Bipolar disorder Mixed episodes Mood

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

Bipolar disorders have been categorized into bipolar I disorder, bipolar II disorder, and bipolar disorder, not otherwise specified (NOS). Bipolar I disorder is characterized by one or more manic or mixed mood episodes. Bipolar II disorder is characterized by one or more major depressive episodes and at least one hypomanic episode. Hypomania is an abnormally and persistently elevated, expansive, or irritable mood, but not of sufficient severity to cause significant impairment in social or occupational function and does not require hospitalization. Most epidemiologic studies have looked at bipolar disorder of all types (bipolar I and bipolar II), or the bipolar spectrum, which includes all clinical conditions thought to be closely related to bipolar disorder. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and 2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. When including the bipolar spectrum, the lifetime prevalence is between 3% and 6.5%.1... 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

Sprinkle capsule 15, 25 mg Atypical Antipsychotics FDA approved for use in bipolar disorder Aripiprazole Abilify Tablets 5, 10, 15, Dosage should be slowly increased to minimize adverse effects (e.g., 25 mg at bedtime for 1 week, then 25-50 mg/day increments at weekly intervals) 10-30 mg/day once daily acute treatment of mania or mixed episodes due to lack of efficacy used as an adjunctive agent with established mood stabilizers Use as monotherapy or in... 

Bipolar disorder, previously known as manic-depressive illness, is a cyclical, lifelong disorder with recurrent extreme fluctuations in mood, energy, and behavior. Diagnosis requires the occurrence, during the course of the illness, of a manic, hypomanic, or mixed episode (not caused by any other medical condition, substance, or psychiatric disorder). 

Two or more major depressive episodes Manic episode major depressive or mixed episode Major depressive episode + hypomanic episode Chronic subsyndromal depressive episodes Chronic fluctuations between subsyndromal depressive and hypomanic episodes (2 years for adults and 1 year for children and adolescents) Mood states do not meet criteria for any specific bipolar disorder... 

For bipolar I disorder, 90% of individuals who experience a manic episode later have multiple recurrent major depressive, manic, hypomanic, or mixed episodes alternating with a normal mood state. 

Divalproex sodium (sodium valproate) is now the most prescribed mood stabilizer in the United States. It is FDA approved only for the treatment of acute manic or mixed episodes, but it is often used as maintenance monotherapy for bipolar disorder. 

In contrast to MDD, the bipolar disorders consist of episodes of depression and episodes of hypomania or mania. This poses a problem for treating the depressed phase of this illness, becanse, as noted earlier, antidepressants can trigger hypomania, mania, or mixed dysphoric mania and can increase the freqnency of manic episodes. Therefore, the hallmark of treating BPAD is the nse of mood stabilizers, with and withont snpplemental antidepressant therapy. Please refer to Table 3.16 for a comparison of the traditional mood stabilizers. 

Bipolar disorder For the maintenance treatment of Bipolar I Disorder to delay the time to occurrence of mood episodes (eg, depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy. 

The longitudinal course of bipolar illness is also characterized by many recurrent episodes, some predominantly depressive, some predominantly manic or hypomanic, some mixed with simultaneous features of both mania and depression (Fig. 5—5) some may even be rapid cycling, with at least four ups and/or downs in 12 months (Fig. 5—6). There is worrisome evidence that bipolar disorders may be somewhat progressive, especially if uncontrolled. That is, mood fluctuations become more frequent, more severe, and less responsive to medications as time goes on, especially in cases where there has been little or inadequate treatment. 

Antidepressants modify the long-term course of bipolar disorder as well. When given with lithium or other mood stabilizers, they may reduce depressive episodes. Interestingly, however, antidepressants can flip a depressed bipolar patient into mania, into mixed mania with depression, or into chaotic rapid cycling every few days or hours, especially in the absence of mood stabilizers. Thus, many patients with bipolar disorders require clever mixing of mood stabilizers and antidepressants, or even avoidance of antidepressants, in order to attain the best outcome. 

FIGURE 7—35. Combination treatments for bipolar disorder (bipolar combos). Combination drug treatment is the rule rather than the exception for patients with bipolar disorder. It is best to attempt monotherapy, however, with first-line lithium or valproic acid, with second-line atypical antipsychotics, or with third-line anticonvulsant mood stabilizers. A very common situation in acute treatment of the manic phase of bipolar disorder is to treat with both a mood stabilizer and an atypical antipsychotic (atypical combo). Agitated patients may require intermittent doses of sedating benzodiazepines (benzo assault weapon), whereas patients out of control may require intermittent doses of tranquil-izing neuroleptics (neuroleptic nuclear weapon). For maintenance treatment, patients often require combinations of two mood stabilizers (mood stabilizer combo) or a mood stabilizer with an atypical antipsychotic (atypical combo). For patients who have depressive episodes despite mood stabilizer or atypical combos, antidepressants may be required (antidepressant combo). However, antidepressants may also decompensate patients into overt mania, rapid cycling states, or mixed states of mania and depression. Thus, antidepressant combos are used cautiously. 

Mood symptoms of depression are associated with many conditions in addition to major depressive disorder, including mood and anxiety symptoms in schizophrenia, schizoaffective disorder, bipolar manic/depressed/mixed/rapid cycling states, organic mood disorders, psychotic depression, childhood and adolescent mood disorders, treatment-resistant mood disorders, and many more (see Chapter 10, Fig. 10-6). Atypical antipsychotics are enjoying expanded use for the treatment of symptoms of depression and anxiety in schizophrenia that are troublesome but not severe enough to reach the diagnostic threshold for a major depressive episode or anxiety disorder in these cases the antipsychotics are used not only to reduce such symptoms but hopefully also to reduce suicide rates, which are so high in schizophrenia (Fig. 11 — 53). Atypical antipsychotics may also be useful adjunctive treatments to anti-... 

Beginning with Kraepelin s (1921) systematic classification of dysphoric mania, considerable attention has been paid to mixed states of bipolar disorder. Kraepelin s model was based on variable symptom patterns expressed in three areas, mood, thought, and motor activity. Once considered to be uncommon, current estimates suggest that the prevalence rate for dysphoric, or mixed mania, is approximately 30 percent (McElroy et al. 1992). Debate continues regarding the status of mixed mania as a distinct affective state versus a form, or stage, of typical mania. However, there is convincing evidence to support the opinion that mixed episodes can be more severe, chronic, and difficult to treat than pure manic or depressive episodes (Clothier,... 

Severe psychiatric illnesses such as bipolar disorder often manifest themselves during adolescence and young adulthood, and result in disruption of educational, occupational, marital, and other pursuits. Residual symptoms are often common between mood episodes, and more than one-half of bipolar patients manifest some degree of functional disability after the onset of the hlness. Poorer outcome is associated with rapid cycling, mixed states, concurrent alcohol and substance abuse, nonadherence to treatment, and poor psychosocial support. 

Predictors of a positive response with valproate include rapid cycling, mixed episodes, comorbid panic disorder, organic mental disorders (e.g., head trauma), and mental retardation. " Low-dose valproate (125 to 500 mg/day) has been reported to be effective in reducing mood cycling in bipolar II disorder and cyclothymia. Oral loading with divalproex sodium, 20 mg/kg per day, may produce a rapid reduction in manic and psychotic symptoms within 4 days without causing major side effects, although there may be a lag time to obtain full antimanic efficacy. Development of tolerance and loss of efficacy with valproate occurs in some patients after several years of treatment." ... 

Before discussing the different types of bipolar disorders, it is important to introduce the reader to what is commonly meant by a mood episode. These mood episodes are generally not diagnosed separately they are considered building blocks for the disorders that follow. The types of mood episodes that clients who suffer from the bipolar disorders may manifest are manic, hypomanic, major depressive, or mixed episodes (American Psychiatric Association, 1994). 

When working with the bipolar 1 disorders it appears that either depressive episodes, manic episodes, or mixed episodes can be involved (Maxmen Ward, 1995). Practitioners should keep in mind that clients with bipolar I disorders will often report depressive episodes as well as the agitation and hyperactivity that often are associated with it In this condition a full depressive episode is also reported, and 20% to 30% of clients may continue to have mood fluctuations (lability) between episodes that are significant enough to disturb interpersonal or occupational relations. In some cases the development of psychotic features may occur, and when this happens subsequent manic episodes ate more likely to also have psychotic features (American Psychiatric Association, 1994). 

In the bipolar II disorders, there have been one or more major depressive episodes and no history of either a manic or mixed episode. Bipolar II disorders are best described as alternating episodes of major depression and periods of hypomania (Maxman Ward, 1995). These hypomanic symptoms include increased levels of energy and mood that are not as intense as manic episodes, and clients with bipolar II disorder do not become delusional or requite acute hospitalization (American Psychiatric Association, 1994). 

Katagiri H, Takita Y, Tohen M, Phguchi T, Kanba S, Takahashi M. Safety and efficacy of olanzapine monotherapy and olanzapine with a mood stabilizer in 18-week treatment of manic/mixed episodes for Japanese patients with bipolar 1 disorder. Curr Med Res Opin 2012 28(5) 701-13. 

In the bipolar affective disorders (BPADs), periods of normal mood are interspersed with episodes of mania, hypomania, mixed states, or depression. BPAD differs from MDD in that there is a bidirectional natnre to the mood swings and, for many patients, the rate of cycling is more rapid in BPAD than MDD. The phases of BPAD inclnde mania, hypomania, and depression, though mixed states, the simultaneous presentation of symptoms of both mania and depression, are common. 

Prevention of recnrrence of affective disorder Insight into how best to use lithium to reduce the recurrence of new mood episodes continues to accrue. In long-term prospective study in five centers, the International Group for the Study of Lithium-Treated Patients examined the relative stability of patients with predominantly atypical features (n = 100 e.g. mixed states or rapid cycling) or more typical bipolar features (n = 142) over a mean of 10 years [16 f. There were no differences in the overall measures of morbidity in the two groups. 

---