Mania, bipolar disorder-related

Disturbances of sleep are typical of mood disorders, and belong to the core symptoms of major depression. More than 90% of depressed patients complain of impaired sleep quality [60], Typically, patients suffer from difficulties in falling asleep, frequent nocturnal awakenings, and early morning awakening. Not only is insomnia a typical symptom of depression but, studies suggest, conversely, insomnia may be an independent risk factor for depression. In bipolar disorders sleep loss may also be a risk factor for the development of mania. Hypersomnia is less typical for depression [61] and, in contrast to insomnia, may be related to certain subtypes of depression, such as seasonal affective disorder (SAD). 

The rates of provocation of mania reported with SSRIs appear to be lower than rates with the TCAs and may therefore be a more appropriate therapeutic option in the treatment of depression in patients with bipolar disorder. It is of course difficult to distinguish the beneficial effect of a drug in relation to rare events, but the meta-analysis of the database of one of the SSRIs reported a switch rate of between 2% and 3%, which compares favorably with 11% reported with TCAs [S. A. Montgomery 1995d). 

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). 

The sequence, number, and intensity of manic and depressive episodes are highly variable. The cause of the mood swings characteristic of bipolar affective disorder is unknown, although a preponderance of catecholamine-related activity may be present. Drugs that increase this activity tend to exacerbate mania, whereas those that reduce activity of dopamine or norepinephrine relieve mania. Acetylcholine or glutamate may also be involved. The nature of the abrupt switch from mania to depression experienced by some patients is uncertain. Bipolar disorder has a strong familial component, and there is abundant evidence that bipolar disorder is genetically determined. 

Goldstein, T., Frye, M., Denicoff, K., Smith-Jackson, E., Leverich, G., Bryan, A., et al. (1999). Antidepressant discontinuation-related mania Critical perspective observation and theoretical implications in bipolar disorder. Journal of Clinical Psychiatry, 60, 563-567. 

Although mania has been associated with olanzapine (SEDA-24, 68 SEDA-25, 68 SEDA-26, 62), it has also been used in the treatment of acute mania. In a 12-week, double-blind, double-dummy, randomized trial, 120 patients with bipolar disorder type I hospitalized for an acute manic episode were randomly assigned to either sodium valproate (n = 63) or olanzapine (n = 57) and were followed in hospital for up to 21 days (60). Valproate and olanzapine had similar short-term effects on clinical or health-related quality of life outcomes in bipolar disorder adverse effects that occurred in a higher percentage of olanzapine-treated than valproate-treated patients included somnolence (47% versus 29%), weight gain (25% versus 10%), rhinitis (14% versus 3%), edema (14% versus 0%), and slurred speech (7% versus 0%) no adverse events occurred significantly more often with valproate. 

Revicki DA, Paramore LC, Sommerville KW, Swann AC, Zajecka JM. Divalproex sodium versus olanzapine in the treatment of acute mania in bipolar disorder health-related quality of life and medical cost outcomes. J Clin Psychiatry 2003 64 288-94. 

Olanzapine Alcohol Olanzapine is a second generation antipsychotic used to treat schizophrenia and mania related to bipolar disorder. Olanzapine binds neurotransmitter receptors of several classes including dopaminergic, adrenergic, and serotonergic receptors [249, 250]. 

Several medical, medication-induced, or substance-related causes of mania and depression have been identified (see Table 68-2 for causes of mania and Table 67-1 in Chap. 67 on depressive disorders for causes of depression). " A complete medical, psychiatric, and medication history physical examination and laboratory testing are necessary to rule out any organic causes of mania or depression. An accurate diagnosis is important because some psychiatric and neurologic disorders present with manic-like symptoms. For example, attention-deficit/hyperactivity disorder and a manic episode have similar characteristics thus individuals with bipolar disorder may be misdiagnosed and prescribed central nervous system stimulants. Use of any substance that affects the central nervous system (e.g., alcohol, antidepressants, caffeine, central nervous system stimulants, hallucinogens, or marijuana) can worsen symptoms and decrease the... 

Another risk of antidepressants in vulnerable patients (particularly those with unrecognized bipolar depression) is switching, sometimes suddenly, from depression to hypomanic or manic excitement, or mixed, dysphoric-agitated, manic-depressive states. To some extent this effect is dose-related and is somewhat more likely in adults treated with tricyclic antidepressants than with serotonin reuptake inhibitors, bupropion, and perhaps with MAO inhibitors. Risk of mania with newer sedating antidepressants, including nefazodone and mirtazapine, also may be relatively low, but some risk of inducing mania can be expected with any treatment that elevates mood, including in children with unsuspected bipolar disorder. 

Modem psychiatric treattnents were introduced in 1949, when lithium carbonate was discovered as treatment for mania by Australian psychiatrist John F. Cade (Figure 1.45). After Cade s initial report, lithium therapy was principally developed in 1954 by Mogens Schou (Aarhus University, Denmark). In 1969, 20 years after its discovery by John Cade and after a decade of trials, the Psychiatric Association and the Lithium Task Force recommended lithium to the FDA for therapy of mania. A breakthrough had been achieved in the treatment of manic depression, and the genetically related forms of recurrent depression. Bipolar disorders, which afflict about 1% of adults, are now treated with drugs called mood stabilizers, especially lithium and valproic acid, both discovered decades earlier, but nothing better has yet emerged. ... 

Sodre LA, Biicker J, Zortea K, Sulzbach-Vianna MF, Gama CS. Virada manfaca induzida pela amantadina no transtorno bipolar relate de trSs cases. [Mania switch induced by amantadine in bipolar disorder report of three cases.] Rev Bras Psiquiatr 2010 32(4) 467-9. 

Lithium salts are used in the treatment of bipolar affective disorder (i.e., manic depression) and occasionally in mania (but its slow onset of action is somewhat of a disadvantage in this case). Its mechanism of action is still open to debate, but lithium has effects on brain monoamines, on neuronal transmembrane sodium flux, and on cellular phosphatidylinositides related to second messenger systems. Lithium is administered in two salt forms, lithium carbonate (8.98) and lithium citrate (8.99). Side effects are common and include diarrhea, kidney failure, and drowsiness with tremor. 

Schizophrenia-related disorders, such as schizophreniform disorder, can closely mimic an acute exacerbation of mania. Attention to premorbid personal and family history may help differentiate them from mood disorders. A definitive diagnosis may not be possible, however, until the course of the illness is followed for a period of time. Clinical clues include the propensity of bipolar manics (in contrast to schizophrenics) to demonstrate pressured speech, flight of ideas, grandiosity, and overinclusive thinking. Hallucinations are less common than delusions in both mania and depression, with delusions normally taking on the qualities of expansivity, hyperreligiosity, or grandiosity. Delusions are also relatively less fixed than in schizophrenia. 

Lithium has no specific therapeutic effect on mania or other states of overexcitement. Its brain-disabling effect is not specific for patients diagnosed as manic or bipolar. Lithium will subdue or suppress the mental and physical functioning of animals, newborn infants and nursing infants of mothers who take lithium, and normal volunteers, as well as people diagnosed with psychiatric disorders. Lithium-treated volunteers suffer devastating effects on their ability to relate and to function intellectually. Animals show similar taming effects. 

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