The series kicks off with Joseph F. Goldberg, M.D., director of the Affective Disorders program at Silver Hill Hospital in New Canaan, Connecticut, by defining the bipolar entity, “ not otherwise specified,” as sub-threshold mania or hypomania. This type of bipolar disorder had a prevalence rate of 2.4%. This “expert” also notes "approximately a doubling diagnosing bipolar disorder of any type with “greater screening and surveillance.” Also, approximately 2/3 of bipolar patients will identify their first mood symptoms before early adulthood (note a modal peak between 15 and 19).
Hirschfield et al in J Clin Psychiatry. 2003; 64(2): 161-174., has noted that 60% of patients with bipolar disorder were “misidentified with unipolar depression.” As much as 54% of postpartum women appeared to be experiencing unipolar depression but in fact had a history of bipolar disorder. The fact is that there are so many issues that can mimic bipolar presentation: anxiety, substance abuse, steroids, even anti-depressants They ALL can produce secondary manias. They remind us to also consider Cluster B personality disorder which can share with mania or hypomania features such as mood instability or impulsivity.
Eighty five to 90% of children with bipolar disorder also meet the DSM IV criteria for ADHD. Goldberg emphasizes “both the overdiagnosis and underdiagnosis in patients with suspected bipolar disorder.” He advises “examining…symptoms such as decreased need for sleep, increased psychomotor activity, and the cognitive-behavioral and language features that comprise the constellation of mania or hypomania.” Also, he cautions, family history can be “somewhat challenging as bipolar illness does not follow Mendelian inheritance.” Therefore, if a strong family history is not available, this is not a clear negative predictive value.
Charles Borden, an M.D. at the University of Texas, San Antonio Health Science Center, emphasizes that clinicians RARELY see bipolar patients who do not have an anxiety disorder. “If anxiety disorder is present, patients are more likely to have substance abuse disorders, other impulse control disorders, eating disorders, and other personality disorders.” Borden notes: “In particular, if the prevalence rates of all anxiety disorders are grouped together, they are almost as prevalent as bipolar disorder itself, and clinicians rarely see a patient with bipolar disorder who does not have an anxiety disorder.” (Perugi G et al The temporal relationship between anxiety disorder and hypomania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder. J Affect Disord 2001; 67(1-3): 199-206).
One in five with major depressive disorder (MDD) has bipolar disorder. Prevalence studies in MDD show at least 20% of patients with depressive episodes have either type I or type II bipolar disorders. He suggests that clinicians perhaps may fail to elicit histories of hypomanic illness because they are not spontaneously reported.
Claudia Baldassano, M.D., from the University of Pennsylvania, reports a significant reduction in mortality ratios for patients actively in treatment (29.2 versus 6.4% from suicide). Judd et al noted bipolar patients were most likely to be symptomatic with depression. Unfortunately, despite this reality, “monotherapy” is twice as commonly prescribed as mood stabilizers. Aripiprazole (Abilify) “fails to show positive evidence” for bipolar disorder ( despite what seems like a major media campaign touting its benefits for depression).
From a personal perspective, I was relieved to learn that divalproex (Depakote) may be effective for bipolar depression symptoms. She also reports for maintenance therapy “less efficacy” but “better tolerability” for the mood stabilizers. She notes that lamotrigine (Lemictal) is “well-tolerated and that it does not cause weight gain.
Noreen Reilly-Harrington, Ph.D from Mass General Hosptial confirms again that “adjunctive psychological treatments can help reduce relapse and provide patients as well as their families with tools…” She notes that three forms of intensive intervention : (1) cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy, and family-focused treatment, were favorably compared with brief three-session psychoeducational intervention(collaborative care).
She found that any of these three showed (1) Median time to recovery 110 days earlier; (2) Higher year-end recovery rates; and (3) More than one to 1.5 times likely to be clinically well during any study month. She did not report any significant differences between the three intensive treatments. It is interesting that CBT, established in the 1960’s, was primarily used for unipolar depression. However, its main focus still remains education and problem solving. CBT is also effective for co-morbid anxiety, panic disorder, OCD, and social anxiety.
Reilly-Harrington advocates regulating schedules and monitoring moods daily to recognize any early warning signs of relapse. “Patients… take part in the planning of their treatment plan and to exercise choice in control.” Mood charting allows patients to develop awareness about their illness. Such a routine allows successful tracking of medication doses and treatment compliance. We as patients with bipolar disorder are not known for our compliance. She advises regulating daily schedules of activity including sleep-wake cycles, meal times, and work schedules.
In summary, these articles further help emphasize the challenges of identifying bipolar disorder especially with the likelihood of co-occurring and co-morbid problems. Anxiety almost inevitably co-exists with bipolar disorder. These authors offer us appropriate, unique, and effective psychotropic treatment advice. Lastly, although medications remain “the mainstay” of treatment, psychosocial modalities unquestionably enhance and improve outcomes.
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A blog covering the interrelation of bipolar illness, drugs and addiction.
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