Doctor demystifies bipolar disorder
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of madness, it was the age of belief, it was he time of unbelief, it was the season of light, it was It was the season of darkness, it was the spring of hope, it was the winter of despair.
These iconic words from Charles Dickens in A Tale of Two Cities encapsulate the state of mind of someone with a complex neuropsychiatric disorder called bipolar disorder.
Previously called manic-depressive illness, the disease is characterized by dramatic changes in mood, energy, and activity levels that affect a person’s ability to perform daily tasks. These swings in mood and energy are more serious than the normal ups and downs that everyone experiences. Manic-depressive illness was defined by Emil Kraepelin in 1898 and was characterized by recurrent mood episodes of any kind, either depression or mania. The current definition differs from Kraepelinian’s – bipolar disorder is said to have both depression and mania.
Bipolar disorder is often overlooked due to the nature of the disorder itself. Most often it starts with periods of depression, and sometimes a decade can pass, until the person has a manic episode. Simply treating depression in these people will not result in symptom relief. This is why psychiatrists are keeping an eye out for the discovery of the underlying bipolar tendency in people (a) who have an early onset (20-25 years) of multiple periods of depression (b) who have a family history of bipolar disorder (c) who have been diagnosed with ADHD (d) who abuse substances (d) whose onset and end of depression are abrupt (e) whose depression refuses to improve despite treatment (f ) whose depression worsens with antidepressants.
Natasha (name changed) suffered from difficult-to-treat depression. She had seen a host of doctors and mental health professionals. Her depression refused to subside despite years of treatment. I vividly remember his exasperation at not being able to find a solution to his vexing medical problem. During the clinical interview, after carefully probing her symptoms, her mother confirmed that Natasha had periods of slightly elevated mood during which she was found to be more excitable, happier than usual, and as if filled with more energy. These symptoms were never severe enough to disrupt his professional, personal or social spheres. During her 15-year illness, she experienced four such distinct periods. Unfortunately, these were difficult to choose during the first clinical interviews. This was a case of bipolar II disorder, characterized by depression and hypomania. Bipolar II disorder is usually difficult to spot in a single clinical interview and requires clinical examination of symptoms, in the presence of a good informant. The absence of periods of hypomania in the person’s history completely alters the management of the disorder and has therapeutic implications.
Studies have reported that the lifetime prevalence of bipolar I disorder ranges from 0.3% to 1.5%. More recent studies have reported lifetime prevalence rates of 1%, 1.1%, and 2.4% for bipolar I disorder, bipolar II disorder, and subthreshold bipolar disorder, respectively. The prevalence of bipolar I disorder is similar in men and women while it is consistently higher in women with bipolar II disorder.
There is a dynamic interplay between the concepts of “nature” (genes) and “nurture” (environment) in the causation of bipolar disorder. In determining risk factors for lifelong vulnerability, genes play a central role. For the onset of an episode of depression or mania, adverse life events such as bereavement, divorce, financial distress, relationship difficulties, may have a role to play. Factors such as stress, sleep disturbances, substance abuse can also trigger mood swings in genetically vulnerable people. Many women experience their first episode of depression or mania during the postpartum period. Disruption of normal biological rhythms can precipitate the onset of manic or depressive episodes. This has been documented in connection with international travel involving east-west or west-east travel with disruption of the body’s biological clock.
Age of onset and disease course
Bipolar disorder is highly inherited, which means that 70-80% of people with this disorder have a parent with bipolar disorder or unipolar depression. The average age of onset for bipolar disorder ranges from 17 to 30 years old. European data suggests an average age in the late twenties, while US data suggests an average age in the early twenties.
Most people (85%) with bipolar disorder present to the clinician with a first episode of depression. The duration of these episodes is usually between two and five months. Ten percent of patients present with mania and this lasts for about two months. Ninety to 100% of people with bipolar I disorder will develop further mood episodes after the first manic episode. Some may develop a few episodes while others may develop several. The general rule is that previous episodes increase the risk of recurrence for future episodes. During the course of the disease, 80% of people have episodes of depressed mood while the others have a manic or mixed episode.
Undiagnosed bipolar disorder and health care utilization
Bipolar disorder is a clinical diagnosis, and in that it is often missed. Indeed, hypomanic or manic episodes are not frequently brought to the attention of the clinician. A person with hypomania may even enjoy the slightly elevated mood and refuse to consider it part of the disease spectrum. Likewise, periods of intense anger and irritation, which may reflect irritable mania, may be missed altogether. People with hypomania and mania often lack information about their illness to seek clinical consultation.
Additionally, there is often a gap between the onset of mood episodes and seeking help (on average 8-10 years), and it can sometimes take a decade for a bipolar patient to receive the correct diagnosis. An overwhelming 20-40% of bipolar patients are initially misdiagnosed as having unipolar clinical depression and are given antidepressants. This can worsen the longitudinal course of the disorder and lead to poor long-term outcomes. When antidepressants are given without the cover of a mood stabilizer in a person with undiagnosed bipolar disorder, a depressed person shifts to the opposite pole and exhibits extreme manic symptoms. This clinical phenomenon is called “switching” and results in a worsening of the person’s state of mind.
Symptoms of bipolar disorder improve with treatment. Medications are the mainstay of treatment for bipolar disorder in conjunction with talk therapy. Talk therapy can help people learn about their illness, increase medication adherence, and therefore prevent future mood swings. Non-drug approaches include interpersonal and social rhythm therapy (IPSRT), family-focused treatment (FFT), and psychoeducation.
The IPSRT is based on the premise that symptoms of bipolar disorder are triggered by disruptions in daily routines and sleep-wake cycles, and stabilization of these routines is essential for mood stabilization. IPSRT begins after an acute period of illness and focuses on stabilizing daily and nighttime rhythms as well as resolving interpersonal issues that may have preceded the acute episode. Patients learn to follow their routines and sleep-wake cycles and to identify events (eg job changes) that may cause changes in these routines.
Medications called “mood stabilizers” like lithium and dopamine receptor blockers like risperidone are the most common types of medications prescribed for bipolar disorder. These drugs are thought to correct imbalanced brain signaling. Since bipolar disorder is a chronic disease with frequent recurrences, ongoing preventive treatment is recommended. Psychiatrists frequently individualize treatment, which involves a process of trial and error to determine the best fit.
If the person is suicidal or if medications have caused a suboptimal response, a very effective brain stimulation modality called electroconvulsive therapy (ECT) may be used. While the person is under anesthesia, a brief electrical charge is applied to the person’s temples or frontal bone, causing a short-lived seizure. This remodels the signaling pathways in the brain and results in immediate relief. ECT has saved many suicidal people from the clutches of near death.
Ruchi (name changed) is a long-time patient of mine. After recently recovering from a depressive episode, she remarked, “Doc, do you think people will see me as a person or as someone who alternates between mania and depression? I was at a loss for words for a moment, then gathered myself together to make sure that, in all of her suffering, her individuality had remained intact. She was far beyond her periods of mania and depression. She had been a wonderful daughter, a caring wife and an extraordinary mother.
The stigma surrounding this complex but common neuropsychiatric disorder is immense. As a result, many people do not seek help. Lack of awareness also delays seeking help. With the right treatment, people with bipolar disorder can lead productive and fulfilling lives. Mental health is an inalienable right and anyone with bipolar disorder has the right to seek timely care.
Kulkarni is Senior Consultant Psychiatrist, Manas Institute of Mental Health, Hubballi.