Questions about bipolar disorder

[Mrs. Luther073082]

There's a slight chance my brother may have bipolar disorder, so I have some questions.

When were you first diagnosed?

Before diagnosis, had you always struggled with mental health issues, or did bipolar disorder come on suddenly?

How old were you when your symptoms first started?

What were your first symptoms?

Have you ever had an acute psychosis during mania? Once you began recieving treatment, how long did it take you to stabilize and regain normal thinking?

Do other people in your family have bipolar disorder?

Do other people in your family have other mental health issues that are not bipolar disorder?



Thank you in advance to anyone who takes the time to answer my questions.

 

[helpneedednow]

i am a bipolar 1, i was diagnosed aboout 3 months ago. i had several manic episodes where i almost killed myself 4 times. i recieved treatment with citalopram and stavzor. first just got the anti depressent, which did help but was not enough. when i started the stavzor it took about 2 weeks to start feeling it and about 4 weeks before i really felt great. i have since switched to depacote er for cost reasons, no generic for stavzor, and it has not bothered me a bit, still feel good and i can live a normal life again. i am looking for a jobnow that my mind doesent race all the time. i have much more patience and perseverence than before and far less mood swings. my family has it on my fathers side so i do think it is hereditory. i am afraid my son has it also and there is nothing i can do about it, for this i am very sad. i feel like it is my fault for having children, even though they are a blessing, you just cannot help but feel responsible for thier pain. i also have stuttered my whole life and that too weighed heavily on my mind since 2 of my sons stutter also. you know the pain they feel when people make fun of them and treat you as if you are a different person. it brings tears to my eyes even as i write this reply because i feel so terrible about some of the things ive done because i was bipolar. i wish you the best and hope they can help him like they have helped me and may god bless you all!!!!!!

 

[Mrs. Luther073082]

Thanks so much for your reply. Don't feel bad about having children -- I'm sure they are very glad to exist! Everybody goes through hard times/struggles and feels pain, even if they do not have bipolar disorder. No one enjoys life 100% of the time.

 

[Alive again]

There's a slight chance my brother may have bipolar disorder, so I have some questions.

When were you first diagnosed? Age 45

Before diagnosis, had you always struggled with mental health issues, or did bipolar disorder come on suddenly? Previous diagnosis of depression at age 24 on and off antidepressants a couple of times

How old were you when your symptoms first started?In hind sight??? Prior to age 35 I functioned "normally and successfully" but had lots of self doubt. I was suicidal one and off since age 16

What were your first symptoms? Depressions, Manias developed in my 40's and took about 4 years to become fully recognizable. I deal qith BP type 2 and have hypomanias

Have you ever had an acute psychosis during mania? Once you began recieving treatment, how long did it take you to stabilize and regain normal thinking?No, nut I know those who have, and with meds it can still take awhile.

Do other people in your family have bipolar disorder? My son was also diagnoses depression about age 6 or 7and then later diagnosed as BP2 about age 16. My Dad was diagnosed BP2 as an adult in his 50-60's, but symptoms were present before, just not the right generation for help/diagnosis.

Do other people in your family have other mental health issues that are not bipolar disorder? Undiagnosed paternal grandmother, maternal grandmother with anxiety



Thank you in advance to anyone who takes the time to answer my questions.

So onset can seem very sudden, esp for BP1, often onset is in high school to college age but we are all individual as well as similar.

Keep asking questions!

 

[Mrs. Luther073082]

Thanks Alive for your answers! I am not sure what else to ask at this point.

 

[antheadian]

There's a slight chance my brother may have bipolar disorder, so I have some questions.

When were you first diagnosed?

Before diagnosis, had you always struggled with mental health issues, or did bipolar disorder come on suddenly?

How old were you when your symptoms first started?

What were your first symptoms?

Have you ever had an acute psychosis during mania? Once you began recieving treatment, how long did it take you to stabilize and regain normal thinking?

Do other people in your family have bipolar disorder?

Do other people in your family have other mental health issues that are not bipolar disorder?



Thank you in advance to anyone who takes the time to answer my questions.

I was first diagnosed at 21 when I was a junior in college. Before I was diagnosed I had very minor issues with my mood and depression. My mental illness took about 2-3 months to develop into full force. I was diagnosed schizoaffective- bipolar type, but then later bipolar with psychosis which is kind of the same. I had many panic attacks and lots of paranoia and delusions. After mania and psychosis it can take at least 1 month or two months to feel stable again. But I remember the last time I got out of extreme mania and psychosis I ended up in the worst depression which took at least a year to get out of. My brother was diagnosed last year with bipolar. My uncle has paranoid schizophrenia, his also came about when he was in his early 20's. I am also on disability now since 2006 for this even though it started in 2004. Sometimes I wonder if I will ever recover, without having another relapse.

 

[JesusFreak2008]

When were you first diagnosed? 11 years old, It was my first manic episode in a group home, I picked up a table, threw it at a staff member, busted down a locked door, ran in the street naked and laid down screaming that they were raping me and I was going to kill myself. The police restrained me and took me to a psychiatric hospital. I don't remember it all, this is going off my medical records.

Before diagnosis, had you always struggled with mental health issues, or did bipolar disorder come on suddenly? Yes. Mental illness' run in my family. I was suffering with PTSD and Generalized Anxiety along with an Eating Disorder because I was raped as a child, and teased at school, did not fit in, and had really bad panic attacks. Bipolar was something they knew I had from my constant tantrums as a child, but confirmed diagnosis was hard to do.

How old were you when your symptoms first started? Gosh, I don't remember. I first started therapy when I was 7. So I would assume then?

What were your first symptoms? Tantrums, Chronic Insomnia, Rage over nothing, routines, mania, stealing, suicide threats, nightmares, suicide attempts, depression, the list goes on.

Have you ever had an acute psychosis during mania? Once you began receiving treatment, how long did it take you to stabilize and regain normal thinking? Not quite sure what you mean by this. I am currently not on health insurance and SSI won't approve me, so to get the help I need is impossible. I have been on several medications in the past though, and the best one was Seroquel and Depekote with Abilify. It took about a month with medication management and therepy to stabilize. Even now I find myself struggling with mood rages and am going to ask my doctor if I can get a prescription for these again. You never regain normal thinking with bipolar II. The roller coaster goes on forever. The most recent attempt for me was February. I had the bottle of Excedrin, the shower was on and I was in the bathroom, was going to kill myself, but my daughter saved my life. Praise the Lord she cried. She saves me many times, time and time again. I do get in my moods where I have my thoughts though like today.

Do other people in your family have bipolar disorder? Yes. My mother has Bipolar Type I, my Aunt is Schizophrenic. Depression runs in my family.

Do other people in your family have other mental health issues that are not bipolar disorder? See above.

 

[Mrs. Luther073082]

Thank you both for your replies!

 

[Steffenfield]

Hiya Melissa!

Okay, this is directly from UpToDate which many physicians use. You won't find this type of evidence based medicine anywhere online. If you have any additional questions, I'd be more than happy to provide this to you. The following is the exact wording that most physicians will read and use in the diagnosis and treatment of your brother.

Bipolar disorder: Epidemiology and diagnosis



INTRODUCTION — Bipolar disorder is an illness characterized by periods of mood elevation. Patients with bipolar I disorder have episodes of sustained mania, and often experience depressive episodes. Patients with bipolar II disorder have one or more major depressive episodes, with at least one hypomanic episode.

Recognition of bipolar disorder is important; untreated it is associated with substantial morbidity and mortality, and treatment differs from that of unipolar depression. It is not uncommon for bipolar disorder to be underdetected. Patients may present with symptoms of depression, especially in the primary care setting, but a careful history may find evidence of prior manic episodes [1].

This discussion will address the epidemiology, clinical manifestations, and diagnosis of bipolar disorder. Issues related to acute treatment and maintenance therapy for bipolar disorder are discussed separately. (See "Bipolar disorder: Treatment of acute mood episodes" and "Bipolar disorder: Maintenance treatment".)

EPIDEMIOLOGY AND PATHOGENESIS — The lifetime prevalence of bipolar disorder has traditionally been estimated as about one percent [2]. More recently, a spectrum of bipolar conditions has been proposed [3], including subthreshold bipolar disorder, with a higher prevalence (2.6 to 6.5 percent) [4-7]. The World Health Organization identified bipolar disorder as the sixth leading cause of disability-adjusted life years worldwide among people ages 15 to 44 years [2].

The true prevalence of bipolar disorder is uncertain; the diagnosis is likely to be missed when patients are seen with depression and not specifically asked about symptoms suggesting prior episodes of mania or hypomania [4,8]. In a study of outpatients being treated for depression in a family medicine clinic, a screening questionnaire for bipolar disorder (the Mood Disorder Questionnaire or MDQ [9]) was positive in 21.3 percent; two thirds of those screening positive had never been diagnosed with bipolar disorder [8]. The sensitivity and specificity of the MDQ in this population was 0.6 and 0.9 respectively, when results of screening were compared to DSM-IV criteria as determined by the Structured Clinical Interview.

Bipolar I disorder affects men and women equally; bipolar II disorder is more common in women [3]. The age of onset is generally between 15 and 30 years [10-12]. Newly diagnosed mania is uncommon in children and in adults over the age of 65 [13].

Genetics — Family, twin, and adoption studies demonstrate the importance of genetics in the pathogenesis of bipolar disorder [14-17]. The approximate lifetime risk in relatives of a bipolar proband is 40 to 70 percent for a monozygotic twin and 5 to 10 percent for a first degree relative, compared with 0.5 to 1.5 percent for an unrelated person [16]. In a large population study of 2 million nuclear families in Sweden, risk for bipolar disorder was increased if a parent (RR 6.4, 95% CI 5.9-7.1) or sibling (RR 7.9, 7.1-8.8) had bipolar disorder [18]. Risk for bipolar disorder was also increased, though to a lesser extent (RR 2.4-3.9), in first degree relatives of patients with schizophrenia, and risk of schizophrenia was similarly increased in relatives of patients with bipolar disorder, indicating some common genetic effect.

The search for candidate genes has been the subject of considerable study, although no single gene has been identified [14,15]. It is likely that a complex interaction between genetic and environmental factors is involved. Most candidate gene studies have focused upon neurotransmitter systems influenced by the medications used in the clinical management of this disorder, but no clear findings have emerged [16].



• Linkage studies have suggested a role for the tryptophan hydroxylase 2 (TPH2) gene [19]; tryptophan hydroxylase is the rate limiting enzyme in the synthetic pathway for serotonin.

• Genome wide association studies have found a variety of genetic variants associated with bipolar disorder, with CACNA1C the most consistent susceptibility locus. This gene codes for a subunit of a calcium channel and is involved in channel gating [20]. A role for calcium channel function in bipolar disease is suggested by a study in which lithium, one of the most common therapeutic agents for bipolar disease, resulted in downregulation of calcium channel subunits in mouse brain tissue [21].

CLINICAL MANIFESTATIONS AND DIAGNOSTIC CRITERIA — The diagnosis of a specific mood disorder is based on a patient's presenting symptoms and history of prior symptoms. Diagnostic criteria for bipolar disorder are discussed below (see 'Bipolar disorder' below). The distinction between bipolar disorder, depression, and other depressive syndromes is presented in a flow diagram (algorithm 1).

Mania — Diagnostic criteria for mania from the American Psychiatric Association are shown in a table (table 1) and include the following [22]:



• A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary)

• During the period of mood disturbance, at least three or more of the following symptoms are present:



- inflated self esteem or grandiosity

- decreased need for sleep

- more talkative than usual

- racing thoughts or flight of ideas

- distractibility

- increase in goal-directed activity

- excessive involvement in pleasurable activities that have a high potential for painful consequences, such as spending money or sexual indiscretion.



• The mood disturbance leads to significant impairment in social or occupational functioning.

• The symptoms are not directly due to substance use or a general medical illness.

The most common behavioral symptoms associated with manic episodes include pressured speech, hyperverbosity, physical hyperactivity and agitation, decreased need for sleep, hypersexuality, and extravagance (ie, financial, social, and recreational) [23]. Less common features include violence, religiosity, pronounced regression, and catatonia. Impaired insight is a frequent component of the manic state and may impair compliance with medications.

Patients with mania may experience depression, irritability, expansiveness, or mood lability during an episode of mania as often as they experience euphoria [23]. A "mixed episode" is characterized by a sufficient number of depressive symptoms to meet the criteria for a major depressive episode while also meeting the criteria for mania.

Hypomania — Hypomania refers to a briefer duration of manic symptoms (at least four days), and is often used to refer to a less severe level of symptoms. The DSM-IV criteria are shown in a table (table 2). Psychosis does not occur with hypomania, but often does with mania. Hypomania causes mild functional impairment, and can even improve functioning, while mania causes distortions of perception and somatic functioning, and impairment in social functioning. Mania often leads to hospitalization; by definition, hypomania does not.

Depression — The DSM-IV criteria for major depression are shown in the table (table 3) [22]. Diagnosis requires that at least five of nine symptoms are present during the same period and that one of the symptoms must be either depressed mood or loss of interest. Symptoms should be present daily or for most of the day, or nearly daily for at least two weeks.

The symptoms must cause clinically significant distress or impairment in functioning, are not due to the direct effects of a substance (eg, drug abuse or medications) or a medical condition (eg, hypothyroidism), and do not occur within two months of the loss of a loved one (unless associated with pathologic grief). (See "Depression: Clinical manifestations and diagnosis" and "Grief and bereavement".)

Mixed state — A mixed state refers to the presence of both depressive and mood elevated (manic or hypomanic) symptoms simultaneously. It may thus occur with bipolar I or bipolar II disorder. The frequency of mixed states is estimated between 20 and 70 percent [3]. in a large cross-sectional study of patients with bipolar disease, 12 percent of 1380 patients with depressive symptoms had concurrent mania as defined by meeting all DSM-IV criteria for mania, but some manic symptoms were present in more than one half of the patients [24]. The most common symptoms were irritability, racing or crowded thoughts, psychomotor agitation, or increased talkativeness concurrent with symptoms of depression. The presence of subsyndromal manic features correlated with more severe bipolar illness (earlier onset, rapid cycling, greater likelihood of suicide attempts).

Bipolar disorder — Bipolar disorder is divided into two subtypes (table 4):



• Patients with bipolar I disorder have a history of at least one manic episode, with or without past major depressive episodes. Although not required for the diagnosis of bipolar I disorder, depression is present more commonly than mania for most patients.

• Patients with bipolar II disorder have a history of at least one episode of major depression and at least one hypomanic episode. Hypomania is characterized by a mood elevation that is abnormal for the individual but does not seriously impair functioning or require hospitalization. Although patients with bipolar II disorder display fewer manic symptoms, their illness may have an equivalent impact on quality of life and, as with bipolar I, is associated with an increased suicide risk.

In addition, patients may have subthreshold bipolar disorder, defined as episodes of major depression and mood elevated symptoms that do not rise to the threshold of hypomania. A study of a community sample found that among 488 people identified with major depression, 41 percent had subthreshold bipolar disorder (and the remainder had pure unipolar major depressive disorder) [25].

Clinical course — The course of bipolar I disorder is marked by relapses and remissions, often alternating manic with depressive episodes. Ninety percent of individuals who have one manic episode have another within five years [11]. Ninety percent of individuals with bipolar disorder have at least one psychiatric hospitalization and two-thirds have two or more hospitalizations in their lifetime [2]. Bipolar II is less well studied, and the course is less well understood.

Depressive symptoms are more frequent over the course of bipolar disorder than are manic symptoms, although the latter define the disorder [26]. Patients with bipolar I disorder experience depression three times more frequently than mania; patients with bipolar II disorder experience depression 37 times more frequently than hypomania [27].

The course of bipolar disorder is influenced by high rates of comorbid alcohol or substance abuse. Over a lifetime, almost two-thirds of patients with bipolar disorder will meet diagnostic criteria for an addictive disorder [10,11]. Both the substance abuse and mood disorder should be addressed during therapy. Comorbid anxiety disorder is also common [28,29]. (See "Dual diagnosis: Severe mental illness and substance use disorders".)

The course of illness is specified as rapid cycling if four or more mood episodes occurred during the previous 12 months [22].

Suicide — The life expectancy of individuals with bipolar disorder is significantly reduced. Between 25 and 50 percent of people with this diagnosis attempt suicide, and 15 percent die by suicide [30]. This represents a significantly higher proportion of attempts among patients with bipolar disorder than among those with other Axis I diagnoses, including depression. A report from the Epidemiologic Catchment Area Database found that the lifetime rates of suicide attempts among people with bipolar disorder, unipolar depression, and other Axis I diagnoses were 29, 16, and 4 percent, respectively [31].

Risk factors for suicidal behavior in bipolar disease include [26]:



• Personal or family history of suicidal behavior

• Severity and number of depressive episodes

• Alcohol or substance abuse

• Level of pessimism

• Level of impulsivity or aggression

• Younger age of onset

 

[Steffenfield]

Distinguishing unipolar and bipolar depression — Patients with bipolar disorder, particularly those with bipolar II disorder who do not exhibit overt symptoms of mania, are frequently misdiagnosed as having unipolar depression. Establishing the diagnosis of bipolar disorder is essential, in order to appropriately treat acute episodes and provide maintenance therapy. Mood stabilizing medications are indicated for most patients with depression and bipolar disorder to prevent mood swings to manic or hypomanic states. (See "Bipolar disorder: Maintenance treatment".)

Patients with bipolar, compared to unipolar, depression are more likely to have a family history of bipolar disorder and to have earlier age of onset [32]. Patients presenting with depression should be specifically asked about symptoms of mania or hypomania:



• Have you experienced sustained periods of feeling uncharacteristically energetic?

• Have you had periods of not sleeping but not feeling tired?

• Have you felt that your thoughts were racing and couldn't be slowed down?

• Have you had periods where you were excessive in sexual interest, spending money, or taking unusual risks?

Alternatively, patients could be asked to complete the Mood Disorders Questionnaire (MDQ) [9].

Cyclothymia — Cyclothymia is defined as the presence of numerous periods of hypomania and of depression, persisting for at least two years, that do not meet DSM criteria for a major depression (table 4). It is considered to be one of the bipolar disorders and is treated with mood stabilizing medications. (See "Bipolar disorder: Treatment of acute mood episodes".)

DIFFERENTIAL DIAGNOSIS — Many psychiatric conditions may mimic, and at times coexist with, bipolar disorder, including: schizophrenia; schizoaffective disorder; posttraumatic stress disorder; abuse of alcohol, cocaine, or amphetamines; and personality disorders such as narcissistic, borderline and histrionic personalities [12,33]. In addition, symptoms associated with several medical illnesses resemble manic episodes, including thyrotoxicosis, partial complex seizures, systemic lupus erythematosus, cerebrovascular accident, human immunodeficiency virus, tertiary syphilis, and steroid-induced mood symptoms [11,12].

The concept of bipolar II disorder can potentially cover a wide spectrum of behaviors. Some have raised concerns about the effects of labeling common psychological or social phenomena as medical, and whether this could lead to overprescribing of psychoactive medications [34].

EVALUATION — A complete medical and psychiatric history and evaluation are necessary to establish the diagnosis of bipolar disorder, given the broad differential diagnosis when manic symptoms are present [11,12,33]. Since bipolar depression and mixed states are associated with a significantly increased risk for suicide, assessment of suicidality is an essential component of evaluation.

Patient evaluation should include:



• Physical examination with a particular focus upon the neurologic and endocrine systems

• Observation for signs of abuse of alcohol or other substances

• Laboratory testing including thyroid stimulating hormone (TSH), complete blood count, chemistries, and urine toxicology for substances of abuse

Additional testing such as an electroencephalogram or brain imaging can be directed by relevant findings in the history and examination [11,12,35].

INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Bipolar disorder (manic depression)".) We encourage you to print or e-mail this topic review, or to refer patients to our public web site, UpToDate Inc., which includes this and other topics.

SUMMARY



• Bipolar disorder is an illness characterized by periods of mood elevation; patients with bipolar I disorder have episodes of sustained mania, and often experience depressive episodes. Patients with bipolar II disorder have one or more major depressive episodes, with at least one hypomanic episode. ("(see 'Introduction' above).

• Patients with bipolar disorder have a high rate of alcohol and substance abuse, as well as anxiety disorder. The rate of suicide attempts (between 25 and 50 percent) is higher than for other Axis I diagnoses. (See 'Clinical manifestations and diagnostic criteria' above.)



• The primary care physician should be alert to symptoms suggesting the possibility of bipolar II disorder in patients who are diagnosed with unipolar depression. Patients with bipolar disorder are more likely to have a family history of bipolar disorder, and present at an earlier age. (See 'Distinguishing unipolar and bipolar depression' above.)



• Evaluation of patients with suspected bipolar disorder should include an assessment of suicidality and evidence of substance abuse. (See 'Evaluation' above.)

REFERENCES

​

1. Manning, JS, Haykal, RF, Connor, PD, Akiskal, HS. On the nature of depressive and anxious states in a family practice setting: the high prevalence of bipolar II and related disorders in a cohort followed longitudinally. Compr Psychiatry 1997; 38:102.
2. Woods, SW. The economic burden of bipolar disease. J Clin Psychiatry 2000; 61 Supp 13:38.
3. Benazzi, F. Bipolar disorder--focus on bipolar II disorder and mixed depression. Lancet 2007; 369:935.
4. Das, AK, Olfson, M, Gameroff, MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA 2005; 293:956.
5. Hirschfeld, RM, Holzer, C, Calabrese, JR, et al. Validity of the mood disorder questionnaire: a general population study. Am J Psychiatry 2003; 160:178.
6. Kessler, RC, Berglund, P, Demler, O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
7. Merikangas, KR, Akiskal, HS, Angst, J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry 2007; 64:543.
8. Hirschfeld, RM, Cass, AR, Holt, DC, Carlson, CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract 2005; 18:233.
9. Hirschfeld, RM, Williams, JB, Spitzer, RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000; 157:1873.
10. Suppes, T, Dennehy, EB, Gibbons, EW. The longitudinal course of bipolar disorder. J Clin Psychiatry 2000; 61 Suppl 9:23.
11. Hilty, DM, Brady, KT, Hales, RE. A review of bipolar disorder among adults. Psychiatr Serv 1999; 50:201.
12. Sachs, G. Approach to the patient with elevated, expansive, or irritable mood. In: The MGH Guide to Psychiatry in Primary Care, Stern, TA, Herman, JB, Slavin, PL (Eds), McGraw-Hill, New York 1998. p.347.
13. Robins, LN, Regier, DA. Psychiatric disorders in America: The Epidemiologic Catchment Area Study. New York, Free Press 1991.
14. Potash, JB, DePaulo, JR Jr. Searching high and low: a review of the genetics of bipolar disorder. Bipolar Disord 2000; 2:8.
15. Craddock, N, Jones, I. Molecular genetics of bipolar disorder. Br J Psychiatry 2001; 178:S128.
16. Craddock, N, Jones, I. Genetics of bipolar disorder. J Med Genet 1999; 36:585.
17. Kieseppa, T, Partonen, T, Haukka, J, et al. High concordance of bipolar I disorder in a nationwide sample of twins. Am J Psychiatry 2004; 161:1814.
18. Lichtenstein, P, Yip, BH, Bjork, C, et al. Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. Lancet 2009; 373:234.
19. Lin, YM, Chao, SC, Chen, TM, et al. Association of functional polymorphisms of the human tryptophan hydroxylase 2 gene with risk for bipolar disorder in han chinese. Arch Gen Psychiatry 2007; 64:1015.
20. Ferreira, MA, O'Donovan, MC, Meng, YA, et al. Collaborative genome-wide association analysis supports a role for ANK3 and CACNA1C in bipolar disorder. Nat Genet 2008; 40:1056.
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26. Yatham, LN, Kennedy, SH, O'Donovan, C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005; 7 Suppl 3:5.
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[Steffenfield]

Bipolar disorder: Maintenance treatment

INTRODUCTION — Bipolar disorder is characterized by periods of mood elevation consisting of mania or hypomania. There are two types of bipolar disorder [1]. Bipolar I disorder is diagnosed in patients with a history of at least one episode of mania. Nearly all patients with bipolar I disorder also have episodes of major depression, but these are not required to make the diagnosis. Bipolar II disorder is diagnosed in patients who have had at least one hypomanic episode plus at least one episode of major depression.

Most patients require maintenance treatment following stabilization and remission of a mood episode. Standard maintenance treatment consists of pharmacotherapy plus adjunctive psychotherapy.

Many patients with bipolar disorder do not receive maintenance treatment. An observational study of 154 patients found that 61 percent received adequate maintenance pharmacotherapy throughout the maintenance phase for a variety of patient and clinician related reasons [2].

Maintenance treatment for bipolar disorder will be reviewed here. The different phases of treatment for bipolar disorder, the treatment of acute bipolar mood episodes, and the epidemiology, clinical manifestations, and diagnosis of bipolar disorder are discussed separately. (See "Bipolar disorder: Treatment of acute mood episodes" and "Bipolar disorder: Epidemiology and diagnosis".)

INDICATIONS, GOALS, AND DURATION — Clinicians should consider maintenance therapy for every patient with bipolar disorder because it is such a highly recurrent illness. As an example, in the Systematic Treatment Enhancement Program for Bipolar Disorder, there were 858 patients ill with a mood episode who recovered. Nearly 50 percent subsequently had a recurrent mood episode during follow-up lasting only two years, despite receiving treatment at specialty mood disorder clinics [3].

Recurrence of bipolar mood episodes is associated with a greater number of suicide attempts [4-8]. In addition, a long-term observational study found that bipolar patients who received maintenance treatment between mood episodes had much lower rates of completed suicide compared to those not treated (standardized mortality ratio 6.4 versus 26.5) [9].

A greater number of mood episodes is associated with poorer psychosocial functioning because each recurrence can cause severe social and occupational damage [10]. Maintenance treatment also leads to lower costs [11]. Another reason to prescribe maintenance treatment is that a recurrent mood episode may not remit as readily as the prior episode. Thus, multiple treatment guidelines recommend maintenance pharmacotherapy following a single manic episode [12,13].

Most maintenance treatment studies have primarily or exclusively enrolled patients with bipolar I disorder. Nevertheless, we recommend maintenance pharmacotherapy for all patients with bipolar disorder for several reasons. Patients with bipolar II disorder are symptomatically ill over 50 percent of their lives following onset of the illness and are at high risk for suicide [13,14]. In addition, some patients with bipolar II disorder actually have bipolar I disorder, but have yet to suffer their first episode of mania. Multiple treatment guidelines also recommend maintenance treatment for bipolar II disorder despite the lack of evidence [13,15].

The goals for maintenance therapy are to reduce subsyndromal symptoms, maintain recovery from acute mood episodes and prevent recurrence of new episodes, reduce the risk of suicide, and promote psychosocial functioning.

Patients often ask how long maintenance treatment will last. This will vary for each patient, but factors to consider include how many years the patient has had bipolar disorder and the number of mood episodes and hospitalizations that have occurred during that time. Maintenance treatment should last longer for patients with a more severe course of illness. An inability to tolerate side effects may truncate the duration of maintenance treatment, or for female patients, the decision to conceive children may interrupt treatment.

Most patients require maintenance treatment for years, and many for their entire lives. Some patients are discouraged by the prospect of taking their medication "forever." In such cases, it is important to emphasize the long-term relationship between the clinician and patient, and that the need for maintenance treatment will be periodically reevaluated in light of the patient's progress in maintaining symptomatic and functional stability.

PHARMACOTHERAPY — Maintenance medications usually consist of the same regimen that successfully treated the acute mood episode. This practice is supported by a study of patients with acute mania who were stabilized with divalproex. Those who continued divalproex during maintenance therapy were euthymic significantly longer than those who switched to lithium or placebo [16]. Given other studies that suggest lithium is superior to divalproex or valproate, this suggests that maintaining the same regimen rather than switching reduces recurrence of mood episodes [17] (see 'Lithium' below).

Clinicians should initially attempt to manage patients with monotherapy to enhance compliance and to minimize side effects and costs.

First line — Clinicians should consider these medications first because they are consistently supported across multiple studies:



• Lithium

• Lamotrigine

• Olanzapine

• Quetiapine

The order the drugs are presented here reflects our general order of preference, based upon relative efficacy and risk of side effects, as well as cost.

Lithium — Lithium has been more widely studied as a maintenance treatment for bipolar disorder than any other medication. It is prescribed initially at 300 mg two to three times per day. It is then titrated to achieve a target 12-hour serum trough level of 0.8 to 1.2 mEq/L, and taken once or twice per day. The serum level can be reduced to 0.6 mEq/L for patients unable to tolerate higher levels. Common side effects include weight gain, tremor, gastrointestinal distress, impaired ability to concentrate urine, polyuria, and hypothyroidism.

A meta-analysis of five controlled trials found relapses occurred significantly less often in patients who received lithium compared with placebo (40 versus 60 percent of patients) [18]. Thus, lithium reduced the rate of recurrence by 34 percent (risk ratio 0.66, 95% CI 0.52-0.85). A prior meta-analysis yielded essentially the same results (risk ratio 0.65, 95% CI 0.50-0.84) [19].

A subsequent open-label study randomly assigned 330 patients to lithium monotherapy, valproate monotherapy, or lithium plus valproate following stabilization on the combination for one to two months [17]. Patients were followed for up to two years, and relapse occurred least often in patients who received the combination, compared with lithium monotherapy or valproate monotherapy (54 versus 59 versus 69 percent). Time to relapse was longer for those who received lithium monotherapy compared to valproate monotherapy (hazard ratio 0.71, 95% CI 0.51-1.00), and for those who received the combination compared to valproate (hazard ratio 0.59, 95% CI 0.42-0.83). There was no significant difference between those who received lithium monotherapy compared with the combination.

Lithium also reduces the risk of suicide [20]. A meta-analysis of different types of treatment studies (including randomized controlled trials) found a 13-fold decrease in annual rates of attempted or completed suicide for patients receiving lithium treatment compared with those not receiving lithium (0.2 versus 2.6 percent) [21].

Lamotrigine — Lamotrigine is typically started at a dose of 25 mg per day for weeks one and two and then increased to 50 mg/day, taken in two divided doses, for weeks three and four. The dose can then be titrated up by 25 to 50 mg/day, one week at a time for each increase. The slow titration reduces the risk of Stevens-Johnson syndrome (erythema multiforme bullosum), a serious and life-threatening skin rash. The target dose ranges from 50 to 200 mg per day taken in two divided doses. An extended release formulation is also available. Common side effects include nausea, dyspepsia, pain, insomnia, and nonserious skin rash.

A meta-analysis of three randomized controlled trials found lamotrigine reduced the risk of relapse compared with placebo by 16 percent (risk ratio 0.84, 95% CI 0.71-0.99) [18].

Olanzapine — Olanzapine is usually prescribed at a dose of 5 to 20 mg/day at bedtime. Olanzapine causes weight gain, dyspepsia, constipation, dry mouth, somnolence, fatigue, insomnia, extrapyramidal symptoms, and hyperprolactinemia.

A 48-week maintenance study in 361 patients found relapse occurred in significantly fewer patients who received olanzapine compared with placebo (47 versus 80 percent) [22,23]. Olanzapine thus reduced the risk of relapse by 42 percent (risk ratio 0.58, 95% CI 0.49-0.69). In addition, the median time to relapse of any mood episode was significantly longer in the group receiving olanzapine (174 versus 22 days).

A second randomized maintenance trial in 431 patients, lasting one year, found that olanzapine was as effective as lithium [24]. Recurrence occurred in a similar proportion of patients who received olanzapine or lithium (30 versus 39 percent of patients, absolute risk reduction 8.8%, 95% CI -0.1% to 17.8%).

Quetiapine — Quetiapine is initially prescribed at a dose of 50 mg/day once or twice per day, and usually titrated to a target dose of 300 to 800 mg/day taken in two divided doses, although some patients will do well with taking the medication only at bedtime. An extended release version is available for once a day dosing at bedtime. Common side effects include sedation, fatigue, weight gain, dry mouth, dyspepsia, constipation, and orthostatic hypotension.

Two controlled trials each demonstrated the efficacy of quetiapine as a maintenance treatment [15]. A pooled analysis found recurrent mood episodes occurred in significantly fewer patients who received quetiapine compared with placebo (24 versus 40 percent). In addition, time to recurrence was significantly longer with quetiapine.

 

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Second line — We consider these medications second line for maintenance treatment because the evidence supporting their use is not as extensive or consistent as it is for the first line drugs (see 'First line' above:



• Aripiprazole

• Divalproex

Aripiprazole — Aripiprazole is usually prescribed once a day at a dose of 15 or 30 mg/day. Common side effects include tremor, akathisia, anxiety, nausea, dry mouth, and weight gain.

A 100-week maintenance study found time to recurrence of any mood episode (primary endpoint) was significantly longer for patients who received aripiprazole compared with placebo (hazard ratio 0.53, 95% CI 0.32-0.87 ) [25]. Relapse occurred in fewer patients receiving aripiprazole compared with placebo, but the difference was not significant (32 versus 52 percent of patients).

Divalproex — Divalproex is prescribed at a dose of 500 mg twice per day initially and titrated to achieve a target 12-hour serum trough level of 50 to 125 mcg/mL. Long acting preparations are available that can be prescribed once per day. Common side effects from divalproex include somnolence, weight gain, gastrointestinal distress, elevated transaminases, tremor, and alopecia.

A maintenance study found that patients randomly assigned to divalproex, lithium, or placebo did not differ significantly in time to relapse, the primary outcome measure [18,26]. However, relapse of any mood episode occurred in significantly fewer patients who received divalproex compared with placebo (24 versus 38 percent). Divalproex thus reduced the risk of relapse by 37 percent (risk ratio 0.63, 95% CI 0.44-0.90).

An open-label study found that maintenance treatment with valproate was inferior to lithium [17]. (See 'Lithium' above.)

Other options — Asenapine, carbamazepine, and oxcarbazepine may be helpful for the many patients who are refractory to maintenance treatment with first or second line medications. However, the evidence supporting the use of these other options is inferior to the evidence for first and second line drugs. The evidence for these other options is also inferior to the evidence supporting the use of certain medication combinations. (See 'First line' above and 'Second line' above and 'Medication combinations' below.)

Asenapine — Asenapine is prescribed at a dose of 5 to 10 mg twice per day. Common side effects include weight gain, sedation, dizziness, insomnia, and extrapyramidal symptoms.

A short-term study suggests asenapine prevents early relapse of mood episodes as well as olanzapine [27]. Patients who completed a three-week randomized trial comparing asenapine versus olanzapine for treatment of acute manic or mixed episodes were enrolled in a nine-week extension study if they wished to continue treatment. Scores on various rating scales revealed no significant difference between the two drugs.

Carbamazepine — Carbamazepine is prescribed twice per day to achieve a target 12-hour serum trough level of 4 to 8 mcg/mL. Serious side effects include blood dyscrasias and life-threatening rashes. Common side effects include dizziness, somnolence, ataxia, gastrointestinal distress, and elevated transaminases.

A meta-analysis of four randomized controlled trials in which patients received maintenance treatment with either carbamazepine or lithium found the two medications were similarly efficacious in preventing recurrence or hospitalization (none of the studies included a placebo arm) [28].

Oxcarbazepine — An alternative to carbamazepine is oxcarbazepine, based upon limited evidence of effectiveness in treating acute mood episodes and its structural similarity to carbamazepine [29-31]. In addition, oxcarbazepine is generally better tolerated and easier to prescribe because it does not induce its own metabolism, as does carbamazepine. The initial dose of oxcarbazepine is 300 mg taken twice daily, which is titrated by 600 mg/day at weekly intervals to a target dose of 1200 to 2400 mg/day taken in two divided doses. Clinicians should monitor serum sodium because oxcarbazepine can cause hyponatremia. Common side effects include dizziness, ocular disturbances, gastrointestinal distress, and somnolence.

A systematic review found insufficient evidence to recommend oxcarbazepine for maintenance treatment of bipolar disorder [32].

Medication combinations — Clinicians commonly use medication combinations for maintenance treatment [33,34]. Recurrent mood episodes often occur during maintenance treatment with one drug, and the increased efficacy of medication combinations often outweighs the increased side effects and costs. For patients who have an inadequate but partial response to an agent that is tolerated, we suggest clinicians add a second medication.

There is a large number of possible medication combinations one can use. However, we suggest following certain principles when combining drugs to increase the efficacy of maintenance therapy [35]:



• Attempt to prescribe only two medications, although three may be necessary

• The combination should not pose significantly greater safety or tolerability risks

• Drugs should not have the same mechanism of action

• Drugs should not have opposing mechanisms of action

In addition, clinicians need to be aware of possible pharmacokinetic interactions. As an example, carbamazepine induces hepatic P450 enzymes and thus the metabolism of concomitant medications.

Certain medication combinations have evidence to support their use.

Lithium plus anticonvulsant — Lithium's status as the longest and most widely studied drug for bipolar disorder has led to its use for maintenance treatment in combination with several medications, including valproate, lamotrigine, and carbamazepine [17,36-39]. (See 'Lithium' above.)

Mood stabilizer plus second generation antipsychotic — Studies have found that a mood stabilizer (lithium or anticonvulsant) plus a second generation antipsychotic is superior to a mood stabilizer plus placebo for maintenance treatment. Specifically, these studies used lithium or divalproex as the mood stabilizer, and the second generation antipsychotic was quetiapine, long-acting injectable risperidone (dose of 25 to 50 mg every two weeks), ziprasidone, or olanzapine [40-44] (see 'Lithium' above and 'Divalproex' above and 'Quetiapine' above and 'Olanzapine' above).

Clozapine added to treatment-as-usual (any number or combination of mood stabilizers, antidepressants, or anxiolytics) was effective in open-label prospective or retrospective studies [45-47]. The dose of clozapine ranged from 25 to 900 mg/day, taken in two divided doses. Clozapine causes rare, but potentially lethal agranulocytosis, and thus requires regular monitoring of white blood cell counts every week or every two weeks. In addition, clozapine should not be combined with carbamazepine.

Electroconvulsive therapy — Maintenance electroconvulsive therapy (ECT) can be used for patients who respond to ECT for treatment of acute mood episodes and who have failed many other maintenance medication regimens and psychotherapies [13]. Most of the evidence supporting the effectiveness and tolerability of maintenance ECT comes from case reports, but there have been four prospective studies and one randomized study [48-54]. The frequency of maintenance ECT in these reports and studies ranged from once a week to once a month. Maintenance medications are often prescribed in conjunction with maintenance ECT, including anticonvulsants.

ADJUNCTIVE PSYCHOTHERAPY — While the cornerstone of maintenance treatment is pharmacotherapy, adjunctive psychotherapy can help patients accept their chronic illness and thus promote medication adherence, early detection of prodromal symptoms, and behavioral changes and improved functioning [13,55]. In addition, psychotherapy can help patients cope with the psychosocial consequences of prior mood episodes, ongoing subsyndromal symptoms, fear of future recurrent episodes, and help ameliorate distress and interpersonal conflicts.

Different options include:



• Psychoeducation

• Cognitive-behavioral therapy

• Interpersonal and social rhythm therapy

• Marital and family therapy

Maintenance psychotherapy usually consists of the same therapy used during the acute mood episode. This practice is supported by a study of patients with acute mood episodes who were stabilized for four weeks with pharmacotherapy plus one of two adjunctive psychotherapies (either interpersonal and social rhythm therapy or the control therapy, called intensive clinical management) [56]. Following stabilization, subjects were randomly assigned to maintenance therapy with the same psychotherapy or to switch to the other psychotherapy. Relapse occurred in significantly fewer patients who maintained the same therapy compared to those who switched (18 versus 40 percent).

Each therapy can be provided in a group or individual format. In addition, different types of psychotherapies can be combined with each other [55]. All of these therapies are structured and time-limited.

A systematic review and meta-analysis of randomized controlled trials found that psychologic therapies, specifically adapted for bipolar disorder and added to treatment with medication, significantly reduced the probability of relapse or recurrence by 26 percent (relative risk 0.74, 95% CI 0.64-0.85) [57]. The analysis included different types of psychotherapy: group psychoeducation, individual psychoeducation, cognitive-behavioral therapy, and family-focused therapy. The review concluded that patients should be euthymic prior to initiating psychotherapy, and that the number of prior mood episodes was not associated with the number of relapses during maintenance psychotherapy.

A randomized trial of 293 outpatients not included in the meta-analysis compared three forms of intensive psychotherapy over nine months (family-focused, interpersonal and social rhythm, or cognitive-behavioral therapy) with a less intensive "collaborative care" approach (three sessions over six weeks) [58]. Patients receiving psychotherapy were significantly more likely to be well during any study month, but especially in later months, suggesting that psychotherapy was useful in preventing relapse. Psychotherapy also improved measures of social functioning, compared to collaborative care, but did not significantly impact vocational functioning [59]. The three types of intensive therapy did not differ significantly for any of the outcomes.

Psychoeducation — Psychoeducation is a structured program intended to teach patients and family members about the nature of bipolar disorder, including the etiology, clinical features, treatment options, and course of illness. In addition, adherence to treatment and coping skills are reinforced. (See 'Information for patients' below.) Nearly all other types of psychosocial interventions include an element of psychoeducation because of its demonstrated success and the ease of administering it.

Teaching patients to recognize and manage prodromal symptoms prevents recurrences and hospitalizations, and improves psychosocial functioning. A meta-analysis of randomized controlled trials compared patients receiving this intervention plus treatment as usual (medication and outpatient appointments with a psychiatrist) with patients receiving treatment as usual [60]. The intervention led to a significantly longer time until recurrence of any mood episode (hazards ratio 0.57, 95% CI 0.39-0.82) and significantly reduced hospitalizations by 33 percent (12 versus 18 percent of patients, risk ratio 0.67, 0.47-0.95). In addition, social functioning was significantly better 18 months after baseline in patients who received the intervention.

A second meta-analysis of randomized controlled psychoeducation trials found significantly fewer patients in group psychoeducation relapsed to any mood episode compared with patients in control groups (19 versus 35 percent, OR 0.42, 95% CI 0.21-0.86) [61].

Cognitive-behavioral therapy — Cognitive-behavioral therapy (CBT) systematically addresses dysfunctional thoughts, emotions, and behaviors by helping patients learn to think of themselves and their illness in a more positive manner and to change their behavior by setting realistic and observable goals. CBT may also include educating patients about bipolar disorder and teaching coping skills for psychosocial stressors.

A meta-analysis of three controlled trials found significantly fewer relapses in patients who received CBT compared with the control group (49 versus 79 percent of patients, OR 0.24, 95% CI 0.12-0.51) [61].

Interpersonal and social rhythm therapy — This therapy helps patients stabilize their daily routines and sleep/wake cycles, and helps patients resolve interpersonal problems related to grief, role transitions, role disputes, and interpersonal deficits. A two-year maintenance study found time to recurrence of any mood episode was significantly longer in patients who received adjunctive interpersonal and social rhythm therapy compared with patients receiving the adjunctive control treatment [62].

Family therapy — Family therapy encompasses different types of interventions that vary in their theoretical orientation and focus. The therapy may address relationships between family members, behavioral change, communication, problem-solving skills, psychoeducation, or the need to view the family as a single system.

Evidence for the benefits of family therapy in preventing recurrent mood episodes is inconsistent. Two systematic reviews found adjunctive family therapy provided no additional benefit [61,63]. However, another review concluded adjunctive family therapy effectively prevents relapse and improves functional outcomes [64].

 

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STOPPING MAINTENANCE TREATMENT — Patients may decide to stop maintenance medications because of side effects, inadequate response, medical illness, pregnancy, or a wish to be medication-free after a prolonged period of euthymia. Clinicians should closely monitor these patients because of the high risk of early recurrence of mood episodes. A review analyzed the rate of recurrence in 14 lithium maintenance treatment studies that involved discontinuation of previously successful lithium treatment [65]. More than 50 percent of new mood episodes occurred within 10 weeks of discontinuing lithium in patients who had been previously stable for a mean of 30 months.

We suggest tapering maintenance medications slowly, over a period of at least two to four weeks, and monitoring patients for recurrence. An open-label study prospectively followed patients who had been stable on lithium monotherapy for a mean of 43 months and then decided to discontinue treatment [65]. Significantly more recurrences occurred among patients who discontinued lithium in less than two weeks compared with discontinuation over two to four weeks (94 versus 53 percent of patients).


INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Bipolar disorder (manic depression)".) We encourage you to print or e-mail this topic review, or to refer patients to our public web site, UpToDate Inc., which includes this and other topics. This material should be used as part of treatment. (See 'Psychoeducation' above.)

The National Institute of Mental Health also has educational material explaining the symptoms, course of illness, and treatment in a booklet entitled "Bipolar Disorder" that is available online at at the website NIMH · Bipolar Disorder or through a toll-free number, 866-615-6464. The web site also provides references, summaries of study results in language intended for the lay public, and information about clinical trials currently recruiting patients.

More comprehensive information is provided in the many books written for patients and family members, including The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, written by David J. Miklowitz, PhD (published by The Guilford Press, 2002) and An Unquiet Mind: A Memoir of Moods and Madness, written by Kay Jamison PhD (published by Random House, 1995).

The Depression and Bipolar Support Alliance (http://www.dbsalliance.org or 800-826-3632) is a national organization whose mission is to educate members about bipolar disorder and how to cope with it. Other functions include increasing public awareness of the illness and advocating for more research and services. The organization is administered and maintained by patients and family members, and has local chapters.

The National Alliance on Mental Illness (NAMI: National Alliance on Mental Illness - Mental Health Support, Education and Advocacy or 800-950-6264) is a similarly structured organization devoted to providing education, support, and advocacy for patients with any mental illness. Bipolar disorder is one of their priorities.

 

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SUMMARY AND RECOMMENDATIONS



• Bipolar disorder is a highly recurrent illness. We recommend maintenance treatment for patients with bipolar I disorder (Grade 1B). We also suggest maintenance treatment for patients with bipolar II disorder (Grade 2C). (See 'Indications, goals, and duration' above.)



• The goals for maintenance therapy are to reduce subsyndromal symptoms, maintain recovery from acute mood episodes and prevent recurrence of new episodes, reduce the risk of suicide, and promote psychosocial functioning. (See 'Indications, goals, and duration' above.)



• The duration of maintenance treatment will vary for each patient, but most patients require treatment for years, and many for their entire lives. Maintenance treatment should last longer for patients with a more severe course of illness. We suggest clinicians wait until patients achieve at least two years of stability before making an attempt to discontinue maintenance treatment (Grade 2B). (See 'Indications, goals, and duration' above.)



• We initial monotherapy with lithium rather than another agent or combination of medications (Grade 2B). Lithium is dosed to achieve a 12-hour serum trough level of 0.8 to 1.2 mEq/L, which can be reduced to 0.6 mEq/L for patients unable to tolerate higher levels. (See 'First line' above.)



• Many patients are unresponsive or intolerant of lithium. For these patients, we suggest lamotrigine, olanzapine, or quetiapine (Grade 2B) (see 'First line' above). For patients that do not respond to or cannot tolerate these drugs, aripiprazole or divalproex are reasonable alternatives. (See 'Second line' above.)



• For patients who have an inadequate but partial response to an agent that is tolerated, we suggest clinicians add a second medication (Grade 2B). Common combinations include lithium plus an anticonvulsant, such as valproate, lamotrigine, or carbamazepine. Other combinations that are useful consist of a mood stabilizer, such as lithium or valproate plus a second generation antipsychoti,c such as quetiapine, long-acting injectable risperidone, ziprasidone, or olanzapine. (See 'Medication combinations' above.)



• We suggest adjunctive psychotherapy for euthymic patients (Grade 2C). Psychotherapy can help patients accept their chronic illness, promote medication adherence, improve early detection of prodromal symptoms and behavioral changes, and improve functioning. Specific psychotherapies include psychoeducation, cognitive-behavioral therapy, and interpersonal and social rhythm therapy. (See 'Adjunctive psychotherapy' above.)

 

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[Mrs. Luther073082]

Thanks for the information!

 

[Steffenfield]

Yeah, of course, Melissa.

So that wasn't too much info? *lol*

 

[A.Nony-Mouse]

There's a slight chance my brother may have bipolar disorder, so I have some questions.

When were you first diagnosed?

Before diagnosis, had you always struggled with mental health issues, or did bipolar disorder come on suddenly?

How old were you when your symptoms first started?

What were your first symptoms?

Have you ever had an acute psychosis during mania? Once you began recieving treatment, how long did it take you to stabilize and regain normal thinking?

Do other people in your family have bipolar disorder?

Do other people in your family have other mental health issues that are not bipolar disorder?



Thank you in advance to anyone who takes the time to answer my questions.

I was 17 when I was finally diagnosed with BPD1. I'd had bouts of depression as long as I can remember, my mom says since I was about 9 when depression first got me. My first manic episode was when I was was 15, shortly after my best friend died. My symptoms were pretty much textbook. I stole money, ran away, was promiscuous, along with the less dramatic symptoms, including racing and, paranoid thoughts, as well as thoughts of grandeur. I've been treated since the age of 9 and no medicine has ever worked for me. Not for the depression or for the mania, because of this I am no longer in "treatment" I'm letting God treat me. Thankfully I have been stable since the end of January, with His help I will stay stable. My grandma has struggled with depression(I think BPD as well). My mother, brother and a sister are all bipolar.

I hope it all works out with your brother.

 

[Mrs. Luther073082]

Thank you for the reply!

 

[bsd31]

There's a slight chance my brother may have bipolar disorder, so I have some questions.

When were you first diagnosed?

In 2007

Before diagnosis, had you always struggled with mental health issues, or did bipolar disorder come on suddenly?

Since I was around 12 or 13, but never diagnosed. I just knew something was off. That I wasn't anything like my peers. At least nothing like the normal ones.

How old were you when your symptoms first started?

BP symptoms? Probably mid teens to early 20s.

What were your first symptoms?

My motivation to do anything was all over the place. It would cycle (still does). For about 90 days I was king of the world then for about 180 days nothing could ever go right or make me happy. It took a while to see the pattern but at some point I did. It's pretty much like clock work.

Have you ever had an acute psychosis during mania? Once you began receiving treatment, how long did it take you to stabilize and regain normal thinking?

No acute psychosis but in the past I'd be overwhelmed with psychotic thoughts and day dreams.

I can't speak to how long it took me to stabilize or regain normal thinking because I don't do medicine. *I have but for me personally I've made a choice not to use it any longer.

*Note that I am talking about my own decision on a personal level in regards to medication. This is in no way to encourage anyone else to do as I have done. Always consider your doctor's advice in regards to your own treatment and make a decision based on that advise.

Do other people in your family have bipolar disorder?

I suspect so, but no diagnosis that I'm aware of.

Do other people in your family have other mental health issues that are not bipolar disorder?

Yes. Had an aunt on my mother's side who went to the puzzle palace to live out most of her adult life. My father's side of the family has several known mental health problems. They also self medicate on the whiskey quite a bit. I have half sisters and a brother on both sides of my family and I suspect they are all screwed up to one extent or another.