Clinical:Bipolar disorder

Other Names

• Manic depressive illness
• Manic depressive psychosis

Diagnosis

Diagnostic Criteria according to the International Classification of Disease ICD 10

F31 Bipolar affective disorder A disorder characterized by two or more episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar. Includes: manic-depressive: · illness · psychosis · reaction Excludes: bipolar disorder, single manic episode ( F30.- ) cyclothymia ( F34.0 )

F31.0 Bipolar affective disorder, current episode hypomanic The patient is currently hypomanic, and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past.

F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms The patient is currently manic, without psychotic symptoms (as in F30.1), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past.

F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms The patient is currently manic, with psychotic symptoms (as in F30.2), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past.

F31.3 Bipolar affective disorder, current episode mild or moderate depression The patient is currently depressed, as in a depressive episode of either mild or moderate severity (F32.0 or F32.1), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past.

F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms The patient is currently depressed, as in severe depressive episode without psychotic symptoms (F32.2), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past.

F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms The patient is currently depressed, as in severe depressive episode with psychotic symptoms (F32.3), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past.

F31.6 Bipolar affective disorder, current episode mixed The patient has had at least one authenticated hypomanic, manic, depressive, or mixed affective episode in the past, and currently exhibits either a mixture or a rapid alteration of manic and depressive symptoms. Excludes: single mixed affective episode ( F38.0 )

F31.7 Bipolar affective disorder, currently in remission The patient has had at least one authenticated hypomanic, manic, or mixed affective episode in the past, and at least one other affective episode (hypomanic, manic, depressive, or mixed) in addition, but is not currently suffering from any significant mood disturbance, and has not done so for several months. Periods of remission during prophylactic treatment should be coded here.

F31.8 Other bipolar affective disorders Bipolar II disorder Recurrent manic episodes NOS

F31.9 Bipolar affective disorder, unspecified

Treatment

As chronic mental illness, the treatment of bipolar disorder may be divided into phases: acute exacerbation - either manic or depressive; relapse prevention, treatment of co-occurring conditions - including substance abuse problems - and maintenance. The treatment of Bipolar Disorder should include a combination of medication and psychotherapy. The Texas Algorithm for Bipolar Disorder can be found here and the American Psychiatric Association Practice Guidelines here.

Classic Mood Stabilizers

Lithium

Lithium is the classic mood stabilizer. It is a very affordable medication, however has a number of clinically significant side effects. When treating a acute manic episode lithium usually needs to be supplemented with an antipsychotic. Therapeutic lithium levels range from 0.6 to 1.2 mEq/L. See the Lithim page for futher information.

Valproic Acid

Valproate (valproic acid or divalproex) is approved for the treatment of acute mania only. The doses range from 750 to 2,500 mg/day and there is an extended release format. Therapeutic valproic levels range from 50 to 120 μg/mL.

Carbamazepine

Typical doses to treat mania are between 600 and 1,800/day. Therapeutic carbamazepine levels range from 4 to 12 μg/mL. Generally seen as more effective in rapid-cycling illness, carbamazepine appears to be less effective overall than lithium or sodium valproate. A congener of carbamazepine, oxcarbamazepine, is also available, however higher doses are likely required.

Second Generation Antipsychotics

Over the last decade a new generation of antipsychotics has entered the market and rapidly become an important option in treating acute mania and maintenance of bipolar disorder. They are, on order of appearance on the market:

Risperidone

The main commercial name: Risperdal. Produced by Janssen Pharmaceuticals. Part of Johnson & Johnson.

Initial dosage: 1 mg BID; Maintenance: 2-8 mg BID.

Most clinically significant side effects: Orthostatic hypotension and reflex tachicardia, insomnia, and agitation.

Long terms side effects: weight gain and prolactin elevation.

Olanzepine

Commercial name: Zyprexa. Produced by Lilly.

Initial dosage: 5-10 mg QD, usually at bedtime; Maintenance: 10-40 mg QHS.

Most clinically significant side effects: drowsiness, dry mouth, akathisia and sedation.

Long terms side effects: weight gain and lipid and glucose metabolism alterations.

Quetiapine

Commercial name: Seroquel. Produced by Astra Zeneca.

Initial dosage: 50 mg QHS; Maintenance: 600-800 mg QD. Max: 1200 mg QD.

Most clinically significant side effects: Orthostatic hypotension, sedation.

Long terms side effects: weight gain and lipid and glucose metabolism alterations.

Ziprazodone

Commercial name: Geodon. Produced by Pfizer.

Initial dosage: 20 mg BID; Maintenance: 80 mg BID.

Most clinically significant side effects: QTc prologation.

Aripiprazole

Commercial name: Abilify. Produced by Bristol-Meyers BMS.

Initial dosage: 10-15 mg qAM; Maintenance: 10-30 mg per day.

Most clinically significant side effects: headache, nausea and vomiting, usually resolving in a week.

Paloperidone

Commercial name: Invega. Other Janssen product - a metabolite of risperidone.

Initial dosage: 6 mg/day. Can be given once a day.

Long terms side effects: weight gain and prolactin elevation. Similar to risperidone.

Anticonvulsants

Lamotrigine

Lamotrigine is an anticonvulsant that has been shown to have some effectiveness in treating depressive episodes. Like other anticonvulsants, regalar serum monitoring is required.

History

Aretaeus of Cappadocia is usually cited as the first to provide an accurate clinical description of mania and depression happening in the same patient. Beyond his contributions to the understanding of schizophrenia, Emil Kraepelin is also credited with the key distinctions between manic depressive illness and dementia praecox (schizophrenia) as well as between bipolar disorder and major depression.

Emil Kraepelin (1856-1926). Source: Courtesy of the National Library of Medicine

Aretaeus of Cappadocia (1st Century C.E.). Source: Courtesy of the National Library of Medicine

Epidemiology

Incidence

The annual incidence of bipolar disorder is less then 1%. Accurate estimates are difficult due to the bipolar spectrum.

Prevalence

The lifetime prevalence of bipolar disorder is estimated between 0.5 to 2.4% of the population.

Age of Onset

The age of onset for bipolar disorder ranges from childhood onset cases (5-6 years old) to late onset after 50 years old. The mean age of onset is 30.

Marital status

Bipolar disorder is more common in single or divorced persons.

Clinical Trials

There are hundreds of active clinical trials on bipolar disorder check here