Internet Mental Health
 
BIPOLAR I DISORDER
 


Prediction: Episodic For Lifetime (Untreated Mania Lasts 6 Weeks, Depression Lasts 11 Weeks)

      Occupational-Economic:
  • Bipolar disorder accounts for 7% of the disability caused by mental illness; a minority are chronically disabled and require a disability pension
      Wisdom vs Irrationality:
  • Depression and mania impair judgment; severe episodes can cause psychosis
      Courage vs Negative Emotion:
  • Depressive episodes cause: depressed mood, generalized anxiety, guilt, anger, suicidal behavior, lack of confidence, pessimism, hypersensitivity to rejection
  • Manic episodes cause: elated mood, over-talkativeness or racing speech, hyperactivity, over-confidence, over-optimism
  • Mixed episodes rapidly alternate between depressive and manic episodes in the same day/week
      Helping Others vs Detachment:
  • Social withdrawal during depression (but over-socializing during mania)
      Self-Control vs Disinhibition:
  • Manic episodes cause: harmful impulsiveness, hypersexuality, emotional instability, unstable and chaotic social life
      Justice vs Antagonism:
  • Manic episodes cause: grandiosity, irresponsibility, physical violence
      Medical:
  • Manic episodes cause: denial of illness, increased risk of death due to accident or other illness


Explanation Of Symbols


(Note: The presentation of Bipolar I Disorder, Depressive Episode is identical to that of Major Depressive Disorder. The presentation of Bipolar I Disorder, Mixed Episode, is a mixture of Depressive and Manic Episode presentations.)


SYNOPSIS

Bipolar Affective Disorder F31 - ICD10 Description, World Health Organization
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.

    F31.0 Bipolar affective disorder, current episode hypomanic

    The patient is currently hypomanic, and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past.

    F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms

    The patient is currently manic, without psychotic symptoms (as in F30.1), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past.

    F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms

    The patient is currently manic, with psychotic symptoms (as in F30.2), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past.

    F31.3 Bipolar affective disorder, current episode mild or moderate depression

    The patient is currently depressed, as in a depressive episode of either mild or moderate severity (F32.0 or F32.1), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past.

    F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms

    The patient is currently depressed, as in severe depressive episode without psychotic symptoms (F32.2), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past.

    F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms

    The patient is currently depressed, as in severe depressive episode with psychotic symptoms (F32.3), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past.

    F31.6 Bipolar affective disorder, current episode mixed

    The patient has had at least one authenticated hypomanic, manic, depressive, or mixed affective episode in the past, and currently exhibits either a mixture or a rapid alteration of manic and depressive symptoms. Excl.:single mixed affective episode (F38.0)

    F31.7 Bipolar affective disorder, currently in remission

    The patient has had at least one authenticated hypomanic, manic, or mixed affective episode in the past, and at least one other affective episode (hypomanic, manic, depressive, or mixed) in addition, but is not currently suffering from any significant mood disturbance, and has not done so for several months. Periods of remission during prophylactic treatment should be coded here.
Bipolar I Disorder, Manic Episode - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with bipolar I disorder needs to meet all of the following criteria:

  • For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

    Manic Episode

    • A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behavior or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

    • During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

      • Inflated self-esteem or grandiosity.

      • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

      • More talkative than usual or pressure to keep talking.

      • Flight of ideas or subjective experience that thoughts are racing.

      • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

      • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).

      • Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

    • The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

    • The episode is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition.

      A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis.

  • The above criteria constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

  • The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Bipolar I Disorder, Depressive Episode - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with bipolar I disorder, depressive episode, needs to meet all of the following criteria:

  • For a diagnosis of bipolar I disorder, it is necessary to have met the following criteria for a manic episode in the past.

    Manic Episode

    • A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behavior or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

    • During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

      • Inflated self-esteem or grandiosity.

      • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

      • More talkative than usual or pressure to keep talking.

      • Flight of ideas or subjective experience that thoughts are racing.

      • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

      • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).

      • Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

    • The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

    • The episode is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition.

      A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis.

  • The above criteria constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

  • For a diagnosis of bipolar I disorder, depressive episode, it is necessary to currently meet the following criteria for a major depressive episode.

    Major Depressive Episode

    • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

      Note: Do not include symptoms that are clearly attibutable to another medical condition.

      • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

      • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

      • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

      • Insomnia or hypersomnia nearly every day.

      • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

      • Fatigue or loss of energy nearly every day.

      • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

      • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

      • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

    • The episode is not attributable to the physiological effects of a substance or to another medical condition.

      Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in the above criteria, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.

    • The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Bipolar I disorder is a very serious mental illness, but usually it has an excellent outcome when treated. The average age of onset of bipolar depression is 17-18, and 30 is the average age of onset of bipolar mania (but bipolar I disorder can start at any age). It usually starts as repeated episodes of depression which later are followed by one or more manic (or mixed manic and depressive) episodes. When untreated, this disorder often causes school/job failure, relationship/marital failure, and a 15% risk of suicide.

Effective Therapies

Untreated patients often must be hospitalized to assure their safety and that of others. Most patients respond to a combination of a mood stabilizer (lithium, valproate/divalproex, or carbamazepine) plus an antipsychotic medication. Medication should be taken lifelong. Clonazepam is added to treat mania. Antidepressant medication is often ineffective during depression, and must be stopped during mania (or it will increase the mania). Clozapine and electroconvulsive therapy (ECT) are used for treatment refractory patients. Psychological treatments are not a substitute for medication, but are helpful for depression (but not mania). Educating patients and their families about this disorder is always beneficial.


Excellent Very Honest Documentary On Bellevue Psychiatric Hospital


Ineffective Therapies

Cognitive behavioral therapy (CBT) is not effective in preventing relapse in bipolar I disorder; however CBT is effective in reducing symptoms in major depressive episodes, although the effect size is small. Vitamins, dietary supplements, and acupuncture are all ineffective for mood disorders.


Lack Of Social Skills During Bipolar I Disorder

There are social skills that are essential for healthy social functioning. During depressive episodes of bipolar I disorder, individuals lack the essential social skills of self-confidence, optimism, belonging, and sociability. These are the same social skills that are lacking in individuals with major depressive disorder, persistent depressive disorder, avoidant personality disorder and social anxiety disorder.

    Social Skills That Are Lacking During The Depressed Episodes Of Bipolar I Disorder

    SOCIAL SKILL LOW LEVEL HIGH LEVEL
    Self-Confidence Feeling inferior or shy Having a good opinion of oneís self and abilities; socially confident and out-going
    Optimism Pessimism or expecting the worst Having a positive outlook on life; expecting a good outcome; hopeful
    Belonging Fearing rejection by others Feeling liked and accepted by friends, and included in their group; not fearing rejection
    Sociability Social withdrawal Friendly; interested in social contacts and activities

During manic episodes of bipolar I disorder, individuals have all these social skills to excess. During mixed episodes of bipolar I disorder, individuals can rapidly alternate between manic and depressive episodes. Some believe that "negative thinking causes depression". This belief can't explain how bipolar individuals in a mixed phase can repeatedly alternate between depression and mania. This sudden switching strongly suggests that mixed bipolar I disorder has a physiological, rather than a psychological, causation.

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, helping others, self-control, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")

    Bipolar I Disorder: Negative Emotion, Disinhibition
            Wisdom vs Irrationality:
      • Depression and mania impair judgment; severe episodes can cause psychosis
            Courage vs Negative Emotion:
      • Depressive episodes cause: depressed mood, generalized anxiety, guilt, anger, suicidal behavior, lack of confidence, pessimism, hypersensitivity to rejection
      • Manic episodes cause: elated mood, over-talkativeness or racing speech, hyperactivity, over-confidence, over-optimism
      • Mixed episodes rapidly alternate between depressive and manic episodes in the same day/week
            Helping Others vs Detachment:
      • Social withdrawal during depression (but over-socializing during mania)
            Self-Control vs Disinhibition:
      • Manic episodes cause: harmful impulsiveness, hypersexuality, emotional instability, unstable and chaotic social life
            Justice vs Antagonism:
      • Manic episodes cause: grandiosity, irresponsibility, physical violence
Summary

Bipolar I Disorder is one of the most severe forms of mental illness and is characterized by recurrent episodes of mania and (more often) depression. The condition has a high rate of recurrence and if untreated, it has an approximately 15% risk of death by suicide. It is the third leading cause of death among people aged 15-24 years, and is the 6th leading cause of disability (lost years of healthy life) for people aged 15-44 years in the developed world.

Causation

Bipolar I Disorder is a life-long disease and runs in families but has a complex mode of inheritance. Family, twin and adoption studies suggest genetic factors. The concordance rate for monozygotic (identical) twins is 43%; whereas it is only 6% for dizygotic (nonidentical) twins. About half of all patients with Bipolar I Disorder have one parent who also has a mood disorder, usually Major Depressive Disorder. If one parent has Bipolar I Disorder, the child will have a 25% chance of developing a mood disorder (about half of these will have Bipolar I or II Disorder, while the other half will have Major Depressive Disorder). If both parents have Bipolar I Disorder, the child has a 50%-75% chance of developing a mood disorder. First-degree biological relatives of individuals with Bipolar I Disorder have elevated rates of Bipolar I Disorder (4%-24%), Bipolar II Disorder (1%-5%), and Major Depressive Disorder (4%-24%).

The finding that the concordance rate for monozygotic twins isn't 100% suggests that environmental or psychological factors likely play a role in causation. Certain environmental factors (e.g., antidepressant medication, antipsychotic medication, electroconvulsive therapy, stimulants) or certain illnesses (e.g., multiple sclerosis, brain tumor, hyperthyroidism) can trigger mania. Mania can be triggered by giving birth, sleep deprivation, and major stressful life events.

Symptoms

In adults, mania is usually episodic with an elevation of mood and increased energy and activity. In children, mania is commonly chronic rather than episodic, and usually presents in mixed states with irritability, anxiety and depression. In adults and children, during depression there is lowering of mood and decreased energy and activity. During a mixed episode both mania and depression can occur on the same day.

Comorbidity

Comorbidity is the rule, not the exception, in bipolar disorder. The most common mental disorders that co-occur with bipolar disorder are anxiety, substance use, and conduct disorders. Disorders of eating, sexual behavior, attention-deficit/hyperactivity, and impulse control, as well as autism spectrum disorders and Tourette's disorder, co-occur with bipolar disorder. The most common general medical comorbidities are migraine, thyroid illness, obesity, type II diabetes, and cardiovascular disease.

Associated Mental Disorders

Bipolar I Disorder is often associated with: alcoholism, drug addiction, Anorexia Nervosa, Bulimia Nervosa, Attention-Deficit Hyperactivity Disorder, Panic Disorder, and Social Phobia.

Diagnostic Tests

There are no diagnostic laboratory tests for Bipolar I Disorder. Thus diagnosis is arrived at by using standardized diagnostic criteria to rate the patient's behavior. Onset of mania after age 40 could signify that the mania may be due to a general medical condition or substance use. Current or past hypothyroidism (or even mild thyroid hypofunction) may be associated with Rapid Cycling. Hyperthyroidism may precipitate or worsen mania in individuals with a preexisting Mood Disorder. However, hyperthyroidism in individuals without preexisting Mood Disorder does not typically cause manic symptoms.

Differential Diagnosis

Bipolar I Disorder must be distinguished from:

  • Mood Disorder Due to a General Medical Condition (e.g., due to multiple sclerosis, stroke, hypothyroidism, or brain tumor)

  • Substance-Induced Mood Disorder (e.g., due to drug abuse, antidepressant medication, or electroconvulsive therapy)

  • Other Mood Disorders (e.g., Major Depressive Disorder; Dysthymia; Bipolar II Disorder; Cyclothymic Disorder)

  • Psychotic Disorders (e.g., Schizoaffective Disorder, Schizophrenia, or Delusional Disorder)

  • Since this disorder may be associated with hyperactivity, recklessness, impulsivity, and antisocial behavior; the diagnosis of Bipolar I Disorder must be carefully differentiated from Attention Deficit Hyperactivity Disorder, Conduct Disorder, Antisocial Personality Disorder, and Borderline Personality Disorder

Pathophysiology

The pathophysiology of Bipolar I Disorder is poorly understood. However, a variety of imaging studies suggests the involvement of structural abnormalities in the amygdala, basal ganglia and prefrontal cortex. Research is now showing that this disorder is associated with abnormal brain levels of serotonin, norepinephrine, and dopamine.

Prevalence

Bipolar I Disorder affects both sexes equally in all age groups and its worldwide prevalence is approximately 3-5%. It can even present in preschoolers. There are no significant differences among racial groups in the prevalence of this disorder.

Course

The first episode may occur at any age from childhood to old age. The average age at onset is 21. More than 90% of individuals who have a single Manic Episode go on to have future episodes. Untreated patients with Bipolar I Disorder typically have 8 to 10 episodes of mania and depression in their lifetime. Often 5 years or more may elapse between the first and second episode, but thereafter the episodes become more frequent and more severe.

There is significant symptom reduction between episodes, but 25% of patients continue to display mood instability or mild depression. As many as 60% of patients experience chronic interpersonal or occupational difficulties between acute episodes. Bipolar I Disorder may develop psychotic symptoms. The psychotic symptoms in Bipolar I Disorder only occur during severe manic, mixed or depressive episodes. In contrast, the psychotic symptoms in Schizophrenia can occur when there is no mania or depression. Poor recovery is more common after psychosis.

Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months (median duration about 4 months). Depressive episodes tend to last longer (median length about 6 months), though rarely for more than a year, except in the elderly.

Treatment And Outcome

The usual treatment for Bipolar I Disorder is lifelong therapy with a mood-stabilizer (either lithium, carbamazepine, or divalproex / valproic acid) often in combination with an antipsychotic medication. Usually treatment results in a dramatic decrease in suffering, and causes an 8-fold reduction in suicide risk. In mania, an antipsychotic medication and/or a benzodiazepine medication is often added to the mood-stabilizer. In depression, quetiapine, olanzapine, or lamotrigine is often added to the mood-stabilizer. Alternatively, in depression, the mood-stabilizer can be switched to another mood-stabilizer, or two mood-stabilizers can be used together. Sometimes, in depression, antidepressant medication is used. Since antidepressant medication can trigger mania, antidepressant medication should always be combined with a mood-stablizer or antipsychotic medication to prevent mania.

Research has shown that the most effective treatment is a combination of supportive psychotherapy, psychoeducation, and the use of a mood-stabilizer (often combined with an antipsychotic medication). There is no research showing that any form of psychotherapy is an effective substitute for medication. Likewise there is no research showing that any "health food store nutritional supplement" (e.g., vitamin, amino acid) is effective for Bipolar I Disorder.

Since a Manic Episode can quickly escalate and destroy a patient's career or reputation, a therapist must be prepared to hospitalize out-of-control manic patients before they "lose everything". Likewise, severely depressed, suicidal bipolar patients often require hospitalization to save their lives.

Although the medication therapy for Bipolar I Disorder usually must be lifelong, the majority of bipolar patients are noncompliant and stop their medication after one year. At 4-year follow-up of bipolar patients, 41% have a good overall outcome and 4% have died. Women with bipolar disorder lose, on average, 9 years in life expectancy, 14 years of lost productivity and 12 years of normal health

Best Recoveries

The best recoveries are achieved when individuals with Bipolar I Disorder:

  1. Get the correct diagnosis (since many are misdiagnosed as having schizophrenia or "just borderline personality")

  2. Get effective treatment and faithfully stay on it for a lifetime (most individuals require the combination of a mood-stabilizer plus an antipsychotic medication)

  3. Adopt a healthy lifestyle (regular sleep and exercise; no alcohol or drug abuse; low stress)

  4. Regularly see a supportive physician who is knowledgeable about the psychiatric management of this disorder

  5. Learn which symptoms predict the return of this illness, and what additional "rescue" medication should be taken

  6. Learn to trust the warnings given by family and friends when they see early signs of relapse

  7. Learn as much as possible about this illness from therapists, the Internet, books, or self-help groups

TREATMENT

Depressive Episode

Manic Episode

Proven (Better Than Placebo) Treatments for Bipolar Depression

Proven (Better Than Placebo) Treatments for Mania

Promising (But Unproven) Treatments for Bipolar Depression

Promising (But Unproven) Treatments for Mania

Ineffective Treatments for Depression

Ineffective Treatments for Mania

Illness Course for Depression

  • Bipolar Disorder and severe Major Depressive Disorder are episodic, life-long illnesses that need life-long prophylactic treatment
  • Untreated depressive episodes usually last 11 weeks
  • Usually there are multiple episodes of depression if untreated
  • Suicide rate for bipolar patients is 15-22 times the national average
  • Suicide rate in first year off lithium therapy is 20 times the rate when on lithium

Illness Course for Mania

  • Untreated pure manic episodes usually last 6 weeks
  • Untreated mixed (manic+depressive) episodes usually last 17 weeks
  • Usually there are multiple episodes of mania if untreated
  • Mania usually returns 5 months after stopping lithium therapy
  • Within 2-4 years of first lifetime hospitalization for mania, 43% achieved functional recovery, and 57% switched or had new illness episodes

Description

  • Bipolar disorder in children - Epocrates Online
  • Bipolar disorder in adults - Epocrates Online
  • Seasonal affective disorder - Epocrates Online
  • Bipolar disorder - PubMed Health
  • Bipolar Disorder - Wikipedia
  • Bipolar Disorder - PubMed Health
  • Bipolar Disorder - NIMH
  • Bipolar Disorder in Children and Teens: A Parentís Guide - NIMH
  • Bipolar Disorder Genetics Online Mendelian Inheritance in Man
  • Stories

    Free Diagnosis Of This Disorder

    Rating Scales

    Web Community

    Treatment

    Famous Women With Bipolar Disorder

    Dr. Kay Jamison
    Dr. Kay Redfield Jamison, Psychologist and Professor of Psychiatry
    ,
    mental health advocate, author

    Famous Men With Bipolar Disorder

    Kurt Cobain
    Kurt Cobain, musician
    ,
    leader of the band Nirvana

    Medical

    Internet Links to Mood Disorders Sites

    Review Articles On Treatment

  • 2013 Research Review Articles
    • Biological Factors
      • Potential mechanisms of action of lithium in bipolar disorder. Current understanding (Numerous studies report that lithium is effective in the treatment of acute mania and for the long-term maintenance of mood and prophylaxis; in comparison, evidence for its efficacy in depression is modest. However, lithium possesses unique anti-suicidal properties that set it apart from other agents. Interestingly, lithium appears to preserve or increase the volume of brain structures involved in emotional regulation such as the prefrontal cortex, hippocampus and amygdala, possibly reflecting its neuroprotective effects. At a neuronal level, lithium reduces excitatory (dopamine and glutamate) but increases inhibitory (GABA) neurotransmission; however, these broad effects are underpinned by complex neurotransmitter systems that strive to achieve homeostasis by way of compensatory changes.)
    • Pharmaceutical Therapies
      • Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis (Lithium is an effective treatment for reducing the risk of suicide in people with mood disorders. )
      • Treatment of bipolar disorder (Antipsychotic drugs are effective in the acute treatment of mania; their efficacy in the treatment of depression is variable with the clearest evidence for quetiapine. Despite their widespread use, considerable uncertainty and controversy remains about the use of antidepressant drugs in the management of depressive episodes. Lithium has the strongest evidence for long-term relapse prevention; the evidence for anticonvulsants such as divalproex and lamotrigine is less robust and there is much uncertainty about the longer term benefits of antipsychotics. Long-term maintenance and possibly acute stabilisation of depression can be enhanced by the combination of psychosocial treatments with drugs.)
      • A systematic review of the evidence on the treatment of rapid cycling bipolar disorder (Rapid cycling is associated with longer illness duration and greater illness severity in bipolar disorder. A literature review suggested that: (i) rapid cycling patients perform worse in the follow-up period; (ii) lithium and anticonvulsants have comparable efficacies; (iii) there is inconclusive evidence on the comparative acute or prophylactic efficacy of the combination of anticonvulsants versus anticonvulsant monotherapy; (iv) aripiprazole, olanzapine, and quetiapine are effective against acute bipolar episodes; (v) olanzapine and quetiapine appear to be equally effective to anticonvulsants during acute treatment; (vi) aripiprazole and olanzapine appear promising for the maintenance of response of rapid cyclers; and (vii) there might be an association between antidepressant use and the presence of rapid cycling.)
      • Asenapine for the treatment of manic and mixed episodes associated with bipolar I disorder: from clinical research to clinical practice (Asenapine displays quick and reliable effects on manic symptoms, very low risk of depressive switches, efficacy on depressive symptoms during manic and mixed episodes, usually good tolerability and continued longer-term efficacy on residual and subthreshold symptoms. The fast-dissolving sublingual route of administration may favor those who have difficulties in swallowing medications. The relatively low metabolic risk and the lack of anticholinergic side effects contribute to making this medication a useful tool for the treatment of patients with bipolar disorder.)
      • Consensus statement on the use of intramuscular aripiprazole for the rapid control of agitation in bipolar mania and schizophrenia (Of the available agents for rapid tranquillisation, aripiprazole demonstrated a favourable efficacy and safety profile both over the short-term - including in its intramuscular form (IM) - and in the long-term treatment of bipolar I disorder and schizophrenia)
      • Lower rate of depressive switch following antimanic treatment with second-generation antipsychotics versus haloperidol (Treating acute mania with atypicals is associated to 42% less risk of switch to depression than with haloperidol. Nevertheless, caution should be taken when considering this a class effect, as only olanzapine, quetiapine, and ziprasidone may show a better profile.)
    • Psychological Therapies
      • Bipolar affective disorder and psychoeducation (Most bipolar patients cannot be treated only by drugs. Randomized controlled trials of cognitive behavioral therapy, interpersonal and social rhythm therapy, individual, group and family psychoeducation show that these approaches augment stabilizing effect of pharmacotherapy. Patients and their families should be educated about bipolar disorder, triggers, warning signs, mood relapse, suicidal ideation, and the effectiveness of early intervention to reduce complications.)
    • Miscellaneous
      • Bipolar depression in pediatric populations : epidemiology and management (Lithium and lamotrigine are feasible and tentatively efficacious options; however, treatment with quetiapine monotherapy may be no better than placebo. Furthermore, some youth may be at heightened risk for developing manic symptoms after treatment with selective serotonin reuptake inhibitors (SSRIs). Psychotherapy, either alone or adjunctively with medications, provides practitioners with a safe and feasible alternative.)
      • Bipolar disorders and comorbid anxiety: prognostic impact and therapeutic challenges (Many clinical and epidemiological studies have found much higher prevalence rates of generalized anxiety disorder, social phobia, obsessive-compulsive disorder, panic disorder and post-traumatic stress disorder in bipolar patients than in the general population, regardless of age. In the National Comorbidity Survey for instance, the diagnosis of at least one anxiety disorder was made for nearly 90% of bipolar subjects. Many studies point out the poorer outcome for bipolar patients with co-occurring anxiety symptoms: apart from the alarming increase of suicidal ideas and suicide attempts, authors have found a shorter duration of euthymia, more comorbid addictions, mixed states and rapid cycling, and lower response to treatments.)
  • 2009 Research Review Articles
  • 2008 Research Review Articles
  • 2007 Research Review Articles
  • 2006 Research Review Articles
  • Research

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