Questions and Answers
Late-onset bipolar disorder is frequently encountered in community surveys.
False
The average length of a manic episode is approximately 3 months.
False
More than 90% of patients with mania have experienced further episodes of major mood disturbances.
True
Patients with bipolar II disorder tend to have a worse long-term prognosis than those with bipolar I disorder.
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Mortality in patients with bipolar disorder is primarily due to suicide and cardiovascular disease.
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The reduction in life expectancy for men with bipolar disorder is about 5 years.
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Before modern drug treatments, the mortality rate of mania in hospital settings was over 30%.
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The onset of bipolar disorder typically occurs later in life, around 25 years of age.
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Typical antipsychotic drugs, such as chlorpromazine and haloperidol, are effective regardless of the presence of psychotic features.
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Persistent cognitive deficits are associated with a better outcome in bipolar patients.
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Atypical antipsychotic agents are being used less frequently in the treatment of mania compared to typical antipsychotics.
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Manic patients treated with typical antipsychotics are not at risk for extrapyramidal side effects.
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Lithium has been shown to be effective in the acute treatment of mania in multiple placebo-controlled trials.
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Conventional antipsychotic drugs can provide protection against the depressive phases following mania resolution.
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Severely ill patients are often included in placebo-controlled trials for atypical antipsychotic agents.
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The primary aim of drug treatment in mania is to increase physical and mental energy levels.
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Lithium has a response rate of 49%, valproate has a response rate of 48%, and placebo has a response rate of 40%.
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Benzodiazepines are most effective when used alone in the treatment of mania.
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Electroconvulsive therapy (ECT) has been shown to have an overall response rate of 80% in retrospective investigations for acute mania.
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Carbamazepine's efficacy in acute mania has been extensively validated through multiple large-scale studies.
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Valproate is more effective than lithium in patients with prominent dysphoric symptoms and rapid cycling.
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Withdrawal from antipsychotics should be done rapidly to avoid adverse effects.
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Only bilateral ECT has been found to be effective in treating mania.
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The average length of a manic episode is approximately 6 months, suggesting that medication should continue for at least this duration.
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The lifetime risk for bipolar disorder is estimated to be in the range of 0.5-1.0%.
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Bipolar disorder does not have a significant prevalence difference between men and women.
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The mean age of onset for bipolar disorder in community studies is estimated to be around 25 years.
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Bipolar disorder has low comorbidity with anxiety disorders.
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The 6-month prevalence of bipolar disorder is significantly lower than its lifetime prevalence.
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Community surveys have used both ICD-9 and DSM-5 criteria for diagnosing bipolar disorder.
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Study Notes
Epidemiology of Bipolar Disorder
- Lifetime risk of bipolar disorder: 0.3-1.5%
- 6-month prevalence of bipolar disorder is close to lifetime prevalence, indicating chronic nature of the disorder
- Prevalence in men and women is the same
- Mean age of onset: about 18 years in community studies
- Bipolar disorder is highly comorbid with anxiety disorders, substance misuse, and general medical conditions like cardiovascular disease
Treatment of Mania
General Measures
- Drug treatment plays a crucial role in managing mania
- Aim of treatment: reduce physical and mental overactivity, improve psychotic features, and prevent health deterioration
Medication
Typical Antipsychotic Drugs
- Chlorpromazine and haloperidol are effective in treating mania
- Limitations: high doses often required, susceptible to extrapyramidal side-effects, and do not protect against depressive downswings
Atypical Antipsychotic Drugs
- Aripiprazole, asenapine, olanzapine, quetiapine, and risperidone are effective in treating mania
- Improved tolerability profile compared to typical antipsychotic drugs
- May not be generalizable to more severely ill patients
Lithium
- Effective in acute treatment of mania
- Five placebo-controlled trials support its efficacy
Course and Prognosis
- Bipolar disorder usually begins as depression, with the first manic episode manifesting about 5 years later
- Average length of a manic episode: about 6 months
- At least 90% of patients with mania experience further episodes of major mood disturbance
- Interval between episodes becomes progressively shorter with age and number of episodes
- Long-term prognosis is poor, with less than 20% of patients achieving 5 years of clinical stability
Mortality of Bipolar Disorder
- Mortality is significantly increased in patients with bipolar disorders
- About 8% of men and 5% of women hospitalized for bipolar illness die by suicide
- High mortality is also due to general medical conditions like cardiovascular disease and substance misuse
- Life expectancy is reduced by about 13 years in men and 9 years in women
Treatment of Mania (continued)
Lithium
- Response rate: 49%
- As effective as antipsychotic medication, but slower onset of action
- Preferable in highly active states
- Prominent depressive symptoms and psychotic features predict a poorer response to lithium alone
- Rapid cycling disorder also predicts a poor response
Carbamazepine
- Studies have been limited by problems with study design
- Extended-release form showed a clinically significant antimanic effect
- Induces drug metabolizing enzymes in the liver, leading to lower plasma levels of other medications
Valproate
- Greater antimanic activity than placebo and equivalent to lithium
- More effective than lithium in patients with prominent dysphoric symptoms and rapid cycling
- Onset of action is earlier than other mood stabilizers
- Valproate loading (20mg/kg/day) can lead to antimanic effects within 1-4 days
- Tolerable enough for rapid dose escalation
Benzodiazepines
- Useful adjuncts in the treatment of mania
- Rapidly diminish overactivity and restore sleep
- Can be used as sole therapy, but carries a risk of disinhibition
- Most useful as an adjunct to mood stabilizers
Electroconvulsive Therapy
- Widely used to treat mania
- Bilateral ECT better than lithium
- Unilateral and bilateral ECT better than lithium and haloperidol combined
- Effective in acute mania with an overall response rate of 80%
- Also effective in mixed affective states
Continuation Treatment of Mania
- Rapid reduction of drug treatment can lead to sudden recrudescence of the manic disorder
- Medication should continue for at least 6 months
- Atypical antipsychotics decrease the risk of manic relapse
- Patients who were severely ill may be taking a mood stabilizer and an antipsychotic agent
- Withdrawal should be slow due to adverse effects of antipsychotics
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Description
Understand the diagnostic criteria and challenges in defining bipolar disorder, and learn about its lifetime risk and prevalence in industrialized countries.
