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.
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
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.
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.
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.
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
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.
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
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.
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 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.
|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.|
|Sleep and sedation in mania or hypomania; insomnia in depression|
|The combination of a mood stabilizer, an antidepressant and an antipsychotic|
|The combination of a mood stabilizer and an antidepressant|
|A mood stabilizer alone|
|Milder depression in bipolar I disorder|
|Patient with high risk of manic switch or rapid cycling|
|A selective serotonin reuptake inhibitor|
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.
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
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.
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.
|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.
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.
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.