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Understanding Bipolar Disorder

What Clinicians Should Know about Bipolar Disorder

Bipolar disorder affects about 3 % of the population and can have devastating effects. It is the sixth most common cause of disability in the United States. Life-time rates for completed suicide are significantly higher than for the general population. People with bipolar disorder often suffer from lower wages, higher unemployment, work absenteeism, reliance on workman's compensation, higher rates of divorce, lower levels of educational attainment, higher arrest and hospitalization. In one study 81% of individuals with bipolar disorder had a current comorbid medical condition. ("Comorbidity" refers to the co-occurrence of other problems with the illness.) The most frequent comorbid conditions are increased rates of coronary heart disease, hypertension, hyperthyroidism, diabetes, dysplidemias, and hepatitis. These individuals have higher rates of smoking, drug and alcohol abuse, poorer self-care (less exercise, less medical care, inactive lifestyles)-all of which may contribute to higher obesity rates. Increased risk of pulmonary embolism may be a consequence of increased obesity and life-style factors in bipolar disorder. Of course, these medical conditions and life-style problems contribute to the stress in coping with the illness.

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Individuals with bipolar disorder are also more likely to present with other psychiatric problems, sometimes making the diagnosis more difficult. Anxiety disorders, substance abuse, and personality disorders are often comorbid with bipolar disorder. Since patients seldom seek out treatment for "enjoyable" manic highs, many of these individuals have been incorrectly diagnosed as unipolar depression-that is, as having major depressive episodes with no history of mania. Moreover, many manic episodes quickly "evolve" into mixed episodes, characterized by both manic and depressive symptoms, especially irritability--- thereby making it more difficult for the clinician to reach a definitive and accurate diagnosis. This is why any patient with a history of depression should be evaluated for possible bipolar disorder. In many cases, family members may be better than the patient at reporting the accurate history of mood destabilization.

As the name implies, bipolar disorder is cyclical, with patients experiencing many ups and downs throughout their lives. In the largest multi-center study of mood disorders ever conducted--the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)-1,469 participants with bipolar disorder were followed over a 24-month period. During this period, 48.5 % experienced recurrences, with depressive episodes twice as likely to occur as manic episodes.

Higher rates (19.4 %) of bipolar disorder are found in patients with borderline personality disorder than among patients with other personality disorders, although the overlap may sometime reflect a misdiagnosis of borderline personality for patients who are not euthymic (normal mood). Bipolar individuals with comorbid alcohol abuse will have higher rates of rapid cycling, symptom severity, suicidality, aggressivity, and impulsivity. The illness is serious, complicated, chronic and often life-threatening. Clinicians should be ready to collaborate with the patient, family members, prescribing physicians, other medical personnel and anyone who is supportive to the patient's needs.

What Clinicians Should Know about Bipolar Disorder

1. What are the diagnostic signs of bipolar disorder? The clinician should be able to recognize not only manic and depressive states, but also hypomania and mixed states. In addition, the clinician should be able to rule out substance abuse as the cause of a current manic state--- evaluating whether there is a history of mania independent of substance abuse. This is not always easy since many bipolar individuals abuse drugs and alcohol.

2. Bipolar disorder has a high genetic determination. This is important since it helps "medicalize" the illness, taking away some of the moral stigma that these individuals experience. It also helps the patient understand the relevance and necessity of medication. Family members should also be assisted in understanding the biological nature of mood disorders.

3. Treat the specific episode-but plan for future mood destabilization. Bipolar patients often present to the therapist either in a severe depressive episode or during or after a serious manic episode has led to relational, occupational or legal problems. Anti-psychotic medication can help reduce the intensity of manic episodes and can be continued when mood-stabilizers are added on. Depressive phases can also be treated with anti-psychotic medication, anti-depressants, and later with mood stabilizers. However, planning for future "bipolarity" is essential, establishing the need for continued pharmacological treatment.

4. Medication is essential. Although the first line of treatment generally entails lithium, anticonvulsants, and atypical anti-psychotics, some patients may also benefit from thyroid augmentation, clozapine, calcium channel blockers, and electroconvulsive therapy (ECT). Some female patients may benefit from hormonal treatments for mania or hypomania, specifically, tamoxifen and medroxyprogesterone acetate (MPA). Continuing ECT as maintenance (C-ECT) has shown some promise for alleviating the recurrence of episodes .

5. Educate patients and families about the illness. An excellent book for families and patients is The Bipolar Survival Guide by David Miklowitz. Educating patients and families helps take away the stigma of the illness, helps family members realize that the patient is not freely choosing to have an illness, and helps both patients and family members "catch" the early (prodromal) signs of the onset of a depressed or manic mood. This early detection can assist the prescribing physician in adjusting the medications prescribed and can also help the patient plan strategies for coping with manic or depressed moods before they get too far along.

Bipolar disorder may appear to be a pessimistic diagnosis for some. That is understandable, since the diagnosis implies a life-long vulnerability. However, many patients who come to terms with the diagnosis and with having the illness begin to understand why they have had so many problems in relationships, work, and in coping with life problems. For some, the diagnosis frees the individual from the stigma of having a "character defect". It helps take away the blame. It provides a plan for coping with the illness-through medication-but also with the help of psychological treatments such as cognitive-behavioral therapy, family therapy, or interpersonal/social rhythm therapy. None of these treatments guarantees a steady and "normal" mood---patients, families, prescribing physicians and therapists should be ready to cope with ups and downs and be ready to implement more intense treatment when necessary. The good news is that there are more intense treatments--- that is, help for those who a century ago could only look forward to a series of mood episodes that often devastated individual lives.

 

Robert L. Leahy, Ph.D., is the author of Anxiety Free,The Worry Cure and Beat the Blues. He is Clinical Professor of Psychology at Weill-Cornell Medical School. more...

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