The term Bipolar isn’t new to most of us. In fact, it’s often used in the colloquial sense to brand someone who is moody or acting “crazy.” Actors on our screens have played characters with bipolar disorder, trying to give us a glimpse into what it means to l live with this illness. Beyond the jest and theatre, real people who live with this condition. Most of the stories we see or hear are of people who struggle to integrate and live functional, productive lives despite this diagnosis. Is there a silver bullet which can cure this ailment?
Bipolar Disorder is a mental health disorder characterized by dysregulation of mood. It is a chronic mental illness that requires lifetime management and follow up. While it has indeed been a well-known disease for some time, it currently has no cure. However, Bipolar Disorder can be treated and managed with medicine and psychotherapy, allowing for a normal and productive life.
What is Bipolar Disorder?
Bipolar disorder is one of the mental illnesses classified under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It is a mood disorder usually characterized by mood episodes of mania, hypomania and major depression. One experiences periods of these mood episode while at times fluctuating between opposing polarities of the mood spectrum, hence the name “bipolar”.
The major subtypes of Bipolar include
- Bipolar I disorder: patients with a history of at least one episode of mania
- Bipolar II disorder: patients with at least one episode of hypomania, at least one episode of major depression and no history of manic episodes
- Cyclothymic disorder: diagnosed in patients with periods of hypomanic symptoms and depressive symptoms that fall short of meeting the criteria for hypomanic or major depressive symptoms
- Substance induced bipolar disorder is another less common subtype.
What causes Bipolar Disorder?
According to the WHO, it is estimated that bipolar was the 46th greatest cause of disability in the world among 291 diseases and causes of injury. This placed bipolar ahead of breast cancer as well as Alzheimer’s disease. Despite the abundance of research and amassed knowledge on this illness, the pathogenesis is not clearly understood. At present, it is believed to involve both biologic factors, such as genetics and neurobiology, and psychosocial factors.
The lifetime risk of bipolar disorder for first degree relative is between 5-10%. This percentage increases to around 40-70% in twins. What is also clear is that psychosocial stressors, beyond having a part in etiology of the disease, also act as triggers into mood episodes. Stressful periods at work, home or huge life-changing events may overwhelm patients into manic or major depressive episodes. Treatment of this illness focuses on these factors as targets for therapy.
How is Bipolar Disorder diagnosed?
Diagnosis usually begins by diagnosing the mood episodes that comprise bipolar disorder. Both the DSM-V manual and the International Classification of Diseases (ICD-10) have a criterion for each of these episodes that must be met before a conclusive diagnosis is made. The clinician also has to exclude any other relevant disorders that may be the root cause of illness.
In manic episodes, which is often portrayed by characters with bipolar in movies, patient’s usually experience elevated, expansive, or irritable moods. They have increased energy and goal directed activity. This is the high end of the mood spectrum. The symptoms occur for at least one week, nearly every day, for most of the day. A closer look at the symptoms include:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Excessive talkativeness
- Racing thoughts and flight of ideas
- Easy distractibility
- Increased goal-directed activity
- Involvement in experiences that have high potential to cause harm or dreadful consequences e.g. exorbitant shopping sprees, risky business ventures, sexual indiscretions and dangerous drug use
This normally ends up impairing psychosocial functioning or in other words the ability to go to work or meet familial obligations. More worrisome is the probability of run-ins with authority due to acts of civil disobedience and recklessness that usually lead them to getting incarcerated. Patients suffering these episodes may also have psychotic features (hallucinations or delusions) and may end up requiring hospitalization.
Hypomania, just like mania, is also typified by abnormally and persistently elevated or irritable mood, as well as increased energy and activity. The distinction between the two is based on the intensity and duration, with Hypomanic episodes being less severe and requiring only 4 days of symptomatology for diagnosis. Furthermore, Hypomanic episodes don’t usually require hospitalization as the patients don’t experience psychotic features. Impairment of psychosocial functioning is also mild.
3. Major Depression
This is the low end of the mood spectrum where patients suffer low moods with no motivation for activity. It is usually marked by at least five of the following symptoms for at least 2 weeks, most of the day nearly every day
- Depressed mood, also termed as dysphoria
- Reduced interest or pleasure in nearly all daily activities
- Significant weight loss or weight gain (5%in a month) or decrease in appetite
- Lack of sleep(insomnia) or hypersomnia (excessive sleep)
- General fatigue or loss of energy
- Thoughts of worthlessness or inappropriate guilt
- Diminished ability to concentrate
- Recurrent thoughts of death, suicidal ideations or a suicidal attempt
Suicide is a very present danger in patients undergoing a major depressive episode. And just like Manic episodes, Major depressive episodes affect psychosocial functioning greatly and may require hospitalization too.
Important to note is the specificity of timelines and symptoms in accurately diagnosing someone as having bipolar disorder. Diagnosis at times takes time before being made. Follow up with doctors is usually necessary to make an accurate diagnosis.
How is Bipolar Treated?
Despite being a lifelong illness, bipolar disorder can be treated. This is crucial to allow for a normal functional life for ailed patients. Clinicians will use both pharmacotherapy (medication) and psychotherapy. The goal is to first stabilize the patient’s mood to a euthymic (normal) state during the acute mood episodes. Thereafter, they are started on maintenance therapy. This is what affords them the ability to grow their careers, have meaningful relationships and interact with society in a safe way.
Medicines used target the specific mood episode and aim to provide mood stability over a long period of time. Pharmacotherapy used include
- Mood stabilizer drugs such as Lithium
- Antipsychotic drugs such as Olanzapine, Risperidone & Aripiprazole
- Anti-seizure drugs such as Valproate & Carbamazepine
Combination therapy is often preferred with patients being started on lithium plus either an antipsychotic or Valproate in manic episodes. Quetiapine is usually the first-line drug for patients in major depressive disorders. These drugs are also used as maintenance once the patient is out of the acute episode. It may take a while before locking down which specific drugs, combination or dosage works best to achieve treatment.
Important to note is that while these drugs have been scientifically shown to be safe and efficacious in the treatment of Bipolar, they are not without side effects. Lithium levels in the blood must be monitored for toxicity regularly and it’s generally avoided in patients with kidney disease. Certain drugs are avoided in pregnancy due to their ability to harm the unborn child (teratogenicity). Some antipsychotic drugs may even present with obesity as a side effect. This is mostly seen with Olanzapine and Quetiapine. Trained clinicians are however aware of these effects and consider them when starting patients on medication. They also watch out for these during treatment to determine need for either altering the dosage or switching medicine out altogether. As such, they are not a hindrance to treatment.
This arm of treatment serves to help people living with bipolar disorder understand their condition, adhere to medication and hopefully prevent mood episodes by tackling the psychosocial stressors present. It is usually used adjunctively to medication. Psychotherapy seeks to:
- Educate patients about their illness, including symptoms, course of disease and treatment options
- Enhance acceptance of diagnosis and adherence to medication
- Promote self-management e.g. adopting daily routines, being physically active and working on keeping healthy relationships
- Help them manage stress and develop plans to cope with crisis
- Avoid potentially mood destabilizing activities such as alcohol misuse or drug abuse
Cognitive-behavior Therapy (CBT) is mostly selected as the mode of therapy as it has been most widely studied and available. The clinician may however choose other specific types of Psychotherapy to be offered based on the patient’s need. Other therapies available include Family therapy, Interpersonal Psychotherapy or Group Therapy.
3. Electroconvulsive Therapy
ECT is a form of physical therapy where a small electric current is passed through one’s brain to produce a generalized cerebral seizure. It is usually done under anesthesia. Despite controversy and stigma arising from misinformation about ECT, its efficacy in treatment of mood disorders is well established scientifically and clinically proven.
ECT is used in treatment of bipolar disorder where the illness is refractory to medication, that is, not responding to regimen despite graduating to higher doses and using different combinations. It is majorly used to treat severe depression but can also be used in manic episodes unresponsive to medication. It is a safe method of treatment.
We need to be aware that although Bipolar can be a debilitating illness, treatment is available. We can help the people in our society living with this disease. Adherence to medication, receiving therapy and avoiding/coping with stressors is key to ensuring a stable productive life.