Management of Bipolar Disorder

KIM S. GRISWOLD, M.D., M.P.H., and LINDA F. PESSAR, M.D. State University of New York at Buffalo, Buffalo, New York	A patient information handout on bipolar disorder, written by the authors of this article, is provided on page 1357.
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.

Bipolar disorder most commonly is diagnosed in persons between 18 and 24 years of age. The clinical presentations of this disorder are broad and include mania, hypomania and psychosis. Frequently associated comorbid conditions include substance abuse and anxiety disorders. Patients with acute mania must be evaluated urgently. Effective mood stabilizers include lithium, valproic acid and carbamazepine. A comprehensive management program, including collaboration between the patient's family physician and psychiatrist, should be implemented to optimize medical care. (Am Fam Physician 2000;62:1343-53, 1357-8.)

Bipolar disorder is characterized by variations in mood, from elation and/or irritability to depression. This disorder can cause major disruptions in family, social and occupational life. Bipolar I disorder is defined as episodes of full mania alternating with episodes of major depression. Patients with mania often exhibit disregard for danger and engage in high-risk behaviors such as promiscuous sexual activity, increased spending, violence, substance abuse and driving while intoxicated.

TABLE 1 Causes of Secondary Mania The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Bipolar II disorder is characterized by recurrent episodes of major depression and hypomania. Hypomania is manifested by an elevated and expansive mood. The behaviors characteristic of hypomania are similar to those of mania but without gross lapses of impulse and judgment. Hypomania does not cause impairment of function and may actually enhance function in the short term.

Bipolar I disorder is typically diagnosed when patients are in their early 20s. Manic symptoms can rapidly escalate over a period of days and frequently follow psychosocial stressors. Some patients initially seek treatment for depression. Other patients may appear irritable, disorganized or psychotic. Differentiating true mania from mania resulting from secondary causes can be challenging (Table 1).^1,2

Bipolar II disorder typically is brought to medical attention when the patient is depressed. A careful history will usually illuminate the diagnosis. Some depressed patients exhibit hypomania when given antidepressants.³ This variation is sometimes referred to as bipolar III disorder. The criteria for major depressive episode and manic episode, as described in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), are summarized in Table 2.⁴

Epidemiology

The lifetime prevalence of bipolar disorder is 1 percent, which compares to a lifetime prevalence of 6 percent for unipolar depression.⁵ The prevalence of bipolar disorder does not differ in males and females.⁶ The disorder affects persons of all ages. The epidemiologic catchment area study revealed the highest prevalence in the 18-to-24-year age group.⁷ In some patients, however, bipolar disorder does not become manifest until patients are older. One study reported new-onset bipolar disorder in patients older than 60 years.⁸

The incidence of bipolar disorder is increased in first-degree relatives of persons with the disorder, as is the incidence of other mood disorders.⁹ One study revealed a 13 percent risk of bipolar disorder among offspring of persons with the disorder.¹⁰ The risk of unipolar depression was 15 percent, and the risk of schizoaffective disorder was 1 percent.¹⁰ The mode of inheritance remains unclear, and no algorithm exists to predict the risk of bipolar disorder.¹¹ Because of the familial association, genetic counseling should be offered to patients and their families as part of comprehensive educational and supportive approaches.

Clinical Presentations

Patients with symptoms of a mood disorder often do not meet the full criteria for bipolar disorder. Many patients with bipolar disorder are diagnosed as having depression. If agitation is prominent, hypomanic symptoms may be misunderstood as representing an anxiety state. Accurate diagnosis of bipolar disorder requires obtaining a comprehensive psychiatric history.

TABLE 2 Criteria for Major Depressive Episode and Manic 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. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) 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 made by others) 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 gains. 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 indeciseveness, 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 Manic episode A distinct period of abnormally and persistently elevated, expansive , or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 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) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:327,332. Copyright 1994.

Children
Hyperactivity is the most common behavioral manifestation of mania in children.¹² Manic children may exhibit irritability or temper tantrums.¹³ The differential psychiatric diagnoses include attention-deficit/ hyperactivity disorder, conduct disorder and schizophrenia.¹⁴

If agitation is prominent in bipolar disorder, hypomanic symptoms may be misunderstood as reflecting an anxiety state.

Adolescents
Manic symptoms in adolescents are similar to those in adults. Florid psychosis can be a presentation of bipolar disorder in adolescents. Included in the differential diagnosis of mania in adolescents are substance abuse and schizophrenia, which may be challenging to distinguish from bipolar disorder. The normal risk-taking behavior in some adolescents must be distinguished from the reckless nature of manic symptoms.

During Pregnancy
The course of bipolar disorder during pregnancy is variable. Management requires sustained collaboration between the patient's family physician and her psychiatrist. A patient with bipolar disorder should be encouraged to plan pregnancy so that the dosage of her psychiatric medication can be slowly tapered. The risk of relapse is increased with abrupt discontinuation.¹⁵

Patients presenting with acute mania should be evaluated urgently; appropriate transportation of the patient from the office to the hospital must be arranged.

Relapse during pregnancy must be treated aggressively with mood stabilizers. The patient should be admitted to the hospital. If lithium therapy is required, the patient should be counseled regarding the increased risk of cardiovascular malformations in fetuses exposed to lithium. Breast-feeding during lithium therapy is discouraged because lithium is excreted in breast milk.¹⁶

During the postpartum period, worsening of affective symptoms may occur, including rapid cycling, which is sometimes refractory to drug therapy.¹⁷ Women who have worsening of symptoms postpartum may have an increased risk of recurrence.

Comorbid Conditions

Studies of primary care patients with major depressive disorders have demonstrated a tendency toward certain comorbid conditions. In one study,¹⁸ more than 42 percent of patients meeting the criteria for a major depressive disorder (including bipolar disorder) had lifetime histories of substance abuse. In another study,¹⁹ the frequency of substance abuse was 39 percent in adolescents who had symptoms of bipolar disorder. Another study²⁰ revealed a high prevalence of moderate to severe anxiety disorders in association with bipolar disorder, as well as a high prevalence of psychosocial morbidity.

While many patients with bipolar disorder show gradual improvement in the first several years after diagnosis, a substantial subgroup experiences poor adjustment in one or more areas of functioning.²¹ In a study of psychiatric patients who were evaluated 30 to 40 years after the index hospitalization for mania, 24 percent of the sample was considered to be occupationally incapacitated.²²

Treatment

TABLE 3 Laboratory Evaluation of Patients Presenting with Bipolar Disorder Inpatient Complete physical examination Serum levels of lithium, valproic acid (Depakene), carbamazepine (Tegretol) and selected tricyclic antidepressants (if relevant) Thyroid function tests Complete blood count and general chemistry screening Urinalysis if lithium therapy is initiated Electrocardiography in patients older than 40 years Urine toxicology for substance abuse Pregnancy test (if relevant) Outpatient Complete physical examination Serum levels of lithium, valproic acid, carbamazepine and selected tricyclic antidepressants (if relevant) Thyroid function tests Complete blood count and general chemistry screening Urinalysis if lithium therapy is initiated Pregnancy test (if relevant) Second-line tests: urine toxicology for substance abuse and electrocardiography in patients older than 40 years Adapted with permission from Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.

Urgent and Emergent
If a patient with symptoms of acute mania presents to the office, a psychiatrist should be consulted, and the patient should be evaluated urgently. The family physician must know the legal requirements in the community for transferring a patient with acute mania from the office to the hospital. Often, police must be involved. It is inappropriate to expect family members to transport the patient from the office to the hospital, because family members may not appreciate the irrationality of manic thinking and the unpredictability of manic behavior.

The family physician and psychiatrist have the responsibility to inform, educate and support family members in terms of the possible need for the family to petition the court for the patient's admission to a psychiatric unit. It is important to recognize, and to try to allay, the guilt and regret family members often feel in these circumstances.

Patients with newly diagnosed bipolar disorder require a medical evaluation along with a psychiatric evaluation. Table 3²³ lists the recommended laboratory tests for patients evaluated on an inpatient or an outpatient basis. Computed tomography or magnetic resonance imaging and electroencephalography are second-line options in the evaluation of treatment-resistant patients. These studies are not routinely required without a specific clinical reason. Similarly, the need for electrocardiography in patients younger than 40 years rests with the clinician's judgment.

If necessary, and if the patient has been in good general health, mood stabilizers, as well as other drugs used in the treatment of bipolar disorder, can be started before the test results are available. If the need to begin treatment is urgent, medication can be given even before laboratory specimens are obtained.

Collaborative Ongoing Care
Given the chronic nature of bipolar disorder and its impact on the entire family, it is important for the patient's family physician and psychiatrist to develop an effective and collaborative relationship. Informed collaboration depends on an agreed method of communication in a frequency that meets the needs of each physician.²⁴ A Canadian model brings psychiatrists and counselors into family practice offices for shared care.²⁵

At the onset of bipolar disorder, the family physician might seek psychiatric consultation for differential diagnosis and treatment recommendations. Often, the psychiatrist assumes responsibility for initial management until the patient's clinical pattern is determined. During follow-up, both physicians should monitor the patient for signs of psychosis, mood swings, violence and self-harmful behaviors. As the patient's illness stabilizes and management becomes routine, the physicians can renegotiate, with each other and with the patient, responsibility for ongoing care.

Tricyclic antidepressants may induce rapid cycling of symptoms.

When the patient's condition has become stable, the psychiatrist may not need to see the patient as often, although the frequency of follow-up psychiatric visits depends on the course of the illness, the patient's adherence to treatment, medication requirements, the need for ongoing psychotherapy and patterns of care in a particular geographic area. It is important for the patient's family physician and psychiatrist to coordinate medication prescriptions and follow-up laboratory tests such as determination of serum drug levels. In addition, counseling and family therapy are important components of management and may be rendered by the family physician, psychiatrist and/or psychologist.

Medication
Recommendations for drug therapy in patients with bipolar disorder are summarized in Table 4.²³

TABLE 4 Recommendations for Drug Therapy in Patients with Bipolar Disorder Considerations for prescribing mood stabilizers Lithium: For classic, euphoric mania; for mixed manic episode; when a mood stabilizer alone is used to treat depression; when the mood stabilizer must be given in a single evening dose; in patients with liver disease, excessive alcohol use or cocaine use; and in patients older than 65 years Valproic acid (Depakene): For classic, euphoric mania; for mixed manic episode; for mania with rapid cycling; for long-term maintenance therapy in patients who do not tolerate lithium because of the "flat" feeling lithium causes; in patients with structural central nervous system disease, renal disease and cocaine use; and in patients older than 65 years Carbamazepine (Tegretol): For mixed manic episode; for mania with rapid cycling; in patients with structural central nervous system disease or renal disease An antipsychotic agent High- or medium-potency antipsychotic agents are used as adjunctive treatment for mania with psychosis or psychotic depression. A benzodiazepine Sleep and sedation in mania or hypomania; insomnia in depression The combination of a mood stabilizer, an antidepressant and an antipsychotic Psychotic depression The combination of a mood stabilizer and an antidepressant Nonpsychotic depression A mood stabilizer alone Milder depression in bipolar I disorder Bupropion (Wellbutrin) Bipolar depression Patient with high risk of manic switch or rapid cycling A selective serotonin reuptake inhibitor Bipolar depression Adapted with permission from Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.

Medication is the key to stabilizing bipolar disorder. Initial treatment of mania consists of lithium or valproic acid (Depakene). If the patient is psychotic, a neuroleptic medication is also given. Long-acting benzodiazepines may be used for treating agitation. However, in patients with a substance-abuse history, benzodiazepines should be used with caution because of the addictive potential of these agents.

When the patient with bipolar disorder becomes depressed, a selective serotonin reuptake inhibitor (SSRI) or bupropion (Wellbutrin) is recommended.²⁶ The use of tricyclic antidepressants should be avoided because of the possibility of inducing rapid cycling of symptoms.

TABLE 5 Drug Interactions with Lithium Drug Effect on lithium level Management Thiazide diuretics Increased lithium level Avoid this combination or reduce dosage; monitor lithium level Loop diuretics Increased or decreased lithium level Avoid this combination or alter either dosage as needed; monitor lithium level Potassium-sparing diuretics Decreased lithium level Monitor lithium level and adjust dosage Nonsteroidal anti-inflammatory drugs Increased lithium level Use lower dosage of lithium; consider aspirin or sulindac Angiotensin-converting enzyme inhibitors Increased lithium level; toxicity reported Use lower dosage of lithium; monitor lithium level closely Calcium channel blockers Increased or decreased lithium level Monitor lithium level closely Adapted with permission from DeVane CL, Nemeroff CB. 1998 Guide to psychotropic drug interactions. Primary Psychiatry 1998;5:36-75.

TABLE 6 Drug Interactions with Valproic Acid (Depakene) Drug Interaction Management Phenobarbital Increased phenobarbital level Reduce dosage Magnesium- and aluminum-containing antacids Increased valproic acid level Monitor valproic acid level; reduce dosage Carbamazepine (Tegretol) Decreased valproic acid level; possible increased carbamazepine level Monitor valproic acid level; adjust dosage Aspirin and naproxen (Naprosyn) Increased valproic acid level Avoid salicylates or other drugs bound to plasma albumin Clonazepam (Klonopin) Increased sedation Use with caution Adapted with permission from DeVane CL, Nemeroff CB. 1998 Guide to psychotropic drug interactions. Primary Psychiatry 1998;5:36-75.

Drug interactions are an important consideration when prescribing lithium (Table 5),²⁷ valproic acid (Table 6)²⁷ and a selective serotonin reuptake inhibitor (Table 7).²⁷ Information about starting and maintenance dosages for lithium, valproic acid and carbamazepine (Tegretol) is summarized in Table 8.²³

Monitoring Issues
Treatment with mood stabilizers requires periodic laboratory tests to monitor the patient's response to the drug (Table 9).²³ In addition, preventive care includes surveillance for possible comorbidities. Screening for substance abuse and other mental health problems should be conducted routinely. If prodromal symptoms of depression or mania are noted, interventions may include more frequent office visits, crisis telephone calls and intensive outpatient programs.²³ It is important that patients regulate their sleep. Insufficient and irregular hours of sleep often precipitate mood disturbance.

TABLE 7 Drug Interactions with Selective Serotonin Reuptake Inhibitors Drug Interaction Management Alprazolam (Xanax) Increased alprazolam levels Monitor; reduce dosage TCAs Increased TCA level Monitor TCA level Warfarin (Coumadin) Increased warfarin level with fluvoxamine (Luvox) Monitor prothrombin time (INR); reduce fluvoxamine dosage MAOIs Serotonin syndrome Combination of MAOI and SSRI is contraindicated Clozapine (Clozaril) Increased clozapine level with fluvoxamine Monitor clozapine level l-Tryptophan Serotonin syndrome Combination of l-tryptophan and SSRI is contraindicated Phenytoin (Dilantin) Possible phenytoin toxicity Monitor phenytoin level Carbamazepine (Tegretol) Increased carbamazepine level with fluvoxamine and fluoxetine (Prozac) Monitor carbamazpine level Tolbutamide Possible increased hypoglycemia Monitor blood glucose level Theophylline Increased theophylline level with fluvoxamine Monitor theophylline level Cimetidine (Tagamet) Increased SSRI levels Monitor clinically Type Ic antiarrhythmics Increased antiarrhythmic level with fluoxetine, paroxetine (Paxil) and sertraline (Zoloft) Monitor antiarrhythmic drug levels Beta-adrenergic blockers Increased beta-blocker level and enhanced effects Use lower beta-blocker dosage Codeine Inhibited metabolism from fluoxetine, paroxetine and sertraline Use different SSRI St. John's wort Serotonin syndrome Stop St. John's wort before beginning SSRI therapy SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; INR = International Normalized Ratio; MAOI = monoamine oxidase inhibitor. Adapted with permission from DeVane CL, Nemeroff CB. 1998 Guide to psychotropic drug interactions. Primary Psychiatry 1998;5:36-75.

TABLE 8 Starting and Maintenance Dosages of Lithium, Valproic Acid and Carbamazepine and Common Side Effects Initial dosing strategy* Maintenance dosage** Common side effects*** Cost (generic)§ Lithium 900 mg per day; increase by 300 to 600 mg every 2 to 3 days as tolerated 900 to 1,800 mg per day; 1,200 mg may be given as a single bedtime dose if tolerated; otherwise, prescribe twice-daily dosing Therapeutic blood level: 0.8 to 1.5 mEq per L Thirst, polyuria, cognitive complaints, tremor,|| weight gain, sedation, diarrhea, nausea (watch for dehydration, which can lead to toxicity), hypothyroidism (monitor TSH; give levothyroxine [Synthroid] if TSH is elevated) One 300-mg capsule: $0.19 (0.06 to 0.10) Valproic acid (Depakene) 20 mg per kg per day for mania; adjust dosage in 3 to 5 days An alternative is 500 to 750 mg daily; increase by 30 to 50 percent every 2 to 3 days as tolerated 1,000 to 3,000 mg per day. Lower dosages may be used in hypomania. Sometimes it is appropriate to give as a single bedtime dose; otherwise, prescribe twice-daily dosing Therapeutic blood level: 50 to 125 µg per mL Tremor,|| sedation, diarrhea, nausea (use divalproex [Depakote]; give histamine H2-receptor blocker such as ranitidine [Zantac], 150 mg daily); weight gain, hair loss, mild elevation on liver function tests One 250-mg capsule: $1.24 Carbamazepine (Tegretol) 200 to 400 per day; increase by 200 mg daily every 2 to 4 days 400 to 1,200 mg daily; in an occasional patient, it is appropriate to give a single bedtime dose; otherwise, prescribe twice-daily dosing Therapeutic blood level: 4 to 12 µg per mL; not well established Headache, nystagmus, ataxia, sedation, rash, leukopenia (do not combine with clozapine [Clorazil]), mild elevation on liver function tests. Carbamazepine is associated with frequent drug­drug interactions related to induction of cytochrome P450 liver enzymes, resulting in lower drug levels of many other medications. One 200-mg tablet: $0.44 (0.29 to 0.33) TSH = thyroid-stimulating hormone. *--When initiating therapy, consider lower dosages in patients with hypomania and in medically ill or elderly patients. **--Consolidate doses to twice daily or once daily at bedtime if tolerated and efficacious. ***--Many of the side effects are dose related. Tolerance can be enhanced by tailoring the dosage to each patient's tolerance and response. §--Estimated cost to the pharmacist for one tablet or capsule based on average wholesale prices rounded to the nearest dollar in Red book. Montvale, N.J.: Medical Economics Data, 1999. Cost to the patient will be higher, depending on prescription filling fee. ||--Tremor may be relieved with a beta-adrenergic blocker such as atenolol (Tenormin), in a dosage of 50 mg daily. Adapted with permission from Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.

Family and Psychosocial Issues

Significant issues for the patient and family members include the stigma that is frequently associated with mental illness and the need for support and education. Because patients with bipolar disorder lose judgment early in the course of the illness and often engage in high-risk behavior, family members may be interacting with the legal system, the police and the health care system simultaneously. Guilt, anger, grief and ambivalence are frequent feelings among family members as they cope with the difficulties.

Family members must be educated about possible relapses, what to look for and how to handle different situations. The recklessness that accompanies mania can have devastating consequences--including sexually transmitted diseases, financial ruin, traumatic injuries and accidents. Risk-taking causes significant distress to patients and families, and such behavior is a problem for which family physicians, psychiatrists and mental health professionals can intervene with appropriate medical, preventive, educational and social strategies (Table 10).²³ Initial intervention includes education for the patient and family, including informational pamphlets, videos and involvement in support and patient advocacy groups.

TABLE 9 Recommended Laboratory Tests for Monitoring Response to Lithium, Valproic Acid and Carbamazepine Lithium Valproic acid (Depakene) Carbamazepine (Tegretol) First two months of therapy Serum level every 1 to 2 weeks*§ Serum level every 1 to 2 weeks* CBC and liver function tests monthly Serum level every 1 to 2 weeks* CBC and liver function tests monthly Long-term therapy Serum level every 3 to 6 months*§ Thyroid function tests yearly (total T4, T4 uptake and TSH)§ Renal function every 6 to 12 months (serum urea nitrogen, creatinine and electrolytes); 24-hour urine for volume and GFR only if specifically indicated, not routinely Serum level every 3 to 6 months*§ CBC and liver function tests every 6 to 12 months Serum level every 3 to 6 months* CBC and liver function tests every 6 months CBC = complete blood count; T4 = thyroxine; TSH = thyroid-stimulating hormone; GFR = glomerular filtration rate. *--Serum levels of mood stabilizers should be obtained whenever the dosage or clinical situation changes. §--Tests are strongly recommended by the committee that formulated the guidelines for treatment of bipolar disorder. Adapted with permission from Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.

TABLE 10 Psychosocial Issues to Address in the Acute and Maintenance Phases of Bipolar Disorder Acute phase Maintenance phase Monitor suicidality, mood, substance use, sleep patterns and medication compliance. Educate patient and family members about features and biologic nature of the illness and the importance of compliance with therapy. Encourage telephone contact and optimism regarding recovery. Set limits on impulsive behavior in patients with mania. Consider interpersonal or cognitive therapy for patients with depression. Hold family meetings to discuss issues. Inquire about suicidality, mood, medication compliance, life events, substance use, sleep and activity. Educate patient and family members about use of medication, warning signs of relapse, management of stress, sleep hygiene, eating and exercising regularly, limited caffeine and alcohol intake and management of work and leisure activities. Long-range issues may include marital problems, employment and financial problems, peer relationships and modification of personality traits. Adapted with permission from Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.

Patients who are manic or depressed may attempt suicide or homicide. The risk is increased in patients who are psychotic and have severe depressive symptoms concurrent with mania.²⁸ The lifetime suicide risk is 15 percent in patients with bipolar disorder; patients at highest risk are young men in an early phase of illness who have made previous suicide attempts or who abuse alcohol.²⁹ Family members must learn the warning signs of suicide and must be able to distinguish between the signs of mania and those of depression.

Substance use should be discouraged. Even modest social drinking can lead to mood disturbance. In addition, substances such as alcohol can interact with medications, disinhibit patients and contribute to risky behaviors.

Easy access to firearms can supply a ready means of suicide or accident in patients with bipolar disorder.

Guns should be removed from the house. Easy access to firearms can supply a ready means of suicide or accidental injury in a patient with impaired insight and judgment.

If the patient or family has concerns about sexually transmitted diseases, testing and counseling can be offered and preventive strategies explained and encouraged.

Legal intervention may be required in patients who exhibit violent behavior. Spouses should be informed of their legal rights, given crisis intervention information and access to safe houses.

If a patient is out of control in spending money, several avenues should be explored. Patients and family members may need referral to social services and/or to legal counsel. Precautions might include putting the house in the spouse's name, limiting credit lines, creating trust funds and using financial planning services. Support groups are useful, as is family therapy.

Final Comment

Bipolar disorder can be well managed by family physicians in concert with psychiatrists. The consequences of the patient's behavior on the patient's life as well as the lives of family members must be explored. The family physician has a significant contribution to make in terms of education, support and follow-up. Both family physicians and psychiatrists have opportunities to intervene and help these patients and their families.

The authors thank Carlos R. Jaen, M.D., Ph.D., Department of Family Medicine, State University of New York at Buffalo, for support in the preparation of the manuscript.

---

The Authors

KIM S. GRISWOLD, M.D., M.P.H.,
is assistant professor of family medicine and psychiatry in the Department of Family Medicine at the State University of New York (SUNY) at Buffalo School of Medicine and Biomedical Sciences. She received a master's degree in public health from Yale University, New Haven, Conn., and completed a faculty development fellowship in primary care at Michigan State University College of Human Medicine, East Lansing. After graduating from the SUNY­Buffalo School of Medicine and Biomedical Sciences, she completed a family practice residency at Buffalo (N.Y.) General Hospital.

LINDA F. PESSAR, M.D.,
is a psychiatrist and associate professor of clinical psychiatry and family medicine at SUNY­Buffalo School of Medicine and Biomedical Sciences, where she is also director of medical student education in psychiatry. She received a medical degree from Columbia University College of Physicians and Surgeons, New York City, and completed a psychiatry residency at New York State Psychiatric Institute/Columbia Presbyterian Medical Center, New York City.

Address correspondence to Kim S. Griswold, M.D., M.P.H., Department of Family Medicine, State University of New York at Buffalo, Center for Urban Research in Primary Care, 135 Grant St., Buffalo, NY 14213. Reprints are not available from the authors.

REFERENCES

1. Krauthammer C, Klerman GL. Secondary mania. Arch Gen Psychiatry 1978;35:1333-9.
2. Cassem NH. Depression. In: Hackett TP, Cassem NH, eds. Massachusetts General Hospital handbook of general hospital psychiatry. 2d ed. Littleton, Mass.: PSG, 1987:227-60.
3. Hartmann PM. Mania or hypomania after withdrawal from antidepressants. J Fam Pract 1990; 30:471-2.
4. American Psychiatric Association. Task Force on DSM-IV. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, D.C.: American Psychiatric Association, 1994:232-450.
5. Hales RE, Yudofsky SC, Talbott JA, eds. The American Psychiatric Press Textbook of psychiatry. 3d ed. Washington, D.C.: American Psychiatric Press, 1999.
6. Keller MB, Baker LA. Bipolar disorder: epidemiology, course, diagnosis, and treatment. Bull Menninger Clin 1991;55:172-81.
7. Robins LN, Regier DA. Psychiatric disorders in America: the epidemiologic catchment area study. New York, N.Y.: Free Press, 1991.
8. Bebbington P, Ramana R. The epidemiology of bipolar affective disorder. Soc Psychiatry Psychiatr Epidemiol 1995;30:279-92.
9. Werder SF. An update on the diagnosis and treatment of mania in bipolar disorder. Am Fam Physician 1995;51:1126-36.
10. Gershon ES, Hamovit J, Guroff JJ, Dibble E, Leckman JF, Sceery W, et al. A family study of schizoaffective, bipolar I, bipolar II, unipolar, and normal control probands. Arch Gen Psychiatry 1982;39:1157-67.
11. Mitchell P, Mackinnon A, Waters B. The genetics of bipolar disorder. Aust N Z J Psychiatry 1993;27: 560-80.
12. Faedda GL, Baldessarini RJ, Suppes T, Tondo L, Becker I, Lipschitz DS. Pediatric-onset bipolar disorder: a neglected clinical and public health problem. Harv Rev Psychiatry 1995;3:171-95.
13. Hechtman L, Greenfield B. Juvenile onset bipolar disorder. Curr Opin Pediatr 1997;9:346-53.
14. Weller EB, Weller RA, Fristad MA. Bipolar disorder in children: misdiagnosis, underdiagnosis, and future directions. J Am Acad Child Adolesc Psychiatry 1995;34:709-14.
15. Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J. Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996;153:592-606.
16. Packer S. Family planning for women with bipolar disorder. Hosp Community Psychiatry 1992;43: 479-82.
17. Altshuler LL, Hendrick V, Cohen LS. Course of mood and anxiety disorders during pregnancy and the postpartum period. J Clin Psychiatry 1998; 59(suppl 2):29-33.
18. Coyne JC, Fechner-Bates S, Schwenk TL. Prevalence, nature, and comorbidity of depressive disorders in primary care. Gen Hosp Psychiatry 1994; 16:267-76.
19. West SA, Strakowski SM, Sax KW, McElroy SL, Keck PE, McConville BJ. Phenomenology and comorbidity of adolescents hospitalized for the treatment of acute mania. Biol Psychiatry 1996;39: 458-60.
20. Nease DE, Volk RJ, Cass AR. Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients. J Am Board Fam Pract 1999;12:21-31.
21. Goldberg JF, Harrow M, Grossman LS. Course and outcome in bipolar affective disorder: a longitudinal follow-up study. Am J Psychiatry 1995;152: 379-84.
22. Coryell W, Scheftner W, Keller M, Endicott J, Maser J, Klerman GL. The enduring psychosocial consequences of mania and depression. Am J Psychiatry 1993;150:720-7.
23. Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.
24. Nutting PA, Franks P, Clancy CM. Referral and consultation in primary care: do we understand what we're doing? [Editorial] J Fam Pract 1992;35:21-3.
25. Kates N, Craven MA, Crustolo AM, Nikolaou L, Allen C, Farrar S. Sharing care: the psychiatrist in the family physician's office. Can J Psychiatry 1997; 42:960-5.
26. Hartmann PM. Strategies for managing depression complicated by bipolar disorder, suicidal ideation, or psychotic features. J Am Board Fam Pract 1996;9:261-9.
27. DeVane CL, Nemeroff CB. 1998 Guide to psychotropic drug interactions. Primary Psychiatry 1998;5:36-75.
28. Strakowski SM, McElroy SL, Keck PE, West SA. Suicidality among patients with mixed and manic bipolar disorder. Am J Psychiatry 1996;153:674-6.
29. Simpson SG, Jamison KR. The risk of suicide in patients with bipolar disorders. J Clin Psychiatry 1999;60(suppl 2):53-6.

Copyright © 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

---

September 15, 2000 Contents | AFP Home Page | AAFP Home | Search

---