoms of bipolar depression, there is a risk of an "antidepressant-induced" mania where, secondary to the pharmacological treatment, symptoms will switch from depressive to manic. The antidepressant, bupropion, has shown promising results for the treatment of bipolar depression, and trials are currently being conducted with lamortigine, a new anticonvulsant.
Psychotherapy remains an important treatment modality of bipolar disorder. Patients with bipolar disorder need to address issues related to suffering from a chronic illness which disrupts family life, work or school. Issues of noncompliance need to be addressed. Some patients may discontinue their medications in order to enjoy the "high" of manic episodes. Education about the condition is essential and should include the patient's family. At times the individual suffering from mania is not aware of emerging symptoms. The family becomes an important ally in the objective description of the course of an episode, leading to early intervention.
Although progress has been made in the diagnosis and treatment of bipolar disorder, treatment is still not curative. Further studies need to be conducted in order to treat more effectively this condition that affects the lives of many Americans.
-Reprinted by permission of Quest Publishing Co., P.O. Box 1144, Addison, TX 75001-1144 972/919-9600.
For professional, confidential assistance with bipolar disorder or any other personal problem, call MOLAP at 1-800-688-7859.