Bipolar Disorders

• About

  People with bipolar disorder (previously called manic-depressive illness or manic depression) experience a cycle of mood swings between depression and mania (elation). People with a more moderate form of bipolar disorder experience hypomania, a less severe form of mania. Both the manic and depressive phases vary widely in intensity and duration. People with bipolar disorder often spend more time in the depressive phase of illness than the manic or hypomanic phase (see Depression for further description - link here).

  Common symptoms of bipolar disorders are:

  • Emotional changes:
    • Experiencing an elevated, expansive or irritable mood for at least one week
    • Rapid changes in mood between depression and mania, or a mixture of both
    • Moodiness
    • Irritability or anger (1)
  • Cognitive changes:
    • Feeling excessively good about the self (inflated self esteem)
    • Exaggerated ideas about how important one is (grandiosity)
    • Difficulty concentrating, paying attention and remembering things
    • Easily distracted or impulsive
    • Having many ideas or thoughts at the one time (flight of ideas)
  • Behavioral changes:
    • More talkative or having pressured speech
    • Problems with work, social or family life
    • Increased goal-directed activity where the goals are not necessarily beneficial for the person (eg, focusing on a grandiose idea like creating a new invention to the exclusion of everything else)
    • Involvement in pleasurable or risky activities that have the potential for serious negative consequences (eg, excessive spending, increased sexual activity)
    • Increase in impulsivity
  • Physical changes:
    • Decreased need for sleep
    • Changes in energy levels and appetite

  Onset of bipolar disorder in young people
  At least one in every 100 people will experience bipolar disorder at some time during their lives. In Australia, approximately 0.7% of males and 1.0% of females aged 18-24 have had bipolar disorder in the previous 12 months (2).

  Bipolar disorder is the ninth leading contributor to the burden of disease and injury in Australian females aged 15-24, and the tenth leading contributor for males (3).

  Overall, about 50% of people who develop bipolar disorder will do so by the time they are in their early to mid 20s (4).

  Risk factors
  A number of factors are known to increase the likelihood that a person will develop bipolar disorder (5). These include:

  • Genetic vulnerability (for example, bipolar disorder in other family members)
  • Physiological or biological factors including complications during gestation or birth, or abnormal regulation of daily (circadian) rhythms
  • Psychological factors including a childhood history of physical or sexual abuse
  • Experiencing stressful life events

   

  References
  1. Faust DS, Walker D, et al. Diagnosis and management of childhood bipolar disorder in the primary care setting. Clin Pediatr (Phila). 2006 Nov;45(9): 801-808.

  2. Mitchell PB, Slade T, et al. Twelve-month prevalence and disability of DSM-IV bipolar disorder in an Australian general population survey. Psychol Med. 2004 Jul;34(5): 777-785.

  3. Australian Institute of Health and Welfare. Youth Australians: their health and wellbeing. 2007 Cat. no. PHE 87. Canberra: AIHW.

  4. Jablenskey A, McGrath J, et al. Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders. Aust NZ J Psychiatry. 2000 Apr;34(2): 221-236.

  55. Berk M, Conus P, et al. Setting the stage: From prodrome to treatment resistance in bipolar disorder. Bipolar Disord. 2007 Nov;9(7): 671-678.

• Assessment

  Formal systems for the diagnosis of mental illness (1, 2) describe a number of different types of bipolar disorder, including: 

  • Bipolar I disorder (manic episodes have occurred)
  • Bipolar II disorder (hypomanic episodes have occurred)
  • Cyclothymia
  • Bipolar disorder not otherwise specified (NOS)

  Assessment Tools

  To decide whether a young person may be experiencing bipolar disorder, a comprehensive assessment by a mental health professional is required.  As a first step, the assessment involves asking questions about a range of aspects of a person life including their:

  • Home and Environment; 
  • Education and Employment; 
  • Activities; 
  • Drugs and Alcohol; 
  • Relationships and Sexuality; 
  • Conduct Difficulties and Risk-Taking; 
  • Anxiety and Eating; 
  • Depression and Suicide; 
  • Psychosis and Mania

  To specifically assess for the presence of manic symptoms consistent with bipolar disorder, a comprehensive Mental State Examination by a mental health professional trained in clinical assessment is required. It may also be beneficial to use a standardized assessment rating scale, such as the Young Mania Rating Scale (YMRS) to comprehensively assess symptoms of mania.

  See the Young Mania Rating Scale for more information (3).

  References

  1. DSM-IV Bipolar disorders

  2. ICD-10 Bipolar affective disorder

  3. Young BC, Biggs JT, et al. A rating scale for mania: Reliability, validity and sensitivity. Br J Psychiatry. 1978 Nov;133: 429-435.

• Treatment

  Early detection and treatment of bipolar disorder can improve its long-term outcome (1, 2).  Accurate diagnosis is essential to provide appropriate treatment, but this can be difficult in the early stages of bipolar disorder as (3):

  • Mania may be misdiagnosed as psychosis
  • It can be difficult to differentiate bipolar depression from unipolar depression
  • Co-existing disorders (eg, medical illness, substance use) can complicate the process

  Treatment of bipolar disorder should include (4, 5):

  • Assertive case management
  • Appropriate medication (using mood stabilizers, antidepressants and antipsychotics as needed)
  • Psychological therapy
  • Family and group therapy (including family psychoeducation)
  • Vocational interventions

  It is important to note that young people may have had the illness for a much shorter time than older patients and the response to medications may be better in the early stages (2). The long-term use of medication may be needed to prevent relapse.

  In areas where specialised early intervention services do not exist, general practitioners have an opportunity to make an early diagnosis and provide initial treatment illness before review by a psychiatrist (5). A psychiatrist will generally devise a treatment strategy and may provide continued clinical management individually or in conjunction with the GP (see (6) for further information).

  The evidence map provides reference details for studies of prevention and treatment interventions for bipolar disorders in young people.

   

  References
  1. Birmaher B, Axelson D. Course and outcome of bipolar spectrum disorder in children and adolescents: A review of the existing literature. Dev Psychopathol. 2006 Fall;18(4): 1023-1035.

  2. Mao AR, Findling RL. Growing evidence to support early intervention in bipolar disorder. Aust NZ J Psychiatry. 2007 Aug;41(8): 633-666.

  3. Danner S, Fristad MA, et al. Early-onset bipolar spectrum disorders: Diagnostic issues. Clin Child Fam Psychol Rev. 2009 Sep;12(3): 271-293.

  4. Berk M, Hallam K, et al. Early intervention in bipolar disorders: Opportunities and pitfalls. Med J Aust. 2007 Oct 1; 187(Suppl): s11-14.

  5. Faust DS, Walker D, et al. Diagnosis and management of childhood bipolar disorder in the primary care setting. Clin Pediatr (Phila). 2006 Nov;45(9): 801-808.

  6. Bipolar Disorder: Australian treatment guidelines for consumers and carers 2009. Royal Australian and New Zealand College of Psychiatrists.

   

• Guidelines

  The following authoritative guidelines provide evidence-based information about the practical treatment of bipolar disorders:

  Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder (2007) American Academy of Child and Adolescent Psychiatry 

  Australian and New Zealand Clinical Practice Guidelines for the Treatment of Bipolar Disorder (2004) Royal Australian and New Zealand College of Psychiatrists

  Treatment Guidelines for Children and Adolescents with Bipolar Disorder (2005) Child Psychiatric Workgroup on Bipolar Disorder

  Guidelines for the management of patients with bipolar disorder: update 2007 (2007) Canadian Network for Mood and Anxiety Treatments (CANMAT)

  Bipolar disorder. The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. (2006) National Institute for Health and Clinical Excellence (NICE) CG 38, United Kingdom

• More info

  The following selected articles provide more information about bipolar disorders

  James AC, Javaloyes AM. The treatment of bipolar disorder in children and adolescents. J Child Psychol Psychiatry. 2001 May;42(4): 439-449.

  Morriss R, Faizal, MA, et al. Interventions for Helping People Recognise Early Signs of Recurrence in Bipolar Disorder. Cochrane Database of Syst Rev. 2007 Jan 24;(1): CD004854.

  Berk M, Hallam K, et al. Evidence and implications for early intervention in bipolar disorder. J Mental Health. 2010 Apr;19(2): 113-126.

  Berk M, Hallam K, et al. Health related quality of life and functioning in bipolar disorder: the impact of pharmacotherapy. Expert Rev Pharmacoecon Outcomes Res. 2006 Oct;6(5): 509-523.