New Study Gives an Important Update on Bipolar Disorder

Bipolar disorders are characterized by episodes of mania, hypomania, and depression. DSM-5-TR (the Diagnostic and Statistical Manual of Mental Disorders) defines a manic episode as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).” Manic symptoms include inflated self-esteem, decreased need for sleep, racing thoughts and/or speech, distractibility, agitation, and impaired judgment.

Manic episodes cause social and occupational impairment and can have psychotic features. Hypomanic episodes have similar symptoms but are less severe and by definition do not require hospitalization or have psychotic features.

Individuals with bipolar I disorder have a history of manic episodes that interfere with function or necessitate hospitalization. In addition to manic episodes, depressive episodes are common. Those with bipolar II disorder have milder hypomanic symptoms/episodes in addition to major depressive episodes.

Andrew Nierenberg and colleagues recently published a review article in the Journal of the American Medical Association (JAMA) about the diagnosis and treatment of bipolar disorder. Some of this information may not be well known, and we thought it would be useful to summarize a few important points.

Bipolar disorder is common. Approximately 1 percent of the world’s population will have bipolar I disorder during their lifetimes, and over 1.5 percent will have bipolar II disorder. In the U.S., the combined percentage may be higher—up to 4 percent or more.

The consequences of these disorders are substantial. As we mentioned in an earlier post, bipolar disorder is associated with premature mortality. Life expectancy is decreased by 12-14 years. The authors note that about 34 percent of individuals with bipolar disorder attempt suicide and over 15 percent take their own lives.

Individuals with bipolar disorder experience more time suffering from depressive episodes than manic episodes. Depressive episodes account for 75 percent of symptomatic time.

Bipolar disorder is associated with comorbid psychiatric disorders. The two most common are anxiety disorders, occurring in over 70 percent of individuals with bipolar disorder, and substance use disorders, occurring in about 56 percent.

Pharmacotherapy is the mainstay of treatment. Various psychotherapies and lifestyle changes are also helpful.

Lithium, mood-stabilizing anticonvulsants, and antipsychotics are the three classes of drugs utilized in treating bipolar disorder. These drugs are often used in various combinations. Pharmacologic treatment varies depending on the stage of illness, i.e., acute treatment may require different pharmacological approaches than treatment to maintain remission of symptoms.

Electroconvulsive therapy (ECT) can be effective for treating symptoms of bipolar depression that are resistant to medications. Over 75 percent of people respond to ECT, and in over 50 percent, symptoms remit. However, follow-up treatments are needed to decrease the risk of relapse.

The review article also discusses information related to various drugs. Here are a few details about lithium and antipsychotics that may not be well-known:

1. Lithium can be helpful both in the acute and maintenance phases of treatment. In addition to side effects such as hypothyroidism (treatable with thyroid medication), clinically significant decreases in kidney function can occur in those taking lithium long-term. Kidney function should be routinely monitored.
2. Lithium is associated with a substantial (over 70 percent) decrease in suicide rate and a major decrease in all-cause mortality, decreasing it by more than half.
3. Antipsychotics are helpful in both the acute and maintenance phases of the illness. There can be cardiovascular, metabolic, and movement disorder side effects that vary depending on the specific drug.
4. Antipsychotics are associated with a dose-dependent increase in 5-year mortality ranging from a 13 percent increase with lower doses to a 69 percent increase with moderate doses to an over 2-fold increase with high doses.

To summarize, bipolar disorder is a common illness with serious functional, social, medical, and psychiatric consequences. Individuals can be helped by various pharmacologic interventions, lifestyle changes, and psychotherapies. There are different considerations in selecting specific medications.

Much more research is needed to better understand this disorder and to develop preventative and therapeutic interventions.

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This column was written by Eugene Rubin, M.D., Ph.D., and Charles Zorumski, M.D.