Bipolar disorder clinical presentation

Whitworth P, Kendall DA Effects of lithium on inositol phospholipid hydrolysis and inhibition of dopamine D, receptor-mediated cyclic AMP formation by carbachol in rat brain slices. J Neurochem 53 536-541, 1989 Whybrow PC The therapeutic use of triiodothyronine and high dose thyroxine in psychiatric disorder. Acta Med Austriaca 21 44-47, 1994 Whybrow PC Update on thyroid axis approaches to treatment of rapid cycling bipolar disorder. Paper presented at the annual meeting of the New Clinical Drug Evaluations Unit (NCDEU), Boca Raton, EL, May 30, 1996... 

The diagnosis of bipolar disorder is made based on clinical presentation, a careful diagnostic interview, and review of the history. There are no laboratory examinations, brain imaging studies, or other procedures that confirm the diagnosis. 

The differential diagnosis of depression is organized along both symptomatic and causative lines. Symptomatically, major depression is differentiated from other disorders by its clinical presentation or its long-term history. This is, of course, the primary means of distinguishing psychiatric disorders in DSM-1V. The symptomatic differential of major depression includes other mood disorders such as dysthymic disorder and bipolar disorder, other disorders that frequently manifest depressed mood including schizoaffective disorder, schizophrenia, dementia, adjustment disorder, and post-traumatic stress disorder, and, finally, other nonpsychiatric conditions that resemble depression such as bereavement and medical illnesses like cancer or AIDS. 

It is still debated whether patients with two previous episodes should receive maintenance treatment. Overall, maintenance treatment has been recommended for adult depressed patients with two episodes who have one or more of the following criteria (Depression Guideline Panel, 1993) (1) a family history of bipolar disorder or recurrent depression, (2) early onset of the first depressive episode (before age 20), and (3) both episodes were severe or life threatening and occurred during the past 3 years. Given that depression in youth has similar clinical presentation, sequelae, and natural course as in adults, these guidelines should probably be applied for youth with two previous major depressive episodes. 

Paradoxically, ECT is equally useful in both the acute manic and depressive phases of bipolar disorder, constituting the only truly bimodal therapy presently available. For example, in their literature review, Mukherjee et al. ( 51) found that ECT was associated with marked clinical improvement or remission in 80% of patients undergoing treatment for an acute manic episode. This is not the case for lithium, valproate, or CBZ, which, at best, have relatively weak acute antidepressant effects. Drug therapies may also induce a switch from a depressed to a manic phase, whereas ECT can control both phases of the illness. 

Bipolar disorder (manic-depressive illness) represents one of the most dramatic presentations in all of medicine and simultaneously poses one of the more difficult therapeutic challenges. It is characterized by mania or hypomania, alternating irregularly or intermingling with episodes of depression however, a small group (approximately 1%) may only experience recurrent manic episodes (i.e., unipolar mania). The estimated risk of developing a bipolar disorder is 0.5% to 1%, and the incidence of new cases per year is in the range of 0.01 % for men and 0.01 % to 0.03% for women (1). Bipolar spectrum can be conceived of as a continuum of more to less severe clinical presentations ... 

In the United States, the Research Diagnostic Criteria (RDC) (19) and the DSM-IV (8) both provide clear inclusion and exclusion criteria for a current episode ( Table 9-2). Evaluation of past episodes can be made using the Schedule for Affective Disorders and Schizophrenia—Lifetime Version (SADS-L) ( 20) or the Structured clinical Interview for DSM (21). In other countries, the Present State Exam (PSE) (22) can reliably distinguish mania from other disorders. Table 9-3 reviews the various clinical presentations of primary bipolar disorder and their related DSM-IV diagnoses ( 23) (see also Appendix A, Appendix G, and Appendix H). 

Recently, Calabrese (240) reviewed the use of topiramate in bipolar disorder and also presented the results of two additional studies. He noted that, thus far, topiramate had been studied in 12 open clinical trials involving a total of 224 patients, mainly in manic and mixed states, and generally as an augmentation strategy. 

We would emphasize that, while all of these approaches are theoretically important and may possess clinical applicability, with the exception of the atypical antipsychotic olanzapine, none is presently approved by the FDA for treatment of bipolar disorder. 

This is perhaps the earliest documented clinical description of bipolar disorder. Keen observers noticed not only that certain individuals suffered from depression but also that, seemingly inexplicably, their mood would suddenly switch into the polar opposite from dejection to unbridled excitement, from profound despair to limitless optimism, or from paralyzing fatigue to superhuman levels of activity and energy. Bipolar disorder, as it is presently termed, historically has been called manic-depressive insanity (as it was called in Kraepelin s [1919/1971, 1976] time) or manic-depressive illness. The term bipolar was coined several decades ago in an effort to reflect the hallmark of the disorder two opposite poles of the affective continuum. 

Developing an animal model of bipolar disorder is challenging, due to the dramatically different clinical presentations of mania and depression. Animal models of depression are described above, and can be considered to model the depres-... 

McConviUe BJ, Sorter MT, Foster K, Barken A, Browne K, Chaney R. In Lithium versus Valproate Side Effects in Adolescents with Bipolar Disorder. New Clinical Drug Evaluation Unit Progam. Presented at the NCDEU... 

Treatment of bipolar disorder must be individualized because the clinical presentation, severity, and frequency of episodes vary widely among patients. Treatment approaches should include both nonpharmacologic and pharmacologic strategies (Table 68-6). Patients and family members should be educated about bipolar disorder (e.g., symptoms, causes, and course) and treatment options. Longterm adherence to treatment is the most important factor in achieving stabilization of the disorder. 

Social work practitioners in clinical practice quickly learn that as with many other mental illnesses, the psychiatric problems clients present are complex and multifaceted. It is not unusual that clients with bipolar disorders often have other psychiatric problems that require attention and treatment. For example, many clients with bipolar disorder also have alcohol or drug-related problems (Carlson, Bromet, Jandorf, 1998). Identifying other disorders is important during the assessment phase and continues to be so throughout the treatment phase. Clients with a history of alcohol and drug use will require special considerations when it comes to prescribing medications for the bipolar disorder. Failure to obtain this information at the point of assessment can put a client in harm if the client uses medications while taking these substances. 

LF sometimes is used as an alternative or adjunct to antidepressants in severe, especially melancholic, recurrent depression, as a supplement to antidepressant treatment in acute major depression, including in patients who present clinically with only mild mood elevations or hypomania (bipolar II disorder), or as an adjunct when later response to an antidepressant alone is unsatisfactory. In major affective disorders, LT has stronger evidence of reduction of suicide risk than any other treatment. Clinical experience also suggests the utility of IF in the management of childhood disorders that are marked by adult-like manic depression or by severe changes in mood and behavior, which are probable precursors to bipolar disorder in adults. Evidence of efficacy of Li in many additional episodic disorders (e.g., premenstrual dysphoria, episodic alcohol abuse, and episodic violence) is unconvincing. 

Introduced in clinical practice in the 1960s, lithium was the first mood stabilizer to be used in China. This was followed by carbamazepine and sodium valproate. For many years, these were the only treatment options available as mood stabilizers. Although lamotrigine was approved for maintenance treatment of bipolar I disorder in 2003 by FDA (Food and Drug Administration) in the USA, this indication has not yet been approved by the Chinese authorities. At present, only one atypical antipsychotic drug, risperidone, has been approved for treating acute mania (February 2005 by SFDA [State Food and Drug Administration]) in China (see Table 6.1). 

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