Therapy for Patients with Bipolar Disorder
Prevalence and Neuroscience of Bipolar I Disorder
Bipolar I disorder, often known as manic-depressive disorder, is a mental condition characterized by periods of extreme mood elevation and high energy, followed by episodes of depression. The alternating pattern of mania and depression is a hallmark of bipolar disorder. Between mania and depressive periods, people with bipolar I illness may lead regular lives.
According to the National Institute of Mental Health (2022), Bipolar I disorder affects approximately 2.5% (6 million individuals) of the population in the United States. The symptoms of bipolar 1 disorder first occur in adolescence or early adulthood, generally before the age of 50. The exact etiology of the disease is unknown; however, neurochemical, genetic, and environmental factors have been implicated to have a role.
Researchers have discovered that brain circuits in various parts of the brain govern emotions and mood by producing serotonin, norepinephrine, and dopamine (Young & Juruena, 2021; Scaini et al., 2020). The imbalance of neurotransmitters and faulty brain circuit functioning play an important part in the development of bipolar I disorder.
Furthermore, a combination of genetics and environmental factors is implicated in developing this disease; hence, the probability of having bipolar I in persons with certain specific genes and close family members with bipolar I is increased. Environmental variables such as chronic severe stress or trauma, feeling overwhelmed, and drug addiction may all contribute to the development of bipolar I disorder.
Bipolar 1 Presentation, and its DSM-5 Diagnostic Differences from the other Types of Bipolar Related Disorder (Bipolar II)
Manic episodes are characterized by euphoria, irritability, and disruptive and aberrant behaviors such as a quick shift of mind from one concept to the next, fast, uninterruptible, and pressured speech, high energy, high activity, grandiosity, drug misuse, egoism, and hypersexuality (APA, 2013). Following a manic episode, depression may occur quickly or later.
The majority of people have extended periods without bouts of mania and depression-cycling symptoms, and there are uncommon examples of fast cycling in those with Bipolar I. Another potential for people with bipolar disorder is that their mania and depression moods occur on the same day, which is known as a mixed characteristic.
The depressive mood of persons with Bipolar I is similar to that of typical clinical depression, with decreased energy, reduced appetite, suicidal thoughts, low self-esteem, and anhedonia (inability to enjoy pleasure) that lasts for weeks or months but seldom more than a year.
DSM-5 Diagnostic Differences Between Bipolar I and Bipolar II
Bipolar II disorder is the second bipolar-related illness type to which bipolar I will be compared. The manic phase in bipolar 1 is defined by an excessively high, expansive, or irritated mood that lasts at least one week and occurs virtually every day (criteria A), as well as at least three of the following symptoms: increased self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas, easy distractibility, increase in goal-directed activities, and increased involvement in highly pleasurable but dangerous activities such as sex and overspending (criteria B), the symptoms cause marked dysfunction in social, occupational, and other vital areas of functioning (Criteria C), and the symptoms are not attributed to the physiological effects of a substance abuse (criteria D) (APA, 2013).
Bipolar 1 may also have a hypomanic phase, in which the symptoms are identical to the manic phase, but the time of excessively high, expansive, or irritated mood lasts at least four consecutive days rather than one full week (APA, 2013). Bipolar 1 may also have a depressive episode, which presents as a low mood with loss of interest, weight loss, insomnia, psychomotor agitation, fatigue, worthlessness, the difficulty of focus, and recurring thoughts of death (APA, 2013).
While complete manic and depressive episodes characterize bipolar I condition, bipolar II is distinguished by one hypomanic and one full depressive episode, as defined by the DSM-5 diagnostic criteria. The two illnesses may appear in clinically similar ways, necessitating a mental healthcare clinician who is familiar with the DSM-5 diagnostic criteria to identify and establish an accurate diagnosis.
Special Populations and Consideration
Treatment of mental disorders in children and adolescents may be challenging. The first obstacle arises from the difficulty in diagnosing mood disorders since it may be difficult to distinguish, for example, bipolar 1 illness from age-appropriate mood changes (Brickman & Fristad, 2022). The difficulties may result in a decline in the diagnosis of mood disorders in children and adolescents, resulting in inadequate treatment of the illnesses.
The second difficulty is that children and adolescents have not reached the legal age of consent and must rely on their parents and guardians’ choices to seek care and treatment, which may result in underdiagnosis and undertreatment of mood disorders. Pregnancy and postpartum changes are key phases to consider when treating bipolar individuals.
Pregnancy and postpartum states have been proven to increase the likelihood of relapse in people with bipolar illnesses, owing to hormonal changes during these times (Sharma et al., 2020). Women with bipolar illnesses who are hoping to conceive should engage closely with their mental healthcare specialists to develop methods for properly managing their condition. Because of the increased risk of suicide in the senior population, mood problems may be catastrophic.
The elderly population has limited social support and affection, which may be related to the loss of loved ones, insufficient financial support due to retirement, and may have difficulty accessing care due to physical immobility or multiple comorbidities, all of which increase their risk of suicidal ideation. To reduce suicidality, elderly people need careful attention and care from mental health professionals as well as accessible family members.
In terms of emergency care, bipolar 1 disorder might appear similar to any other mental illness or organic disease, prompting care providers to have a high clinical acumen to avoid missing the diagnosis.
FDA and/or Clinical Guidelines Approved Pharmacological Treatment Options
Bipolar I disorder is treated with mood stabilizers, antipsychotics, and sedative-hypnotics such as benzodiazepines. Lithium, for example, is the widely used mood stabilizer used to regulate largely classical euphoria or manic episodes rather than a depression-mania combination mood at the same time (Hafeman et al., 2020).
Before administering lithium, care providers must assess renal and thyroid function and avoid the drug if the baseline organ functions are abnormal. Further, Lithium has a narrow therapeutic window, necessitating cautious prescription and frequent monitoring of the patients on the drug. Valproate (antiseizure medicine) may be utilized for quick-acting mood balancing during acute bouts of mania.
Valproate (Depakote) is often administered using a loading dosage strategy, which begins with a high dose and results in mood stabilization after a few days of treatment. Other anti-seizer drugs used to treat mania and depression include carbamazepine and lamotrigine. Some antipsychotic drugs, such as Haldol and Thorazine, are used to treat manic and manic-depressive mixed moods.
Benzodiazepines, such as Xanax and diazepam, are used for the short-term treatment of acute manic symptoms such as anxiety and sleeplessness; however, benzodiazepines do not address the core symptoms of bipolar I and should only be considered as an adjunct treatment. In general, since benzodiazepine medications may be abused and misused by certain patients, doctors must exercise extreme care while administering them.
Common antidepressants such as Prozac, Zoloft, and Paxil are ineffective in treating depressive mood in people with bipolar I illness since they may increase manic episodes. The FDA-approved drugs for bipolar I depression include Symbyax (olanzapine-fluoxetine), Lurasidone, Caplyta, Seroquel, and Vraylar. In addition, electroconvulsive therapy (ECT) may be an effective treatment for manic and depressive moods in people with bipolar I.
Bipolar 1 disorder prevention may be difficult due to the unclear nature of its etiology; nonetheless, there are several approaches to reduce the risks associated with bipolar I development. Stress reduction, medications, sleep hygiene management, reducing/stopping alcohol or drug usage, and developing strong friends/family/society support are among the strategies.
Examples of Prescription
Indication: Bipolar disorder
Initial dosage: 1800 mg PO per day divided 8 hourly. Increase the dose as tolerated to target serum lithium concentrations of 0.8-1.2 mEq/L (acute goal) or 0.8-1.0 mEq/L (maintenance goal)
Indication: Depression associated with bipolar 1 disorder, Major depressive disorder
Initial dosage: Fluoxetine 20 mg plus 5 mg Olanzapine PO every night at bedtime. Make dosage adjustments, if indicated, according to efficacy and tolerability within dose ranges of fluoxetine 20-50 mg and olanzapine 5-12.5 mg
Indication: Bipolar depression
Initial dosage: Lurasidone 20 mg PO per day initially, may increase the dose if needed, not to exceed 120 mg/day
Mood disorders are among the most common mental diseases that have existed since antiquity. Bipolar and depressive diseases are common mood disorders that gradually debilitate patients. Bipolar disorder is categorized into distinct categories according to the DSM-5 diagnostic criteria, with a narrow line of demarcation. A mental healthcare provider with DSM-5 understanding and good clinical acumen is essential to make correct diagnoses and progress patients’ treatment.
Several psychopharmacologic medications show promising results in illness therapy. However, the use of pharmacologic agents may be limited by side effects, patient comorbidities, and patient preferences. Thus, a clinician’s duty in the therapy of mood disorders is to prescribe and justify drugs according to the patient’s requirements.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596
Brickman, H. M., & Fristad, M. A. (2022). Psychosocial treatments for bipolar disorder in children and adolescents. Annual Review of Clinical Psychology, 18(1), 291–327. https://doi.org/10.1146/annurev-clinpsy-072220-021237
Hafeman, D. M., Rooks, B., Merranko, J., Liao, F., Gill, M. K., Goldstein, T. R., Diler, R., Ryan, N., Goldstein, B. I., Axelson, D. A., Strober, M., Keller, M., Hunt, J., Hower, H., Weinstock, L. M., Yen, S., & Birmaher, B. (2020). Lithium versus other mood-stabilizing medications in a longitudinal study of youth diagnosed with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 59(10), 1146–1155. https://doi.org/10.1016/j.jaac.2019.06.013
National Institute of Mental Health. (2022). Bipolar disorder. National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/bipolar-disorder
Scaini, G., Valvassori, S. S., Diaz, A. P., Lima, C. N., Benevenuto, D., Fries, G. R., & Quevedo, J. (2020). Neurobiology of bipolar disorders: a review of genetic components, signaling pathways, biochemical changes, and neuroimaging findings. Revista Brasileira de Psiquiatria (Sao Paulo, Brazil: 1999), 42(5), 536–551. https://doi.org/10.1590/1516-4446-2019-0732
Sharma, V., Sharma, P., & Sharma, S. (2020). Managing bipolar disorder during pregnancy and the postpartum period: a critical review of current practice. Expert Review of Neurotherapeutics, 20(4), 373–383. https://doi.org/10.1080/14737175.2020.1743684
Young, A. H., & Juruena, M. F. (2021). The neurobiology of bipolar disorder. Current Topics in Behavioral Neurosciences, 48, 1–20. https://doi.org/10.1007/7854_2020_179