Bipolar affective disorder (manic depression)

• What is Bipolar Affective Disorder (Manic Depression)
• Statistics on Bipolar Affective Disorder (Manic Depression)
• Risk Factors for Bipolar Affective Disorder (Manic Depression)
• Progression of Bipolar Affective Disorder (Manic Depression)
• Symptoms of Bipolar Affective Disorder (Manic Depression)
• Clinical Examination of Bipolar Affective Disorder (Manic Depression)
• How is Bipolar Affective Disorder (Manic Depression) Diagnosed?
• Prognosis of Bipolar Affective Disorder (Manic Depression)
• How is Bipolar Affective Disorder (Manic Depression) Treated?
• Bipolar Affective Disorder (Manic Depression) References

What is Bipolar Affective Disorder (Manic Depression)

Bipolar affective disorder (BPAD) is a psychological illness that involves severe mood swings. These mood swings take the form of depression or mania and may last for several months at a time.

During the time of depression patients often have great sadness, guilt, no appetite, poor sleep and can not enjoy themselves. Mania is the opposite of this with patients experiencing erratic and excited behaviour.

During mania patients often have increased libido, need less sleep, have excessive energy and can sometimes engage in risky behaviour (such as gambling excessively) or can even become violent.

Hypomania is a less extreme form of mania and while the symptoms are similar they are less intense. Some patients may also have a mixed episode that involves the symptoms of both a manic and depressed episode during a short period of time (less then 1 week).

There are 3 recognised types of BPAD:

• Type I: Patients have very high manic periods and depressive episodes.
• Type II: Patients have severe depressions but only mild manic (hypomanic) episodes.
• Type III: Called Cyclothymic disorder, the patient has only mild depression and mild mania.

There is also a type called Rapid Cycling Bipolar Affective Disorder. With Rapid Cycling the patient changes from depression to manic at least 4 times a year and episodes of depression and mania are short.

Statistics on Bipolar Affective Disorder (Manic Depression)

There is a 2.5% chance of developing BPAD type I & II during your lifetime in Australia. The chance for combined BPAD and Cyclothymic disorder is reported as 5.2%. No racial differences exist. Males are more likely to develop BPAD than females.

Risk Factors for Bipolar Affective Disorder (Manic Depression)

The most significant risk factor for BPAD is a family history of either BPAD or depression, with two thirds of patients with BPAD having some family history of mental illness. Genes are thought to account for 80% of cases of BPAD and research is underway to find out more information about how family history and genetics influence the risk of BPAD.

Progression of Bipolar Affective Disorder (Manic Depression)

BPAD is a lifelong condition with episodes of low and high mood. The course of the illness varies greatly between individuals. Symptoms of BPAD (like depression) usually begin before age 20 with the 15 to 19 year old age group being most common. However, these symptoms are often ignored or misdiagnosed until a later age. The main reason is that almost half of all patients with BPAD will first have an episode of depression (only a quarter will first experience manic symptoms such as excited mood, excess energy, etc).

During life the patient will have episodes of low or high mood. Patients with Type I BPAD will have manic (high mood) episodes and depression (low mood) while Type II with have only mild manic episodes (called hypomanic) and more depressive episodes.

Episodes, even if treated, usually last 3-6 months but can last considerably longer. Depressive symptoms (such as low mood, low enjoyment with life, and a lack of energy) can last for years at a time.

How often episodes occur is extremely variable between patients, however the usual time between first and second episode is about four years and then episodes occur about every year. Episodes often become more frequent over time (especially if untreated). Untreated, a typical BPAD Type I patient will experience 10 episodes of mania during their life with a number of depressive episodes.

Symptoms of Bipolar Affective Disorder (Manic Depression)

Most patients will first present with an episode of depression. Patients will also often have considerable anxiety and sometimes an eating disorder (such as anorexia).

Depressive symptoms are low mood, lack of pleasure, low energy, feelings of guilt, decreased concentration, decreased appetite and decreased sleep. These however are symptoms that are also present with depression or even some forms of schizophrenia, making the diagnosis of bipolar difficult.

About a quarter of patients will present with a manic episode. These patients will present with an elevated mood, excessive energy, decreased sleep, fast talking, sensational ideas, and an inflated self-esteem.

Clinical Examination of Bipolar Affective Disorder (Manic Depression)

The clinical history should be taken from both the patient and a relation or friend as a patient who is in a manic episode will not be able to give an objective view of their condition and risk taking behaviour. The doctor will be looking for several important pieces of information in the history.

For a patient with mania, the doctor will be looking for inappropriate spending, increases in goal directed activities (especially doing extra work that is not required), poor judgement and less need for sleep. If the patient is presenting with depression the doctor will be looking for a loss of pleasure, low mood, social withdrawal, poor motivation, reduced libido, weight loss or gain and poor sleep.

The doctor will take a full detailed history of all the symptoms and when they started and if they have occurred before. Such an interview is the most important tool for making the diagnosis of BPAD and is usually a lengthy process (usually taking more then 45 minutes).

How is Bipolar Affective Disorder (Manic Depression) Diagnosed?

The diagnosis of BPAD is made on the clinical examination (see above) although there are some tests to exclude other causes for mania. These tests include thyroid function tests, calcium levels, tests for infection (especially for syphilis or HIV), an electroencephalogram (to rule out epilepsy) and possibly a CT scan (to exclude any brain injury). The doctor may also do a routine drug screen as drugs like amphetamines or cocaine can have the same signs as BPAD.

If a patient is diagnosed with BPAD and started on a medication called lithium the doctor will need to do blood tests every three or so months for lithium levels and several other blood tests.

Prognosis of Bipolar Affective Disorder (Manic Depression)

Almost all patients will recover form a depressive or manic episode in time. However, BPAD often has considerable effect on a person’s functioning and patients with BPAD often have relationship and occupational difficulties. During an episode of mania a person is likely to participate in risky behaviours (such as excessive gambling or risky sexual behaviours) and often places their finances and relationships at risk.

In recent studies about 25-35% of BPAD patients will return to the same level of functioning (education, work, social) that they had before they were diagnosed with BPAD. The majority however, will have continuing problems (especially in the work environment) despite having no ongoing symptoms, meaning the patient will have a normal mood but will continue to find it hard to function like they did before.

There is a high risk of suicide patients with BPAD. About 25% to 50% of patients with BPAD will attempt to commit suicide and about 80% will consider suicide. Although there is no truly accurate suicide figure it is estimated that 10-15% of BPAD patients die as a result of suicide. Suicide attempts are rare during mania but common during depressive episodes.

How is Bipolar Affective Disorder (Manic Depression) Treated?

The main treatment for BPAD is long term medication. There are several categories of treatment. There is different treatment for manic episodes, depressive episodes and rapid cycling. Apart for these treatments to stop episodes of depression and mania there is also long term maintenance therapy. There is also some psychotherapy available.

Treatment of a manic episode

For less severe episodes a single drug can be used. Such drugs include:

• Lithium;
• Valproate;
• Carbamazepine.

For more severe cases of mania the best treatment is a combination of two drugs. The drugs that are used in severe mania are called anti-psychotics. The two drugs of this type that have been shown to be effective for treating mania are Risperidone (Risperdal) and Olanzapine. One of these drugs used in combination with lithium, Valproate or Carbamazepine is the best treatment of a severe manic episode. In extreme cases ECT can also be tried. In this therapy the patient is put to sleep and then a controlled dose of electricity is applied to the patient’s head.

Treatment of depressive episodes

Treatment of a depressive episode in BPAD is different to the treatment of depression. Traditional anti-depressant medication should not be used in BPAD as this medication can bring on episodes of mania or hypomania and cause severe mood swings. Lithium is often used. The other main drug that can be used is Lamotrigine which has been shown to be very good in the treatment of depressive episodes in BPAD. The final treatment for depressive episodes is ECT. The treatment has been shown to be a good alternative to drug treatment in patients with depressive episodes.

Rapid cycling

Treatment of rapid cycling can be difficult as some drugs can in fact make the condition worse. The drugs that are used are lithium and Lamotrigine. Lamotrigine has been shown to have excellent results in the treatment of rapid cycling and does not cause mania or hypomania. Valproate has also been suggested for rapid cycling although there is no good evidence to support its use.

Long term maintenance treatment

The goal of this therapy is to stop a patient with BPAD who is presently well going into an episode of mania or depression. This is often difficult and it is often impossible to stop these episodes. The drugs with the best scientific evidence supporting their use are lithium and Lamotrigine. Valproate also has some evidence supporting its use in long term maintenance therapy. Another use of lithium in long term treatment is its ability to decrease the risk of suicide.

Lithium

Lithium has for a long time been the gold standard for mood stabilisation. It is effective in both manic and depressive episodes and for long term maintenance therapy. The most common side effects include slight shaking of the hands, thirst, queasiness (usually goes away after some time), headache, tiredness, irregular pulse, loss of appetite, weight gain, bloating and muscle weakness. When a patient is placed on lithium treatment their doctor will do routine blood tests.

Psychotherapy

Psychotherapy can be used in BPAD. The goals of psychotherapy in BPAD are to improve regular taking of medicines, reduce any substance abuse (such as alcohol), improve lifestyle and help patients recognise symptoms of depression or mania earlier so that they seek appropriate treatment as soon as possible.

There are 3 general types of psychotherapy that have been shown to be useful:

• Psycho-education – This educates the patient about BPAD, early signs of a manic or depressive episode and the importance of long term medication. There is good evidence for psycho-education as it improves regular taking of medicines and can help patients identify any stresses that will lead to an episode and try to change them.
• Family Focus Therapy – This includes psycho-education but also helps to improve communication and problem solving within the family. The therapy has been shown to be effective at reducing the number of manic or depressive episodes over time.
• Cognitive Behavioural Therapy (CBT) – This works in a number of ways. Like psycho-education, it increases a patient’s knowledge of the illness but it also helps the patient with returning to full functioning. Many patients with BPAD do not return to full employment or social life even when they are symptom-free. Cognitive behavioural therapy works to help restore a patient back to full functioning (full employment, social life, relationships, etc).

Bipolar Affective Disorder (Manic Depression) References

1. Goldney RD, Fisher LJ, Grande ED, et al. Bipolar I and II disorders in a random and representative Australian population. Aust NZ J Psychiatry. 2005;39(8):726-9. Available from: [Abstract]
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4. Hirschfeld RM, Bowden CL, Gitlin MJ, et al. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159(4 Suppl):1-50.
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7. Diagnostic and Statistical Manual of Mental Disorders (4th edition). Washington, DC: American Psychiatric Association; 2000. Available from: [Book]
8. Labbate LA, Rosenbaum JF, Arana GW, et al. Handbook of Psychiatric Drug Therapy. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. Available from: [Book]
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10. Deglin JH, Vallerand AH (eds). Davis’ Drug Guide for Physicians. Medical Wizards Corporation; 2005. Available from: [URL Link]
11. Zaretsky AE, Rizvi S, Parikh SV. How well do psychosocial interventions work in bipolar disorder? Can J Psychiatry. 2007;52(1):14-21. Available from: [Abstract | Full text]

Treatments Used in This Disease:

• Antidepressants
• Psychoeducation
• Conventional Antipsychotics

Drugs/Products Used in the Treatment of This Disease:

• Epilim (Sodium valproate)
• Lamictal (Lamotrigine)
• Lithicarb (Lithium carbonate)
• Risperdal Oral Quicklet (Risperidone)
• Risperdal Oral Solution (Risperidone)
• Risperdal Oral Tablets (Risperidone)
• Serenace (Haloperidol)
• Tegretol (Carbamazepine)
• Zyprexa (Olanzapine)