Rapid cycling bipolar affective disorder

D haenen HA, Bossuyt A Dopamine D2 receptors in depression measured with single photon emission computed tomography. Biol Psychiatry 35 128-132, 1994 Di Costanzo E, Schifano E Dthium alone or in combination with carbamazepine for the treatment of rapid-cycling bipolar affective disorder. Acta Psychiatr Scand 83 456-459, 1991... 

Bauer MS, Whybrow PC, Winokur A. Rapid cycling bipolar affective disorder. I. Association with grade I hypothyroidism. Arch Gen Psychiatry 1990 47 427-432. 

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. 

Q1 The swings of mood from depression Lo mania suggest a diagnosis of manic depressive disorder (bipolar affective disorder). In this condition, the cycle of manic and depressive periods can take place over months or years, but may occur rapidly over weeks or days this varies between patients. On the other hand, there may be several episodes of depression which follow each other, or the patient may experience several episodes of mania in succession. 

Carbamazepine is licenced as an alternative to lithium for prophylaxis of bipolar affective disorder, although clinical trial evidence is actually stronger to support its use in the treatment of acute mania. Carbamazepine appears to be more effective than lithium for rapidly cycling bipolar disorders, i.e. with recurrent swift transitions from mania to depression. It is also effective in combination with lithium. Its mode of action is thought to involve agonism of inhibitory GABA transmission at the GABA-benzodiazepine receptor complex (see also Epilepsy, p. 417). 

I It is used as an adjunct to lithium in the prophylaxis of bipolar affective disorder and has been considered to have particular value in rapid-cycling bipolar disorder. 

Combined treatment approaches are becoming the standard of care, but these approaches are only now being examined. In a 6-month augmentation study, lithium alone was equivalent to lithium + divalproex in the prevention of mood recurrence in rapidly cycling patients with type I and II bipolar affective disorder with co-morbid substance abuse /T / Of 149 patients, most withdrew early (79% poor adherence 42%, nonresponse 26% adverse effects 10%). Of the 31 who remained in the study 55 % relapsed into an abnormal mood state. 

The total costs are likely to reflect the efficacy of treatment. In one industry-sponsored study (Keck et al, 1996b) treatment with lithium or valproate was compared in relation to classical, mixed and rapid-cycling disorder. Treatment with lithium was associated with lower costs than treatment with valproate for classical bipolar disorder, but treatment with valproate was associated with lower costs than treatment with lithium for mixed and rapid-cycling disorders. This is in keeping with the evidence that valproate is more effective than lithium for certain patients with rapid-cycling disorder and probably also for certain patients with mixed affective states. However, these associations are a guide to predicting response to treatment but are not very specific. 

Bipolar I disorder affects men and women equally bipolar II seems to be more common in women. Rapid cycling and mixed mania occur more often in women. Individuals with bipolar disorder commonly have another psychiatric disease with 78% to 85% reporting another Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis during their lifetime. The most common comorbid conditions include anxiety, substance abuse, and eating disorders.2... 

According to the Expert Consensus Panel for Mental Retardation Rush and Frances, (2000), the mainstays of the pharmacological treatment of acute mania or bipolar disorder in adults are anticonvulsant medications (divalproex, valproic acid, or carbamazepine) or lithium. Both divalproex or valproic acid and lithium were preferred treatments for classic, euphoric manic episodes. Divalproex or valproic acid was preferred over lithium and carbamazepine for mixed or dysphoric manic episodes and rapid-cycling mania. For depressive episodes associated with bipolar disorder, the addition of an antidepressant (SSRI, bupropion, or venlafaxine) was recommended. According to the Expert Consensus Panel, the presence of MR does not affect the choice of medication for these psychiatric disorders in adults. 

Problems with mood are often called affective disorders. Depression and mania are often seen as opposite ends of an affective or mood spectrum. Classically, mania and depression are poles apart, thus generating the terms unipolar depression, in which patients just experience the down or depressed pole and bipolar disorder, in which patients at different times experience either the up (manic) pole or the down (depressed) pole. In practice, however, depression and mania may occur simultaneously, which is called a mixed mood state. Mania may also occur in lesser degrees, known as hypomania, or may switch so fast between mania and depression that it is called rapid cycling. ... 

Ghaemi et al. (2002), who reviewed 85 charts of outpatients with affective disorder seen in a clinic, concluded that 37% had an undiagnosed bipolar disorder and that 23% of them had developed a new or worsening rapid-cycling course attributable to antidepressant use. They concluded, Antidepressants seem to be associated with a worsened course of bipolar illness. Ghaemi et al. (2003) reviewed the literature and looked further into the issue of manic conversion. They drew the following conclusions ... 

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. 

Amsterdam JD, Wang CH, Shwarz M, Shults J. Venlafaxine versus lithium monotherapy of rapid and non-rapid cycling patients with bipolar II major depressive episode a randomized, parallel group, open-label trial. J Affect Disord 2009 112 219-30. 

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