Mood disorders bipolar disorder

Post, R., Altshuler, L., Frye, M., Suppes, T., Rush, A., Keck, P., Jr., et al. (2001). Rate of switch in bipolar patients prospectively treated with second-generation antidepressants as augmentation to mood stabilizers. Bipolar Disorders, 3, 259—265. 

The major or most severe psychiatric disorders include depressive disorders, bipolar disorder (manic-depressive illness), and schizophrenia. Depression and bipolar disorder are classified as mood disorders, because the predominant feature of these conditions is an inappropriate or abnormal emotional state. Schizophrenia, on the other hand, is classified as a thought disorder, because the predominant symptoms involve disturbances in perception and thinking. 

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). 

Affective (mood) disorders are characterized by changes in mood. The most common manifestation is depression, arranging from mild to severe forms. Psychotic depression is accompanied by hallucinations and illusions. Mania is less common than depression. In bipolar affective disorder, depression alternates with mania. 

Although lithium is not a true antipsychotic drug, it is considered with the antipsychotics because of its use in regulating the severe fluctuations of the manic phase of bipolar disorder (a psychiatric disorder characterized by severe mood swings of extreme hyperactivity to depression). During the manic phase, the person experiences altered thought processes, which can lead to bizarre delusions. The drug diminishes the frequency and intensity of hyperactive (manic) episodes. 

The mood stabilizers were so called because they prevent recurrences of mood swings in people with bipolar disorder. The evidence for this is best with lithium, but is based on smdies carried out more than 20 years ago. However, recent naturalistic surveys tend to find that lithium is far less useful in general clinical practice than in research settings. Many patients discontinue lithium... 

Depression and mania are both affective disorders but their symptoms and treatments are quite distinct. Mania is expressed as heightened mood, exaggerated sense of self-worth, irritability, aggression, delusions and hallucinations. In stark contrast, the most obvious disturbance in depression is melancholia that often co-exists with behavioural and somatic changes (Table 20.1). Some individuals experience dramatic mood swings between depression and mania. This is known as "bipolar disorder which, like mania itself, is treated with lithium salts or neuroleptics. 

O Patients presenting with depressive or elevated mood features and a history of abnormal or unusual mood swings should be assessed for bipolar disorder. 

The primary treatment for depressive episodes in bipolar disorder is mood-stabilizing agents, often combined with antidepressant drugs. 

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... 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

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... 

A mood disorder questionnaire is completed by the patient that asks about common symptoms of bipolar disorder, problems caused by the symptoms, and family history in a yes-or-no answer format. It is then scored by the clinician. 

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... 

Schizophrenia and bipolar disorder often share certain symptoms, including psychosis in some patients. The prominence of mood symptoms and the history of mood episodes distinguish bipolar disorder and schizophrenia. In addition, the psychosis of schizophrenia occurs in the absence of prominent mood symptoms. 

Personality disorders are inflexible and maladaptive patterns of behavior that deviate markedly from expectations of society. These patterns are stable over time, pervasive and rigid, and lead to distress or impairment in the individual s life. Onset is in adolescence or early adulthood.1 Personality disorders and bipolar disorder may be comorbid, and patients with personality disorders may have mood symptoms. The two diagnoses are distinguished, however, by the predominance of mood symptoms and the episodic course of bipolar disorder, in contrast to the stability and persistence of the behavioral patterns of personality disorders. 

Pharmacotherapy is the cornerstone of acute and maintenance treatment of bipolar disorder. Mood-stabilizing drugs are the usual first-choice treatments and include lithium, divalproex, carbamazepine, and lamotrigine. Atypical antipsychotics other than clozapine are also approved for treatment of acute mania. Lithium, lamotrigine, olanzapine, and aripiprazole are approved for maintenance therapy. Drugs used with less research support and without Food and Drug Administration (FDA) approval include topiramate and oxcarbazepine. Benzodiazepines are used adjunctively for mania. 

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... 

Divalproex sodium is comprised of sodium valproate and valproic acid. The delayed-release and extended-release formulations are converted in the small intestine into valproic add, which is the systemically absorbed form. It was developed as an antiepileptic drug, but also has efficacy for mood stabilization and migraine headaches. It is FDA-approved for the treatment of the manic phase of bipolar disorder. It is generally equal in efficacy to lithium and some other drugs for bipolar mania. It has particular utility in bipolar disorder patients with rapid cycling, mixed mood features, and substance abuse comorbidity. Although not FDA-approved for relapse prevention, studies support this use, and it is widely prescribed for maintenance therapy. Divalproex can be used as monotherapy or in combination with lithium or an antipsychotic drug.31... 

Treatment of depressive episodes in bipolar disorder patients presents a particular challenge because of the risk of a pharmacologic mood switch to mania, although there is not complete agreement about such risk. Treatment guidelines suggest lithium or lamotrigine as first-line therapy.17,41 Olanzapine has also demonstrated efficacy in treatment of bipolar depression, and quetiapine is under review for approval of treatment of bipolar depression.42 When these fail, efficacy data support use of antidepressants. 

Comorbid conditions must be addressed in order to maximize desired outcomes. For comorbid bipolar disorder and attention-deficit/hyperactivity disorder when stimulant therapy is indicated, treatment of mania is recommended before starting the stimulant in order to avoid exacerbation of mood symptoms by the stimulant. 

In clinical psychiatric terms, the affective disorders can be subdivided into unipolar and bipolar disorders. Unipolar depression is also known as psychotic depression, endogenous depression, idiopathic depression and major depressive disorder. Bipolar disorder is now recognised as being heterogeneous bipolar disorder I is equivalent to classical manic depressive psychosis, or manic depression, while bipolar disorder II is depression with hypomania (Dean, 2002). Unipolar mania is where periods of mania alternate with periods of more normal moods. Seasonal affective disorder (SAD) refers to depression with its onset most commonly in winter, followed by a gradual remission in spring. Some milder forms of severe depression, often those with an identifiable cause, may be referred to as reactive or neurotic depression. Secondary depression is associated with other illnesses, such as neuro-degenerative or cardiovascular diseases, and is relatively common. 

Bipolar disorder is characterised by a period of mania, then a period of comparatively normal behaviour (euthymia), before progressing to a period of depression. The rate at which these mood changes occur can vary, being prolonged in some individuals and shorter in others. This periodicity is often characteristic and unchanging for an individual. In some rare instances the mood cycle is not only predictable but also very rapid for instance, 16 hours of mania, followed by 8 hours of euthymia, then 48 hours of depression. 

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