What is manic depression, also known as bipolar disorder?

Manic Depression (Bipolar Disorder)

Manic depression, now formally known as bipolar disorder, is characterized by distinct episodes of mania or hypomania alternating with depression, with marked changes in mood, energy, behavior, and sleep patterns that represent a significant departure from baseline functioning. 1

Diagnostic Features

Bipolar disorder presents with two primary mood states:

• Manic episodes: Last at least 7 days (unless hospitalization is required) and include:

  • Euphoria, grandiosity, or irritability
  • Racing thoughts
  • Pressured speech
  • Decreased need for sleep
  • Increased goal-directed activity
  • Poor judgment and impulsivity 2

• Depressive episodes: Characterized by:

  • Persistent low mood
  • Loss of interest or pleasure
  • Changes in appetite and sleep
  • Fatigue
  • Feelings of worthlessness
  • Suicidal thoughts 3

• Mixed episodes: Last ≥7 days where symptoms of both mania and depression occur simultaneously 1

Types of Bipolar Disorder

• Bipolar I: Requires at least one manic episode (with or without depression) 4
• Bipolar II: Requires hypomania (milder form of mania lasting at least 4 days) and major depression 1
• Bipolar Disorder NOS: Used for cases that don't meet full criteria for other bipolar diagnoses, including:
  • Manic symptoms lasting hours to less than 4 days
  • Chronic manic-like symptoms representing baseline functioning 2

Clinical Course and Presentation

• Approximately 75% of symptomatic time consists of depressive episodes or symptoms 3
• Age of onset typically between 15-25 years, with depression often being the initial presentation 3
• Diagnosis is frequently delayed by approximately 9 years following initial symptoms 3
• Adolescents with bipolar disorder often present with psychotic features and may be misdiagnosed with schizophrenia 1
• Early-onset cases (before age 13) are predominantly male with common premorbid conditions including disruptive behavior disorders and anxiety 1

Cycling Patterns

• Rapid cycling: Four or more mood episodes per year 2
• Ultrarapid cycling: Brief, frequent manic episodes lasting hours to days (5-364 cycles per year) 2
• Ultradian cycling: Repeated brief (minutes to hours) cycles occurring daily (>365 cycles per year) 2

Impact on Health and Mortality

• Life expectancy reduced by 12-14 years 3
• 1.6-2 fold increased risk of cardiovascular mortality 1
• Annual suicide rate approximately 0.9% (compared to 0.014% in general population) 3
• 15-20% of people with bipolar disorder die by suicide 3

Diagnostic Challenges

• Manic-like symptoms can be found in other conditions including disruptive behavior disorders, PTSD, and developmental disorders 2
• True manic symptoms represent marked changes in mental and emotional state rather than situational reactions 2
• Symptoms should be evident across different settings (not isolated to one environment) 2
• Careful assessment of symptom patterns, duration, and association with psychomotor, sleep, and cognitive changes is essential 2

Treatment Approaches

• Pharmacotherapy is the primary treatment for bipolar disorder:

  • Lithium: FDA-approved for acute mania and maintenance therapy (down to age 12) 2, 4
  • Anticonvulsants: Valproate, lamotrigine for maintenance therapy 2
  • Atypical antipsychotics: For acute mania and some for maintenance 2
  • Antidepressants: Should not be used as monotherapy; may trigger manic episodes 3

• Important treatment considerations:

  • Avoid unnecessary polypharmacy while recognizing that multiple agents are often required 2
  • Monitor for metabolic syndrome, obesity, and type 2 diabetes which occur at higher rates in bipolar patients 3
  • Treatment adherence is a significant challenge, with >50% of patients being non-adherent 3

Genetic and Biological Factors

• Strong genetic component with approximately 70% heritability 1
• Four to sixfold increased risk in first-degree relatives 1
• Bipolar I has closer genetic association with schizophrenia, while Bipolar II is more closely associated with major depressive disorder 5

By understanding the complex nature of bipolar disorder and its various presentations, clinicians can provide more accurate diagnosis and appropriate treatment, potentially improving long-term outcomes for those affected by this serious mental health condition.