Bipolar disorder evaluation

The molten carbonate fuel ceU uses eutectic blends of Hthium and potassium carbonates as the electrolyte. A special grade of Hthium carbonate is used in treatment of affective mental (mood) disorders, including clinical depression and bipolar disorders. Lithium has also been evaluated in treatment of schizophrenia, schizoaffective disorders, alcoholism, and periodic aggressive behavior (56). 

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, classifies bipolar disorders as (1) bipolar I, (2) bipolar II, (3) cyclothymic disorder, and (4) bipolar disorder not otherwise specified. Table 69-3 defines mood disorders by type of episode. Table 69-4 describes the evaluation and diagnostic criteria for mood disorders. 

Anticonvulsdnts. An early observation that BN patients may have abnormal electroencephalogram (EEG) resnlts led to specnlation that binge eating may represent an atypical behavioral presentation of seiznre activity. Thus, the first controlled medication study for the treatment of BN evaluated the use of the antiseizure medication phenytoin (Dilantin). Phenytoin was not found to be significantly superior to placebo, and the earlier reports of EEG abnormalities were not confirmed. The results of a subsequent trial of carbamazepine (Tegretol), an anticonvulsant that has been reported to be effective in the treatment of bipolar disorder, were also disappointing. As a result, anticonvulsants are not routinely used in the treatment of BN. 

Akiskal, H.S., Bourgeois, M.L., Angst, J., Post, R., Moeller, H.-J., and Hirschfelt, R. (2000) Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord 59 S5—S30. 

Carbamazepine produces complex effects in a variety of neurotransmitters, receptors, and second messenger and neuropeptide systems (Post et al. 1992, 1994a). Determining which of these effects is most closely associated with its psychotropic properties in bipolar disorder and which of these or other effects may be responsible for the augmentation response in combination therapy with dihydropyridine L-type CCBs remains to be further evaluated. However, discussion of two possibilities might be beneficial. One possibility, of course, is that actions of carbamazepine unrelated to calcium dynamics account for its augmenting effects with nimodipine. The plethora of these other... 

Given the available data, it is extremely important that clinicians evaluate patients with major depression for features of psychosis, because the failure to do so may result in inadequate treatment for the patient. A practical problem encountered by clinicians, however, is the subtlety of delusions. For example, it is not unusual in geriatric depression for patients to present with a somatic preoccupation that borders on delusional. These so-called near delusions may put the patient into the arena of psychotic depression. Some evidence exists that patients with depression with near delusions may respond more favorably to combinations of antidepressants and antipsychotics or ECT. Once the presence of both major depression and psychosis is determined, other psychotic disorders including bipolar disorder and schizophrenic spectrum illness must also be ruled out because this may influence long-term treatment decisions. 

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... 

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). 

Gender differences in the age of onset of bipolar disorder were evaluated by Sibisi ( 43), who used the annual U.K. Inpatient Statistics from the Mental Health Inquiry. The cumulative inception rate was nearly equal for men and women, indicating that the liability is similar between the genders. Results such as these imply that the observed excess of middle-aged, bipolar women may be attributable to life experiences, a greater willingness to seek treatment, or other demographic factors. 

When 22 men and 38 women who had taken lithium for at least a year (mean 6.9 years) for bipolar disorder were evaluated for adverse effects, hypothyroidism requiring thyroid supplementation was found in 16 (14 women and 2 men) 9 had a goiter (637). The area from which some of the patients came was known to have a high background incidence of thyroid dysfunction. 

Post, R., Leverich G., Nolen, W., Kupka, R., Altshuler, L., Frye, M., et al. (2003). A re-evaluation of the role of antidepressants in the treatment of bipolar depression Data from the Stanley Foundation Bipolar Network. Bipolar Disorders, 5, 396—406. 

When 22 women with bipolar disorder (10 taking lithium alone, 10 taking divalproex alone, and 2 taking both) were evaluated for polycystic ovary syndrome, none had typical hormonal screening abnormalities (427). Some type of menstrual dysfunction was present in all ten women taking lithium alone, but it predated use of the drug in all but one. 

Deshauer D, Fergusson D, Duffy A, Albuquerque J, Grof P. Re-evaluation of randomized control trials of lithium monotherapy a cohort effect. Bipolar Disord 2005 7 382-7. 

McConville 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 ProgamPresented at the NCDEU 38th Annual Meeting, 10-13 June, Boca Raton, FL 1998 144 poster no. 74. 

Knoppert van der Klein EAM, Van Kamp IL. A pilot risk evaluation of lithium in pregnancy. Bipolar Disord 2002 4(Suppl 1) 127. 

The aim of another study was to evaluate the long-term efficacy of clozapine in patients with treatment-resistant schizophrenia (n = 34), schizoaffective disorder, bipolar type (n = 30), or bipolar disorder with psychotic features (n = 37), who were treated with clozapine in flexible doses over 48 months (16). After this time, Global Assessment of Functioning scores were improved in all three groups, with significantly greater improvement in the bipolar disorder group compared with the others ... 

Bipolar disorder—this will require a psychiatry evaluation. 

Consider evaluation for another diagnosis or tor a comorbid condition (e.g., bipolar disorder, substance abuse, medical illness, etc.)... 

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