Bipolar disorder is a cyclical mood disorder that fluctuates between episodes of mania and depression.
Bipolar disorder is characterised by a significant disruption in mood and behaviour, which includes both periods of elated and depressed mood. It is a serious long-term condition with a much higher risk of suicide compared to the average population (0.4% annual risk).
Patients with bipolar experience episodes of both mania and depression.
There are two major classification systems use for the assessment and diagnosis of mental health disorders: ICD-10 & DSM-V
While similar, these systems often differ on their interpretation of mental health disorders and how they are diagnosed. Therefore, it is important to state the classification system being used.
Bipolar disorder is recognised as one of the most common and disabling medical conditions worldwide.
The lifetime prevalence of bipolar disorder is estimated between 0.1-2.4% with an overall incidence rate of 0.7 per 100,000 person-years. The condition has an equal sex prevalence and the age of onset is typically before 30 years, although there is an estimated small peak in incidence in the 5th and 6th decades.
There is usually a significant delay (average of eight years in one study) between the first onset of symptoms and presentation to services. This is thought to be due to a long period of ‘subsyndromal’ symptoms that fall short of a ‘full’ episode.
Bipolar disorder can be classified according to different discrete episodes of elated, depressed or mixed disturbances in mood.
These discrete episodes are used to determine the diagnosis of bipolar according to the ICD-10 or DSM-V criteria. It is also important to identify the current episode when assessing a patient with confirmed, or suspected, bipolar.
At present, little is known about the exact cause of bipolar disorder although there are several proposed mechanisms.
Bipolar disorder has a strong heritable component. This means a patient's underlying genetic code, and the expression of that code into the phenotype (observable characteristics), influences whether they develop bipolar disorder. The estimated lifetime risk of bipolar is 5-10 times greater than the general public if a first-degree relative (parent, sibling, child) suffers from the condition. Furthermore, monozygotic twin studies show there is a 40-70% risk of developing bipolar if the other sibling suffers from the disorder.
Other factors that impact on the development of bipolar disorder include hormonal abnormalities (in particular problems with they hypothalamic-pituitary axis) and psychosocial influences. The latter can include childhood maltreatment, social class, social support and self-esteem.
Bipolar disorder is characterised by symptoms of both mania and depression.
Mania is characterised by an abnormal and persistently elevated, expansile or irritable mood, which leads to social and/or occupational impairment in function. There are numerous features suggestive of mania.
Hypomania is characterised by features of mania, but usually not as severe and do not lead to social and/or occupational impairment in function. In particular, there are no psychotic features.
Depression is characterised by a persistently low mood or loss of interest/pleasure in normal activities.
Bipolar disorder is classified based on different ‘episodes’, which are used in the diagnostic criteria.
Both the ICD-10 and DSM-V outline the diagnostic criteria for bipolar, which differ on some important concepts (e.g. number of episodes needed, whether bipolar is differentiation into two types). As part of the diagnostic assessment, it is important to comment on both the diagnosis and current episode (i.e. mania, hypomania, depressive, mixed).
Classifies bipolar as a single entity: bipolar affective disorder
Classifies bipolar disorder into three major categories: bipolar I disorder, bipolar II disorder, cyclothymia
Clinical assessment coupled with routine investigations are important to exclude other causes of elevated or depressed mood.
Other mental health disorders, substance misuse and medical conditions manifesting with primary mental health symptoms (often termed ‘organic’ causes) need to be excluded from the history and examination. Routine investigations like blood tests (e.g. TFTs, cortisol, haematinics) or neuroimaging (e.g. MRI brain) can be used to look for an organic cause.
Initially, patients should be referred to mental health services to confirm the diagnosis, treat the initial episode and provide an ongoing care plan.
Pharmacological therapies are the cornerstone of treatment and some patients may require admission to hospital for further assessment and treatment. The urgency of referral for further assessment depends on the severity of the presentation and whether the person poses a risk to themselves or other people.
If a person with confirmed, or suspected, bipolar requires admission to hospital due to deterioration in their symptoms, every effort should be made for a voluntary admission.
Compulsory admission (i.e. being detained) may be necessary if a patient requires assessment and/or treatment and admission is felt to be in the interests of their own health/safety or for the protection of other people. When arranging compulsory admission utilisation of the Mental Health Act is required.
Pharmacological management is usually required to treat and prevent episodes of mania, hypomania and depression. There are a number of treatment options including antipsychotics, mood stabilisers (e.g. lithium, anti-epileptic medications) and anti-depressants. Treatment can be started acutely and then continued as long-term maintenance therapy.
The choice of treatment depends on the patients co-morbidity, current episode (i.e. mania or depression) and side-effects. The main aim of treatment is to stabilise mood without any relapses into mania or depression.
Psychological interventions can provide mood regulation and self-management skills to help cope with bipolar disorder more effectively.
Several psychological interventions can be used in bipolar disorder. The general aim of each therapy is to provide information about the condition, enable identification of warning signs and symptoms, and to develop skills to be able to cope with the challenges of living with bipolar.
Bipolar disorder is associated with a high lifetime risk of suicide attempts and completion.
It is estimated that up to 59% of patients with bipolar have suicidal ideation and up to 56% will attempt suicide at least once in their lifetime. In addition, there are many issues relating to impaired social functioning and disinhibition including, but not limited to, financial difficulties, sexual issues (unplanned pregnancies, sexually transmitted infections), substance misuse and exploitation.
Bipolar disorder has also been linked to other mental and physical health issues including anxiety, attention-deficit hyperactivity disorder (ADHD), alcohol misuse, cardiovascular disease, chronic lung disease and chronic kidney disease.
There is a 50% risk of a recurrence at one year following an acute episode in bipolar disorder.
Bipolar disorder is characterised by periods of remission and subsequent relapse. Overtime, episodes may become more frequent with shorter intervals between them. As more episodes develop, there may be incomplete recovery leading to greater impairment and worse quality of life. Patients with bipolar have a higher risk death from both suicide and cardiovascular disease.
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