Bipolar disorder is the name now used to describe Manic Depression - the condition where mood veers between two poles or extremes - one of euphoria (mania) and the other of despair (depression). Most of us know of it - if only because of famous sufferers such as Vincent van Gogh - but although bipolar disorder is as common as diabetes, much of it goes unrecognised and inadequately treated. This is a pity because there are now good treatments available that can help keep the condition under control and, to a large extent, allow individuals to carry on normally.

Official estimates say bipolar illness affects 1 to 4 per cent of the population but some researchers believe the real figure is closer to 10 per cent (1). The World Health Organization says it is already the sixth leading cause of disability (2).

There are two main types of bipolar disorder. People who have bipolar I will have experienced at least one severe episode of heightened mood or mania lasting a week, or a mix of manic and depressed symptoms. People with bipolar II will have experienced at least one major depression and some degree of mania although this may be much less severe than in bipolar I and is described as hypomania (3).

In severe cases of bipolar I mania, symptoms can take the form of delusions and hallucinations so must be treated promptly, usually in hospital. More usually, symptoms of mania and hypomania are less obvious; feelings of euphoria, grandiosity, impulsivity, recklessness, and a diminished need for sleep can be ascribed to youthful exuberance. At the depressive end of the spectrum, feelings of anxiety, irritability, hostility and depression can lead to violent or suicidal behaviour. Around one third of uncontrolled bipolar sufferers currently attempt suicide and about half of those succeed (4, 5).

Bipolar disorder typically makes itself felt in a person's late teens or early twenties. Men are just as likely to be affected as women. In nine out of ten cases it recurs periodically throughout life with an average of nine severe episodes over a course of about 20 years (6, 7). The ratio of depressive to manic episodes is greater than two to one in western populations. Compared with mania, episodes of depression also last much longer and carry a higher risk of suicide. Between episodes, sufferers can experience periods of relative calm and stability, with only normal mood variation, or minor symptoms. Today's treatments are geared to maintaining that state and, if or when symptoms erupt, to halting that process.

Diagnosis is difficult

The illness is complex and variable making it difficult for doctors to diagnose. All too often behaviours are marked down to a quirky personality or troubled adolescence. But bipolar disorder has nothing to do with personality, stresses Professor Allan Young, a prominent researcher in the field from University of British Columbia, Vancouver, Canada. "Early diagnosis and treatment are important because the condition impacts on so many aspects of a person's life," he emphasises.

"Unfortunately, bipolar disorder sufferers are more susceptible to anxiety which can adversely impact physical health and wellbeing," Professor Young adds. "There's also a strong risk of them abusing alcohol or other substances."

Misdiagnosis can be a problem as well as no diagnosis. "If bipolar sufferers are misdiagnosed as having only depression or anxiety and are treated with antidepressant drugs alone, there's a high risk of deteriorating", explains Professor Young. Similarly, treatment directed primarily at controlling and preventing mania, or efforts focussed on stopping substance abuse, can fail to tackle depressive symptoms.

Bipolar disorder sufferers are often highly intelligent and creative individuals. History reveals several, such as Charles Dickens and Beethoven, who used their bursts of manic energy to accomplish great achievements. But inability to keep the disorder in check can make it difficult for lesser mortals to hold down jobs and perform consistently well at work (8). Recent US research estimates that bipolar disorder costs the country over $14 billion dollars per year in lost productivity (9).

Bipolar disorder takes a heavy toll on the mind's ability to think, remember and reason normally, Professor Young points out (10). Not just through racing thoughts, lack of sleep, inattentiveness and impaired concentration, but also in more subtle, ways, collectively described as loss of 'executive functioning'. "This includes the ability to plan, dealing with emotions, organise, focus attention where needed, process information and access working memory" he explained. "It's the sort of thing we all take for granted but losing it can be terribly disabling for a bipolar patient."

It can also lead to breakdown of relationships. Bipolar patients are twice as likely to divorce compared to the general population (114). Bipolar mood swings also have repercussions on social life if resulting behaviours upset colleagues and friends as well as partners. Even close family members can sometimes find bipolar behaviours impossible to tolerate. That's probably the most compelling reason for getting bipolar disorder under control. Morbidity and mortality rates are higher in patients with bipolar disorder than they are for those patients suffering from cancer or cardiovascular disease.

Treatment has advanced

When sufferers do get diagnosed and treated - a process that can take up to 10 years - the type of treatment prescribed can vary and some may cause troublesome side effects.

Some older treatments cause so many problems that patients stop taking medication altogether, says psychiatrist Dr Heinz Grunze of Ludwig-Maximilians-University, Munich, Germany. Many patients have been expected to take up to four types of drugs daily, including several with unpleasant side effects (12, 13).

The former mainstay of bipolar treatment was the mood-stabilising therapy lithium. This is highly effective at controlling mania and is used as a maintenance therapy between episodes, as is the anticonvulsant valproate, but these drugs are now considered much less effective in preventing and controlling depressive symptoms and are less widely used (14). Patients receiving lithium need their blood monitoring and can experience side effects such as problems with thinking and memory, weight gain, and tremor that lead many to abandon treatment.

Psychiatrists believe treatment has advanced considerably over the past decade. Several effective new drugs for rapidly controlling mania are now available that can be used instead of, or to allow a reduction of, lithium, Professor Young explains: "Newer antipsychotic drugs, can control mania quickly without so many of the unwelcome side effects associated with older drugs (,15). In particular, it is the uncontrolled jerking or writhing movements that older drugs can cause that are so distressing and stigmatising."

Need for " whole person" treatment

"Doctors are now realising we need to look at patients in a wider sense than before," suggests Professor Young. Traditionally, doctors focussed on mania and depression and only judged drugs on how well they reduced these symptoms. Now they are realising how severely bipolar illness impacts on many aspects of life and acknowledge a need to assess drugs from other perspectives too (16). Side effects, including effects on weight and intellectual function, quality of life, ability to mix well with other people and whether or not a drug produces any consistent troubling minor symptoms are also important. "It is these kind of assessments that can better highlight when treatment is falling short of providing a remedy for the patient as a whole," he comments. Only when every domain of bipolar illness is addressed and doctors get the treatment right will patients get the best chance of fully recovering their ability to participate in normal life.

"What gets you well, keeps you well"

In the past, treatment of acute episodes of mania or depression were followed by a different mood-stabiliser therapy, notes Dr Grunze. The view now is that the treatment that gets you over the worst symptoms will also prevent them recurring. "What gets you well, keeps you well."

The fewer drugs a patient needs to take, the greater is the likelihood they will stick to treatment and take medication as directed. If one medicine is not sufficient, there may be alternatives to adding more drugs to treatment, argue patient groups. Talking therapies are also key, they believe, as is "psycho-education" (17, 18, 19). This is the process of learning to understand the nature of bipolar disorder and the importance of seeking help early when symptoms arise or get worse. It explains when and why medicines must be taken regularly, and teaches ways to cope. By avoiding destabilising triggers such as stress, overwork, and too little sleep, patients can help prevent acute episodes of mania and depression.

The new approach is to manage bipolar illness across all four dimensions - its impact on body, mind, emotions and social life. This means using both the effective medications and the non-drug interventions described above. If adopted by the majority of psychiatrists there is cause for optimism. New research, new thinking and new medicines should help revolutionise the prospects for bipolar patients restoring their life chances.

Mania signs

-- irritability
-- sleeping less without tiring
-- experiencing a rush of energy
-- uncontrolled spending
-- feeling more self-confident than usual
-- socialising/partying out of character
-- talking fast and more than usual
-- disjointed racing thoughts and ideas
-- difficulty concentrating
-- increased desire for sex
-- uncharacteristic reckless behaviour

Depression symptoms

-- prolonged sadness/crying
-- change in appetite: eating more/less
-- sleeping more than usual
-- loss of pleasure in usual interests
-- social withdrawal
-- feelings of worthlessness
-- suicidal thoughts
-- irritability, anger, anxiety
-- negativity and indifference
-- loss of energy/tiredness

References

1. Hirschfeld RM, Calabrese JR, Weissman MM et al. Screening for bipolar disorder in the community. J Clin Psychiatry 2003;64:53-59

2. World Health Organisation. The Global Burden of Disease summary. Harvard University Press. Cambridge. Mass 1996.

3. American Psychiatric Association. Diagnostic and statistics manual of mental disorders (DSM-IV-TR) 4th ed. 3rd rev. Washington DC. American Psychiat. Assoc 2000.

4. Angst F, Stassen HH, Clayton PJ et al. Mortality of patients with mood disorders: follow-up over 34-38 years. J. Affective Disorders 2002; 68: 167-181.

5. Valtonen H et al. Suicidal ideation and attempts in bipolar 1 and II disorders. J Clin Psychiatry 2005; 66: 1456-1462.

6. Suppes T, Leverich GS, Keck PE, et al. The Stanley Foundation Bipolar Treatment Outcome Network II. Demographics and illness characteristics of the first 261 patients. J Affect Disord. 2001;67:45-59. why is this in blue?

7. Judd LL, Akiskal HS, Schettler PJ et al. The long-term natural history of the weekly symptomatic status of bipolar 1 disorder. Arch Gen Psychiatry 2002; 59: 530-7.

8. Michalak EE et al. The impact of bipolar disorder upon work functioning: a qualitative analysis. Bipolar Disord 2007; 9: 126-143.

9. Kessler RC. Prevalence and effects of mood disorders on work performance in a nationally representative sample of US workers. Am J Psychiat 2006; 163: 1561-82006

10. Martinez-Aran A et al. Cognitive function across manic or hypomanic, depressed and euthymic states in bipolar disorder. Am J Psychiat 2004; 161:262-270.

11. Kupfer DJ, Frank E, Grochocinski VJ, Cluss PA, Houck PR, Stapf DA. Demographic and clinical characteristics of individuals in a bipolar disorder case registry. J Clin Psychiatry. 2002;63:120-125. why is this in blue?

12. Goodwin, G.M, Vieta, E. Effective maintenance treatment - breaking the cycle of bipolar disorder. European Psychiatry 2005; 20, 365-371.

13. Zarate CA. Antipsychotic drug side-effect issues in bipolar manic patients. J Clin Psychiatry 2000; 61 (Suppl 8): 52-61.

14. Young A, Newham JI. Lithium in mainenance therapy for bipolar disorder. J Psychopharmacol 2006; 20(suppl 2): 17-22.

15. Tohen M, Jacobs TG, Grundy SC et al. Efficacy of olanzepine in acute bipolar mania: a double-blind rndomised placebo-controlled study. Arch Gen Psychiatry 2000; 57: 841-9.

16. Young A. Bipolar Disorder - the Four Dimensions of Care. 7th International Review of Bipolar Disorders. Abstract book p.23

17. Clarkin JF, Carpenter D, Hull J et al. Effects of treatment and psycho-educational interventions for married patients with bipolar disorder and their spouses. Psychiatry Research 1998; 49: 531-33.

18. Colom F, Vieta E, Martinez-Aran A. A randomised trial on the efficacy of group psycho-education in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003; 60: 402-7.

19. Perry A, Tarrier N, Morriss T et al. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtaining treatment. BMJ 1999; 318: 149-153.

Written by:
By Olwen Glynn Owen
Olwen at macline.co.uk