What is bipolar disorder?

From the Guidelines

Bipolar disorder treatment should prioritize traditional mood stabilizers, such as lithium or valproate, and/or atypical antipsychotic medications as the primary treatment, with other psychotropic agents and psychotherapies used as adjunctive therapy or to address comorbid conditions and problems. When considering treatment options, it's essential to note that most agents only have clearly demonstrated efficacy for treating acute manic symptoms in adults, thus the term antimanic may be a more accurate description 1. The treatment of bipolar disorder typically involves a combination of medication and psychotherapy, with first-line medications including mood stabilizers such as lithium (600-1200 mg/day), valproate (750-1500 mg/day), or lamotrigine (100-200 mg/day), often combined with atypical antipsychotics like quetiapine (300-800 mg/day), olanzapine (5-20 mg/day), or aripiprazole (10-30 mg/day) 1. Some key points to consider when treating bipolar disorder include:

• Lithium is approved down to age 12 years for acute mania and maintenance therapy, and is the only agent with FDA approval for bipolar disorder in youths (age 12 years and older) 1
• Aripiprazole, valproate, olanzapine, risperidone, quetiapine, and ziprasidone are approved for acute mania in adults, and may be used off-label for children and adolescents 1
• The combination of olanzapine and fluoxetine is approved for bipolar depression in adults, and may be considered for adolescents with bipolar depression 1
• Antidepressants (selective serotonin reuptake inhibitors [SSRIs] or nontricyclics) may be useful adjuncts for depression, but caution must be taken to avoid destabilizing the patient’s mood or inciting a manic episode 1
• Lifestyle management is crucial, including regular sleep patterns, stress reduction, avoiding alcohol and recreational drugs, and maintaining a consistent daily routine
• Regular monitoring of medication blood levels and side effects is necessary, particularly for lithium which requires periodic kidney and thyroid function tests 1. With proper treatment, most people with bipolar disorder can lead stable, productive lives.

From the Research

Overview of Bipolar Disorder

• Bipolar disorder is a common, recurrent mental health condition characterized by variable severity and difficulty in diagnosis 2.
• It affects approximately 8 million adults in the US and 40 million individuals worldwide, with a prevalence rate of around 2% of the world's population 3, 4.
• The disorder is marked by recurrent episodes of depression and mania or hypomania, with depressive episodes being the most frequent initial presentation 3.

Clinical Features and Diagnosis

• The age of onset is usually between 15 and 25 years, with depression being the most common initial presentation 3.
• Approximately 75% of symptomatic time consists of depressive episodes or symptoms, and early diagnosis and treatment are associated with a more favorable prognosis 3.
• Diagnosis is often delayed by a mean of approximately 9 years following an initial depressive episode, and misdiagnoses are frequent 4.

Treatment and Management

• Pharmacotherapy with mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, is a first-line treatment that should be continued indefinitely due to the risk of patient relapse 2, 3.
• Antidepressants are not recommended as monotherapy, and their use is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder 2, 5.
• Combination therapy and adjunctive psychotherapy may be necessary to treat symptoms across different phases of illness, and clinical judgment, shared decision making, and empirical follow-up are essential elements of clinical care 4.
• Lithium, valproate, lamotrigine, quetiapine, aripiprazole, and olanzapine are recommended as first-line maintenance options, with lithium being the most effective drug overall 6, 3.

Challenges and Future Directions

• Outcomes are often suboptimal due to insufficient efficacy, side effects, or lack of availability of treatments, and predicting which medication is likely to be most effective or tolerable is not yet possible 4.
• A new era of targeted treatments aimed at causal mechanisms, be they pharmacological or psychosocial, is hoped to be developed as pathophysiological insights into the causes of bipolar disorders are revealed 4.
• Life expectancy is reduced by approximately 12 to 14 years in people with bipolar disorder, with a higher risk of cardiovascular mortality, metabolic syndrome, obesity, cigarette smoking, and type 2 diabetes 3.