Bipolar disorders, concepts

The term "bipolar disorder" originally referred to manic-depressive illnesses characterized by both manic and depressive episodes. In recent years, the concept of bipolar disorder has been broadened to include subtypes with similar clinical courses, phenomenology, family histories and treatment responses. These subtypes are thought to form a continuum of disorders that, while differing in severity, are related. Readers are referred to the Diagnostic and Statisticial Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) for details of this classification. 

Most theories about the origin of mood disorders refer to the subcellular or molecular level, mainly emphasizing an imbalance between different transmitter systems [17] as a possible cause for unipolar depression as well as bipolar disorders. No concrete concepts exist to explain how and in which way such molecular disturbances modify the neural dynamics and lead to an increased mental vulnerability with progressive occurrence of disease episodes. 

Manic depression, now known as bipolar disorder, used to be regarded as a relatively rare condition, perhaps affecting up to 1% of people at some point during their lifetime. However over recent years the concept... 

Lithium for the treatment of manic episodes or bipolar disorder was originally promoted to the public and to the mental health profession as the ultimate example of a specific biochemical treatment for a specific psychiatric disorder. To bolster this claim, it was said that lithium lacks any brain-disabling effects on either patients or normal volunteers. This view of lithium directly challenges the concept of medication spellbinding and brain-disabling principle of psychiatric treatment. Although a number of new drugs have now been added to the mood stabilizer armamentarium, lithium remains the prototype. 

Bipolar disorder has a lifetime prevalence of approximately 1%. During pregnancy, untreated bipolar disorder may result in hospitalization, suicidal ideation, violence, loss of employment, malnutrition, and an increased risk of postpartum psychosis. It does not appear that pregnancy provides protection for the risk of recurrence of symptoms. Women who discontinue the use of mood stabilizing drugs abruptly before conception or who have had four or more episodes of recurrence of symptoms have a substantial risk for recurrence during pregnancy. Risk for recurrence in the first 3 to 6 months postpartum has been estimated at 20% up to 80%. Postpartum psychosis may occur in 10% to 20% of women with bipolar disorder. 

A number of strategies have been used to optimize the use of medications in treating bipolar disorder in pregnancy. Patients who have had a single episode of mania with good recovery may be able to taper medication before conception. Those with multiple and frequent recurrences of symptoms (depression or mania) could attempt to discontinue medications before conception or wait until the pregnancy is diagnosed and then taper medications. Medications could be resumed if symptoms occur or after the first trimester to decrease the... 

FIGURE 6.12 Landscape of disease-to-gene associations. Associations between bipolar disorder and genes. One gene, Phospholipase A2 (PLA2), has an association with a second concept, rheumatoid arthritis. Courtesy of BioVista. 

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