Bipolar disorder

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File:Munch The Scream lithography.png
The Scream by artist Edvard Munch, who is now regarded as probably having suffered from bipolar disorder

Bipolar disorder, also sometimes called manic-depressive disorder, is a mood disorder in which a person experiences episodes of mania and clinical depression without other environmental or medical etiologies. Other causes of manic or depressive symptoms such as hyperthyroidism, reactions to medications or sleep deprivation negate the diagnosis of Bipolar Disorder. These mood cycles, which can vary in frequency can effect the victim's levels of motivation, energy, cognition and overall functioning, and can be disabling as they have extreme shifts in mood between depression and manic euphoria or irritability. The DSM lists two main types of bipolar disorder (recognized clinically as Bipolar I and Bipolar II). Bipolar I is marked by depression marked by hypomaniac episodes (hypomania), and at least one maniac episode(mania), while Bipolar II is depression marked by at least one hypomananiac episdode. Therefore, the former is considered more severe. Some people with Bipolar also experience psychotic symptoms along with the mood disturbance. Treatment of disabling bipolar disorder is with mood stabilizers, prominently lithium salts and/or some anticonvulsant and/or anti-psychotic (also known as neuroleptic) medications. Some antipsychotics have recently been approved for management of acute bipolar mania crises.

Contents

Epidemiology

The lifetime prevalence rate of Bipolar Disorder I and II is between .6 and 2% of the population. Prevelance Rates Bipolar I disorder is gender-neutral, affecting both women and men equally, although Bipolar II is found more frequently in women. There appears to be no difference in frequency among races. Often the disorder starts with a depressive phase, and mania or hypomania then follows. For many years it was believed that Bipolar was a disorder that emerged in late adolescence and young adulthood, but recent research NIMH Roundtable has shown that even young children can suffer from Bipolar symptoms or precursors, including acute anxiety or panic attacks. In the vast majority of cases the symptoms are present for the rest of the persons life, although there are some occasional reports of single manic episodes and then full recovery with no recurrence. It should be noted that manic symptoms that are caused by other medications or diseases or disorders rule out the diagnosis of Bipolar Disorder, and this is possibly the root cause of some of the full recovery case reports.

Etiology

A diagnosis of bipolar disorder means the diagnosis of clinical depression and at least one major manic episode. Quite frequently, a patient will be diagnosed with clinical depression, modified to bipolar after the onset of mania. The causes of a manic episode may from other medical or environmental causes, leaving the diagnosis of Bipolar disorder in doubt. See manic episode or depressive episode. According to the DSM person can have symptoms of mania without having bipolar disorder, or without being depressed.

There are many theories regarding the development of Bipolar disorder. Multiple factors may be involved- stressful events or major life transitions, a family history/ genetic predisposition to psychiatric diagnoses including bipolar disorder, Clinical Depression, or Schizophrenia (This increases a family member's likelihood of having psychiatric symptoms by 10% or more) Genetic Liklihood, past or present drug use (may complicate diagnoses if present and may lead to misdiagnoses), sleep deprivation can also cause a manic like state. Drug use, both legal and illegal may also contribute to the development of Bipolar Disorder. According to the "kindling" theory [1], persons who are genetically prone toward bipolar disorder experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, the mood episode itself is sufficient to trigger reoccurring difficulties. Conversely, Bipolar disorder may be caused by a combination of biological and psychological factors. In some cases the onset of this disorder can be linked to stressful life events. Periods of depression, mania, or "mixed" states of manic (euphoric) and depressive symptoms typically recur and may become more frequent, often disrupting work, school, family, and social life. It is possible to see single occurrences of depression and mania which do not recur.

Drugs and Bipolar: Adderall and other drugs and amphetamines (including meth) have been cited as producing mania, even after the drug is not in the bloodstream. For such a patient, the euphoria of the Adderall might not wear off as quickly as it may for others. They may exhibit manic symptoms while on the drug. Some medications have depression as a side effect. Conversely, often a manic patient will, if untreated, be misdiagnosed by laypersons and even medical professionals as being "high" on meth in a state of "meth psychosis," which also includes the co-occurrence of a string of sleepless nights found in a true, or full blown 'mania.' At this point, without medical intervention, the manic state and sleeplessness can combine to form a vicious cycle which only proper intervention, can end. According to their prescribing information published by the manufacturers antidepressant medications can also possible trigger manic or psychotic episodes which may or may not resolve when the medication is resolved.

Co-occurring conditions

The NIMH states that anxiety disorder and/or obsessive compulsive disorder (mild or severe) may co-occur with or after a Bipolar episode. Such disorders are not necessarily episodic, so they may persist even when one's mood is stable. They may not respond to the medicine(s) that the bipolar disorder does requiring seperate treatment if the symptoms are impairing enough. Bipolar Disorder can be co-morbid with a number of other disorders and problems, including anxiey disorders such as panic disorder, social phobia and substance dependence, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, somatization disorder, personality disorders, suicide and delinquency and possible associations with Tourettes syndrome, impulse control and eating disorders, ADHD, Oppositional Defiant Disorder and conduct disorder.

Links with creativity

Many artists, musicians, and writers have experienced its mood swings, and some credit the condition with their creativity. However, this disease ruins many lives, and it is associated with a greatly increased risk of suicide. Kay Jamison, who herself has bipolar disorder and is considered a leading expert on the disease, has written several books that explore this idea. Research indicates that while manic phases may contribute to creativity (see Andreasen, 1988), hypomanic phases, such as those experienced in cyclothymia, actually contribute more (see Richards, 1988). This is perhaps due to the distress and impairment associated with full-blown mania, which may begin with symptoms of hypomania (ie increased energy, confidence, activity) but soon spirals into full-blown mania, a state much too terrifying and debilitating to allow much creative endeavor.

Additionally, creativity has been linked to almost every medical conditions affecting the brain, including physical and cognitive disabilities.

Manifestations of bipolar disorder: types of episodes

Bipolar disorder manifests itself in numerous ways, most notably:

  • Depression: symptoms include a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant changes in body weight; significant changes in appetite; difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; recurrent thoughts of self-harm, death or suicide. (Some people are also diagnosed and treated for obsessive compulsive disorder, anxiety, and/or panic disorder.)
  • Mania: Abnormally and persistently elevated (high) mood and/or irritability accompanied by at least three of the following symptoms (four if the mood is merely irritable): decreased need for sleep; increased talkativeness; racing thoughts; distractibility; increased goal-directed activity such as shopping, or other tasks carried on in an urgent manner; physical agitation; hypersexuality; excessive involvement in risky activities. The behavior may seem unusual to friends or family, while the person's level of insight may vary, and is higher among those with co-occurring conditions.

Mania is often divided diagnostically into two categories:

Hypomania is often not especially problematic for the person, as he or she typically feels very energetic and in a very good mood. As such, hypomania is often unreported and undiagnosed (this is perhaps the biggest cause of incorrect diagnoses between unipolar and bipolar depression.) Some patients experience only hypomania; in others, hypomania progresses into a full manic state in which the patient has more and more trouble retaining control, and the symptoms become more problematic. For some people, hypomania is an acceptable baseline.

Hypomania and mania can both make a person angry, making the mood shift harder to detect as even government guidelines advise that you watch for euphoria. Some people with bipolar disorder will never have full-blown mania; while others will have it rarely. Others seem to manifest full-blown mania on a regular, sometimes yearly cycle.

  • Mixed state: Symptoms of mania and depression are present at the same time. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and negative thinking, some of which may be automatic (see Automatic Negative Thoughts (ANTs) leading to depression. In a mixed state, depressed mood accompanies manic "activation". Also known as dysphoric mania (from Greek dysphoria: dys, difficulty, phorós, bearer); it does not display euphoric characteristics. This is the form most often seen in children. It has also been described by bipolar individuals as a 'sad mania.' This type of symptomatic manifestation can cause adult bipolar individuals to be especially prone to suicidal ideation or suicide.

Diagnostic criteria

According to the DSM-IV-TR (p. 345), the two principal forms of Bipolar disorder are:

  • Bipolar I disorder, the diagnosis of which requires over the entire course of the individual's life at least one manic (or mixed) state episode which is usually (though not always) accompanied by major depressive episodes.
  • Bipolar II disorder, which over the course of the individual's life must involve at least one major Depressive episode and must be accompanied by at least one hypomanic episode. There must be no manic episodes. If there were manic episodes, the accurate diagnosis would be Bipolar I.

Therefore, bipolar disorder need not have both severe manic episodes and depressive episodes. In certain cases the sufferer has only episodes of mania. There need be no "cycles" of mania and depression.

This is why certain contemporary psychiatrists avoid using the original name, "manic depression", which suggests that all individuals have both mania and depression. It is unrelated with the notion of equal distribution of cycles of mania and depression, since there need not be any cycles at all—in fact, even when there is one (or more) bout of both mania and depression over the course of an individual's life, the two episodes may be so unrelated to each other temporally and otherwise that this need not constitute a cycle. However, a significant portion of individuals with bipolar experience the classical alternating episodes (cycles) of mania and depression and therefore it is overstating the case to say that the classical alternation "rarely" occurs.

The DSM-IV treats these bipolar disorders as variants of mood disorders (or affective disorders). Other types include major depressive disorder and dysthymic disorder. Bipolar and other mood disorders may have no identifiable medical, traumatic or other external cause (exogenous) or may be due to a medical condition (endogenous). Current psychiatric view no longer labels mood episodes as endogenous or exogenous. The exceptions being a substance induced mood disorder or a mood disorder due to a general medical condition.

In order for a person to be properly diagnosed with bipolar disorders, the mood episodes cannot be due to external medication, drugs or treatment for depression.

Cycles in bipolar disorder

Emil Kraepelin, who first described the illness, included in his original description of manic depression the phenomenon that episodes of acute illness, whether mania or depression, are usually punctuated by relatively symptom-free intervals during which the patient is able to function normally both at work and in social affairs.

The cycles of bipolar disorder may be long or short, and the ups and downs may be of different magnitudes: for instance, a person suffering from bipolar disorder may suffer a protracted mild depression followed by a shorter and intense mania. The manic episodes typically include euphoria, tirelessness, and impulsivity particularly relating to activities; the depressed periods may seem much worse following a manic period from the point of view of the patient.

Severe depression or mania may be accompanied by symptoms of psychosis. These symptoms include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time.

Domains of bipolar disorder

Mania

Researchers at Duke University have refined Kraepelin’s four classes of mania to include hypomania (featuring mainly euphoria), severe mania (including euphoria, grandiosity, high levels of sexual drive, irritability, volatility, psychosis, paranoia, and aggression), extreme mania (most of the displeasures, hardly any of the pleasures), and two forms of mixed mania (where depressive and manic symptoms collide)[2].

Hypomania

Hypomania has been described as "mania lite", and is a mild form of mania without progression to psychosis. Many of the symptoms of mania are present, but to a lesser degree than in overt mania. People with hypomania are generally perceived as being energetic, euphoric and overflowing with new ideas, yet they are sufficiently capable of coherent thought and action to participate in everyday life.

It is questionable whether hypomania occurs without being part of a cycle of mania or depression. Patients rarely, if ever, seek out a psychiatrist complaining of hypomania. Johns Hopkins psychologist John Gartner in The Hypomanic Edge contends that many famous people – including Christopher Columbus, Alexander Hamilton, Andrew Carnegie, Louis B Mayer, and Craig Venter (who mapped the human genome) owed their ideas and drive (and eccentricities) to their hypomanic temperaments. The creativity and risky behavior associated with hypomania (and bipolar disorder in general) may suggest why it has survived evolutionary pressures.

Although hypomania sounds in many ways like a desirable condition, it does have significant downsides. Many of the negative symptoms of mania can be present, but to a lesser degree than in full mania. Many hypomanic patients have symptoms of irritability. Hypomania can also be associated with recklessness, excessive spending, sexual adventures and general lack of judgment and out-of-character behaviour that the patient may later regret.

Hypomania is also a common sign of the beginning of a more severe manic episode, and in people who know that they suffer from bipolar disorder, can be used as a warning sign that a manic episode is on the way, allowing them to seek medical treatment whilst they are still sufficiently self-aware before descent into mania occurs.

Bipolar depression

People with bipolar disorder are depressed far more often than they are manic. According to the Stanley Foundation Bipolar Network, bipolar patients spend three times more days in depression than they do in mania. For bipolar II patients, a study by Hagop Akiskal of the University of California, San Diego revealed this population was depressed 37 times more than they were hypomanic.

A 2003 study by Robert Hirschfeld of the University of Texas, Galveston found bipolar patients fared worse in their depressions than unipolar patients. (See Bipolar Depression.)

Cognition

Numerous studies show that bipolar disorder affects a patient's ability to think and perform mental tasks, even in states of remission. Deborah Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has argued these deficits should be included as a core feature of bipolar disorder.

By the same token, research by Kay Jamison of Johns Hopkins University and others have attributed high rates of creativity and productivity to individuals with bipolar disorder. (See Brain Damage.)

The Mood Spectrum

Clinical depression and bipolar disorder are classified as separate illnesses, but psychiatry is increasingly viewing them as part of an overlapping spectrum that also includes anxiety and psychosis.

In a 2003 study, Akiskal and Judd re-examined data from the landmark Epidemiological Catchment Area study from two decades before. The original study found that .08 percent of the population surveyed had experienced a lifetime manic episode (the diagnostic threshold for bipolar I) and .05 a hypomanic episode (the diagnostic threshold for bipolar II). But by tabulating survey responses to include criteria below the diagnostic radar, such as one or two symptoms over a short time period, the authors of the study recalculated the data to arrive at an additional 5.1 percent of the population, adding up to a total of 6.4 percent of the entire population who could conceivably be thought of as having bipolar disorder.

There is also a case that clinical (unipolar) depression can be bipolar disorder waiting to happen. In a 2005 study, Jules Angst and his colleagues at Zurich University tracked 406 patients with major mood disorders over a 20-year period. Of 309 patients presenting with depression, 121 (39.2 percent) eventually manifested as bipolar (24.3 percent to bipolar I, 14.9 percent to bipolar II). In all, more than 50 percent of the study population turned out to have bipolar disorder. (See The Mood Spectrum.)

Environmental factors affecting mood in bipolar disorder

In mid-2003, a twin study was published concerning environmental factors and bipolar disorder. The bipolar twin was found to be far more affected by changes in sunlight. Longer nights resulted in mood and sleep-length changes far greater than the healthy twin. Sunny days also did more to improve mood. In fact, natural light in general was found to have a profound positive effect upon the well-being of the bipolar twin.[3]

Paradoxically, in the 2004 publication of a study using Tel Aviv's public psychiatric hospitals, it was found that "Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature".[4] Unipolar depressed patient admission had no such correlation. High temperature points in the month, as well as high temperature months, were found to be correlated with depressive episodes in admissions.

In contrast, as a dual-diagnosis individual with considerable knowledge of this lifelong affliction, I have found that the bipolar cycle tends towards extreme mania in the mid-to-late-summer, followed by an inevitable crash into depression with the ending of the manic episode coupled with the decreasing natural light in autumn. And, in fact, the self-medication described above has prevented suicidal attempts and ideation, although societal forces tend to demonize the self-medicating individual. Traditional modern physicans, psychiatrists and nurse practitioners are much more apt to deny the bipolar indiviual the medications which in fact can save the very life of the patient because of the incomplete understanding of this disorder. Often a physician will deny a patient a drug such as Xanax, Clonipin or other benzodiazapines in the dual-diagnosis patient for "drug seeking" when the patient through empirical study indeed knows the drug to be helpful, even life-saving. Also, the combined interaction of such anti-anxiety medications with THC described above can be an effective tool to keep bendodizapine tolerance from increasing, and may in fact decrease the needed amount of benzodiazapines to prevent mania- or depression- producing anxiety. I have found this to be true in my own experience during over 20 years of type 1 bipolar.

Bipolar disorder and childbirth

For many women with depression or bipolar disorder, the postpartum period is a period of risk for developing illness. Episodes of bipolar disorder that follow childbirth are traditionally called postpartum depression (PD) puerperal psychosis (PP). Ian Jones of the Department of Psychological Medicine in Cardiff is researching this area.

Dual diagnosis

Bipolar disorder is often complicated by co-occurring alcohol or substance abuse.

Treatment of bipolar disorder

There is no cure for bipolar disorder; the emphasis is on management of the symptoms. A variety of medications are used to treat bipolar disorder; many people with bipolar disorder require multiple medications (sometimes up to five). Some people with bipolar disorder add to or replace their Western medication with herbal or holistic options. Still, even with optimal medication treatment, many people with the illness have some residual symptoms. Cognitive therapy may work to lessen the severity of mood swings by recognizing and managing triggering symptoms or events.

Principles

Medications called mood stabilizers are used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are sometimes also treated with antidepressants, although this carries a risk of inducing mania (especially when no mood stabilizer is also prescribed).

In severe cases where the mania or the depression is severe enough to cause psychosis (and recently sometimes in less severe cases as well, although this remains controversial), antipsychotic drugs may also be used. A new class of atypical antipsychotics are also popular. The FDA has only approved them for acute episodes, if at all. Like most doctors, psychiatrists use medication for "off-label" uses, though this carries more risk of unexpected side effects.

Some people have reported that antipsychotics cause mania, panic attacks, or psychosis. Any agitation should be reported to the doctor immediately.

Medications work differently in each person, and it takes considerable time to determine in any particular case whether a given drug is effective at all, since bipolar disorder is sometimes episodic, and patients may experience remissions and periods of normal functioning (which may last years) whether or not they receive treatment. For this reason, neither patients nor their doctors should expect immediate relief, although extreme mania will seem to dissapate quickly. Dr. John Burrows says that patients should not expect full stabilization for at least 3-4 weeks.

Compliance with medications can be a major problem, because some people becoming manic lose insight, or the awareness of having an illness, and they therefore discontinue medications. They may suddenly find themselves initiating multiple projects often being scattered and ineffective, or may go on a spending spree or take a poorly planned trip landing them in an unfamiliar location without cash. The manic periods, euphoric as they may be, may seem or be disastrous because of the impulsiveness and irrationality that comes with them.

Depression does not respond instantaneously to resumed medication, typically taking 2–6 weeks to respond. Mania may disappear slowly, or it may become depression. Other reasons cited by individuals for discontinuing medication are side effects, expense, and the stigma of having a psychiatric disorder. In a relatively small number of cases stipulated by law (varying by locality but typically, according to the law, only when a patient poses a threat to himself or others), patients who do not agree with their psychiatric diagnosis and treatment can legally be required to have treatment without their consent. Throughout North America and the United Kingdom, involuntary treatment or detention laws exist for severe cases of bipolar disorder and other mental illnesses. In some cases, the burden of proof favors the psychiatrist.

Prognosis

While bipolar disorder can be one of the most severe and devastating medical conditions, fortunately many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Compared to patients with schizophrenia, persons with bipolar disorder are more likely to have periods of normal functioning in the absence of medication. Although schizophrenic patients may have remissions with relatively high levels of functioning, schizophrenic patients tend to suffer some impairment during these intervals in contrast to persons with bipolar disorder who often appear completely healthy when they are between mood swings.

Lithium salts

The use of lithium salts as a treatment of bipolar disorder was first discovered by Dr. John Cade.

Lithium salts have long been used as a first-line treatment for bipolar disorder. In ancient times, doctors would send their mentally ill patients to drink from "alkali springs" as a treatment. They did not know it, but they were really prescribing lithium, which was present in high concentration in the waters. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li+. The two lithium salts used for bipolar therapy are lithium carbonate (mostly) and lithium citrate (sometimes). Approved for the treatment of acute mania in 1970 by the FDA, lithium has been an effective mood-stabilizing medication for many people with bipolar disorder. Lithium is also noted for reducing the risk of suicide[5]. Although lithium is among the most effective mood stabilizers, most persons taking it experience side effects similar to the effects of ingesting too much table salt, such as high blood pressure, water retention, and constipation. Regular blood testing is required when taking lithium to determine the correct lithium levels since the therapeutic dose is close to the toxic dose.

The mechanism of lithium salt treatment is believed to work as follows: some symptoms of bipolar disorder appear to be caused by the enzyme inositol monophosphatase (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. It is involved in signal transduction and is believed to create an imbalance in neurotransmitters in bipolar patients. The lithium ion is believed to produce a mood stabilizing effect by inhibiting IMPase by substituting for one of two magnesium ions in IMPase's active site, slowing down this enzyme.

Lithium orotate is used as an alternative treatment to lithium carbonate by some sufferers of bipolar disorder, mainly because it is available without a doctor's prescription. It is sometimes sold as "organic lithium" by nutritionists, as well as under a wide variety of brand names. There seems to be little evidence for its use in clinical treatment in preference to lithium carbonate. Self-treatment without medical monitoring is potentially dangerous.

Anticonvulsant mood stabilizers

Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives or adjuncts to lithium in many cases. Valproate (Depakote and Depakene) was FDA approved for the treatment of acute mania in 1995, and is now considered by many to be the first line of therapy for bipolar disorder. It is preferable to lithium because its side effect profile seems to be less severe, compliance with the medication is better, and fewer breakthrough manic episodes occur. However, valproate is not as effective as lithium in preventing or managing depressive episodes, so patients taking valproate may also need an SSRI or other antidepressant as an adjunct medicinal therapy. Some research suggests that different combinations of lithium and anticonvulsants may be helpful. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, have been studied to determine their efficacy as mood stabilizers in bipolar disorder. Lamotrigine is particularly promising, as there is evidence it acts as a mood stabilizer and particularly helps bipolar persons with severe depression. [6] Topiramate has not done well in clinical trials, which may be because it seems to help a few patients very much but most not at all. Unfortunately, there are several controlled studies that show that gabapentin is very effective for certain types of epilepsy and has a mild side effect profile but is ineffective for bipolar disorder. Nevertheless, many psychiatrists continue to prescribe topiramate and gabapentin for bipolar disorder, although this is becoming increasingly controversial.

According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician. It should be noted, however, that the therapeutic dose for a patient taking valproate for epilepsy is very different than the therapeutic dose of valproate for an individual with bipolar disorder.

Atypical antipsychotic drugs

The newer atypical antipsychotic drugs such as risperidone, quetiapine, and olanzapine are often used in acutely manic patients, because these medications have a rapid onset of psychomotor inhibition, which may be lifesaving in the case of a violent or psychotic patient. Parenteral and orally disintegrating (in particular, Zyprexa Zydis) forms are favoured in emergency room settings. [7] These drugs can also be used as adjunctives to lithium or anticonvulsants in refractory bipolar disorder and in prevention of mania recurrence. In light of recent evidence, olanzapine (Zyprexa) has been FDA approved as an effective monotherapy for the maintenance of bipolar disorder.[8] A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be just as effective and safe as Lithium in prophylaxis.[9]


Omega-3 fatty acids

Omega-3 fatty acids are also used as an alternative or additional treatment for bipolar disorder. Omega-3 fatty acids are polyunsaturated fatty acids which can be found in wild salmon, flaxseed and walnuts. To receive a significant dose, however, omega-3 fatty acids must usually be taken in the form of a fish oil supplement. An initial clinical trial by Stoll et. al. which produced strongly positive results [10]. It has been hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is eicosapentaenoic acid (EPA) and that supplements should be high in this compound to be beneficial.[11]

However, although there are a number of clinical trials with encouraging results, and widespread anecdotal reports of efficacy, attempts to confirm the hypothesized beneficial effects of omega-3 fatty acids in several larger double-blind clinical trials have so far produced unconclusive results.

Psychotherapy

Certain types of psychotherapy or psychosocial interventions, generally used in combination with medication, often can provide tremendous additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family systems therapy, and psychoeducation.

Electroconvulsive therapy

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Electroconvulsive therapy (ECT) is sometimes used to treat severe bipolar depression in cases where other treatments have failed. Although it has proved to be a highly effective treatment, doctors are reluctant to use it except as a treatment of last resort because of the side-effects and possible complications of ECT, particularly when repeated treatments ("maintenance ECT") are needed.

Medical Marijuana

There are many anecdotal claims that medical marijuana can help control the mood swings associated with bipolar disorder. The euphoriant effect of THC can elevate depressive phases, while the tranquilizing effects of THC are effective at controlling manic phases. While most anti-depressants take several weeks to work at full strength, smoked marijuana is effective in minutes, and eaten marijuana is effective within an hour or two. Also, nasty side effects associated with pharmaceutical anti-depressants such as nausea, sleep disruption, and loss of libido are usually non-existant with medical marijuana. However, since plants cannot be patented and because marijuana is easily grown, there has been a concerted effort by the pharmaceutical industry to suppress the use of medical marijuana. (see Partnership for a Drug-Free America).


Alternative treatments

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Complementary non-Western treatments, such as acupuncture and orthomolecular therapy, are used by people with bipolar disorder, and some research shows that some of them may have some scientific merit.

Treatment issues

Nearly all bipolar treatment studies have involved treating patients in the acute (initial) mania stage, where overmedication is often justified in removing a patient from danger. Less is known, however, about long-term treatment, where relapse prevention and full remission are the main treatment goals.


Until recently, depression was largely overlooked in bipolar disorder. The anticonvulsant medication, lamotrigine is often used for treating bipolar depression, particularly where other drugs have failed and the patient's disorder has a strong depressive component. New clinical trials are finding that certain new-generation antipsychotics such as olanzapine and quetiapine show some beneficial effect in treating bipolar depression. Lithium also has a mild antidepressant effect.

Because there is a danger of antidepressant medications such as SSRIs switching bipolar patients into mania, these medications are used with caution, nearly always with an mood stabilizer.[12].

Research findings

Heritability

Bipolar disorder appears to run in families. The rate of suicide is higher in people who have bipolar disorder than in the general population. In fact, people with bipolar disorder are about twice as likely to commit suicide as those suffering from major depression (12% to 6%).

The rate of prevalence of bipolar disorder is roughly equal in men and women. Lifetime risk of bipolar I disorder is often quoted as around 1%, but when bipolar II is included the true rate may be around 4%.[13]

More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a heritable component. Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

Recent genetic research

Bipolar disorder is considered to be a result of complex interactions between genes and environment. The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Dizygotic twins have a 23% concordance rate. Children of a bipolar parent have a 50% chance of developing schizophrenia, schizoaffective or bipolar disorder. First degree relatives are seven times more likely to develop the condition than the general population.

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3, which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder.[14]

Medical imaging

Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the functional MRI. An important area of imaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Better understanding of the neural circuits involved in regulating mood states may influence the development of new and better treatments, and may ultimately aid in diagnosis.

Personality types

An evolving literature exists concerning the nature of personality and temperament in bipolar disorder patients, compared to major depressive disorder (unipolar) patients and non-sufferers. Such differences may be diagnostically relevant. Using MBTI continuum scores, bipolar patients were significantly more extroverted, intuitive and perceiving, and less introverted, sensing, and judging than were unipolar patients. This suggests that there might be a correlation between the Jungian extraverted intuiting process and bipolar disorder.

Research into new treatments

In late 2003, researchers at McLean Hospital found tentative evidence of improvements in mood during EP-MRSI imaging, and attempts are being made to develop this into a form which can be evaluated as a possible treatment.

It has been hypothesized that bipolar disorder may be the result of poor membrane conduction in the brain and that one possible cause may be a deficiency in omega-3 fatty acids. Following an encouraging small-scale study conducted by Andrew Stoll at Harvard University's McLean Hospital, the Stanley Foundation is sponsoring research regarding the beneficial claims, and several large scale trials of treatment using omega-3 fatty acids are under way.

NIMH has initiated a large-scale study at twenty sites across the U.S. to determine the most effective treatment strategies for people with bipolar disorder. This study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), will follow patients and document their treatment outcome for 5 to 8 years. For more information, visit the Clinical Trials page of the NIMH Web site.

In 2005 two double blind placebo controlled studies were underway at Harvard University and University of Calgary to determine if the trends noted in several open label trials using a mineral, vitamin and amino acid supplement called E.M. Power would continue to demonstrate effectiveness. In preliminary studies, as many as 70% of patients taking the supplements were free of symptoms after slowly having withdrawn from psychotropic medications.

For immediate management of mania, left coloric vestibular stimulation has proven effective in dramatically and rapidly stopping mania for up to 24 hours. Currently there are only case reports, and there has been no organized research on use of the procedure for acute mania.

Another avenue for treatment that has, at times been curative for resolving manic psychosis is by treating an underlying infections such as Lyme disease. Results in these cases suggest that the term bipolar disorder may not accurately represent the actual biological disorders which meet the DSM-IV requirement for a bipolar disorder. For an unknown number of patients, the problem may be a kind of immune mediated disorder provoked by Lyme disease (Toxoplasmosis, Bornea virus), or any or a number of other chronic infections, including something as common as the flu.

Bipolar disorder, talent and famous people

Many famous people are believed to have been affected by bipolar disorder, based on evidence in their own writings and contemporaneous accounts by those who knew them. Bipolar disorder is found in disproportionate numbers in people with creative talent such as artists, musicians, authors, poets, and scientists, and it has been speculated that the mechanisms which cause the disorder may be related to those responsible for creativity in these persons. (Many of the historical creative talents commonly cited as bipolar were "diagnosed" retrospectively after their deaths and thus the diagnoses are unverifiable; however, in cases diagnosed in recent decades there does seem to be at least some correlation between bipolar disorder and creativity.) The possible explanation for this is that hypomanic phases of the illness allow for heightened concentration on activities and the manic phases allow for around-the-clock work with minimal need for sleep. See list of people believed to have been affected by bipolar disorder.

Sources

  • Material from public domain text copied from http://www.nimh.nih.gov/publicat/manic.cfm which states: "All material in this fact sheet is in the public domain and may be copied or reproduced without permission from the Institute. Citation of the source is appreciated."
  • 1, 2, 3 and 4 Links and references showing that gabapentin (Neurontin) is an inappropriate and ineffective medication for bipolar disorder.
  • Suicide rate of persons with bipolar disorder

References

  1. ^  Prevalance Rates
  2. ^  NIMH Roundtable on Pediatric Bipolar
  3. ^  Genetic Liklihood
  4. ^  Link and reference involving kindling theory
  5. ^  Hakkarainen R, et al. (2003). Seasonal changes, sleep length and circadian preference among twins with bipolar disorder. BMC Psychiatry 3 (1), 6.
  6. ^  Shapira A, et al. (2004). Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature. Bipolar Disorder Feb;6 (1), 90–3.
  7. ^  Baldessarini RJ, et al. (2003). Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64 (Suppl 5), 44–52.
  8. ^  1 and 2 Links and references showing the promise of lamotrigine (Lamictal) in the treatment of bipolar depression.
  9. ^  Osher Y, Bersudsky Y, Belmaker RH. Omega-3 eicosapentaenoic acid in bipolar depression: report of a small open-label study. J Clin Psychiatry. 2005;66(6):726–9. PMID 15960565
  10. ^  Stoll AL, Severus WE, Freeman MP et al. (1999), Omega 3 fatty acids in bipolar disorder. A preliminary double-blind, placebo-controlled trial. Arch Gen Psychiatry 56(5):407-412.
  11. ^  Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. PMID 15939837
  12. ^  Barrett TB, Hauger RL, Kennedy JL, Sadovnick AD, Remick RA, Keck PE, McElroy SL, Alexander M, Shaw SH, Kelsoe JR. Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder. Mol Psychiatry. 2003 May;8(5):546–57.

Further reading

Classic works on this subject include

  • Manic-depressive insanity and paranoia by Emil Kraepelin., 1921. ISBN 0405074417 (English translation of the original German from the earlier Eighth Edition of Kraepelin's textbook - now outdated, but a work of major historical importance).
  • Manic-Depressive Illness by Frederick K. Goodwin and Kay Redfield Jamison. ISBN 0195039343 (The standard, very lengthy, medical reference on bipolar disorder.)
  • Touched With Fire: Manic-Depressive Illness and the Artistic Temperament by Kay Redfield Jamison (The Free Press: Macmillian, Inc., New York, 1993) 1996 reprint: ISBN 068483183X
  • An Unquiet Mind: A Memoir of Moods and Madness by Kay Redfield Jamison (Knopf, New York, 1995) (An excellent autobiographical work about what it's like to have bipolar disorder, by the woman who is also one of the medical world's experts on it.) ISBN 0330346512
  • Mind Over Mood: Cognitive Treatment Therapy Manual for Clients by Christine Padesky, Dennis Greenberger. ISBN 0898621283
  • Bipolar Disorder: A guide for patients and families by Francis Mondimore M.D., 1999. ISBN 0801861179 (A detailed in-depth book covering all aspects of bipolar disorder: history, causes, treatments, etc.)
  • The Bipolar Disorder Survival Guide: What You and Your Family Need to Know by David J. Miklowitz Ph.D., 2002. ISBN 1572305258 (An excellent practical guide on managing bipolar disorder)

See also

External links

Support groups

Research

Evidence-based medicine

Other resources

Links about famous people with unipolar or bipolar disorder

News stories

cs:Maniodepresivní psychóza da:Maniodepressiv sindslidelse de:Bipolare Störung es:Desorden bipolar fr:Trouble bipolaire gl:Trastorno bipolar ko:조울증 he:הפרעה דו-קוטבית lt:Maniakinė depresija nl:Bipolaire stoornis ja:双極性障害 pl:Choroba afektywna dwubiegunowa pt:Distúrbio bipolar ru:Биполярное аффективное расстройство fi:Kaksisuuntainen mielialahäiriö sv:Bipolärt syndrom

[[A list of famous people (including Canadians) can be found at http://www.mooddisorderscanada.ca/depression/print/p_famous.htm

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