BIPOLAR

DISORDER
GROUP 3
Calayag, Maricon
Capio, Eunice
Goloyugo, Reya
Nacar, Majestie
 Bipolar disorder, formerly called
manic depression, is a mental
health condition that causes
extreme mood swings that include
emotional highs (mania or
hypomania) and lows (depression).
• When you become depressed, you may feel sad or hopeless and
lose interest or pleasure in most activities. When your mood shifts to
mania or hypomania (less extreme than mania), you may feel
euphoric, full of energy or unusually irritable. These mood swings
can affect sleep, energy, activity, judgment, behavior and the ability
to think clearly.

• Episodes of mood swings may occur rarely or multiple times a year.

While most people will experience some emotional symptoms
between episodes, some may not experience any.

• Although bipolar disorder is a lifelong condition, you can manage

your mood swings and other symptoms by following a treatment
plan. In most cases, bipolar disorder is treated with medications and
psychological counseling (psychotherapy).
Bipolar disorders are classified as

• Bipolar I disorder: Defined by the presence of at least one full-

fledged (ie, disrupting normal social and occupational function)
manic episode and usually depressive episodes
• Bipolar II disorder: Defined by the presence of major depressive
episodes with at least one hypomanic episode but no full-fledged
manic episodes
• Unspecified bipolar disorder: Disorders with clear bipolar
features that do not meet the specific criteria for other bipolar
disorders
• In cyclothymic disorder, patients have prolonged (> 2-year)
periods that include both hypomanic and depressive episodes;
however, these episodes do not meet the specific criteria for a
bipolar disorder.
Bipolar Disorder Can
Shrink Part of
Your Brain's Hippocampus.

The left side of the hippocampus

regulates verbal and visual
memory. This part of
the brain also helps regulate how
you respond to situations
emotionally. When your mood
shifts, your hippocampus
changes shapes and shrinks.
Bipolar patients tend to have gray matter reductions in frontal
brain regions involved in self-control (orange colors), while
sensory and visual regions are normal (gray colors)
The Brain and Bipolar Disorder
Experts believe bipolar disorder is partly caused by an
underlying problem with the balance of brain chemicals
called neurotransmitters.

Norepinephrine and serotonin have been consistently

linked to psychiatric mood disorders such
as depression and bipolar disorder. Nerve pathways
within areas of the brain that regulate pleasure and
emotional reward are regulated by dopamine.
Exact cause of bipolar disorder is unknown. Heredity plays a significant role.
There is also evidence of dysregulation of serotonin, norepinephrine,
and dopamine.

Psychosocial factors may be involved. Stressful life events are often

associated with initial development of symptoms and later exacerbations,
although cause and effect have not been established.

Certain drugs can trigger exacerbations in some patients with bipolar

disorder; these drugs include
• Sympathomimetics (eg, cocaine, amphetamines)
• Alcohols
• Certain antidepressants (eg, tricyclics, monoamine oxidase inhibitors
[MAOIs])
 CAUSES
Biological
People with bipolar disorder
appear to have physical changes
in their brains. The significance of
these changes is still uncertain but
may eventually help pinpoint
causes.
Twin studies have indicated a
concordance rate for bipolar
disorder among monozygotic twins
at 60% to 80% compared to 10% to
20% in dizygotic twins.
 CAUSES
Genetics
Bipolar disorder is more
common in people who
have a first-degree
relative, such as a sibling
or parent, with the
condition. Researchers are
trying to find genes that
may be involved in causing
bipolar disorder.
 CAUSES
Biochemical
Just as there is an
indication of lowered
levels of norepinephrine
and dopamine during an
episode of depression,
the opposite appears to
be true of an individual
experiencing a manic
episode.
 CAUSES
Physiological
Right-sided lesions in
the limbic system,
temporobasal areas,
basal ganglia, and
thalamus have been
shown to induce
secondary mania.
 CAUSES
Medication Side
Effects
Certain medications used to
treat somatic illnesses have
been known to trigger a
manic response; the most
common of these are the
steroids frequently used to
treat chronic illnesses such as
multiple sclerosis and
systemic lupus
erythematosus.
 RISK FACTORS
01 Having a first-degree relative,
such as a parent or sibling, with
bipolar disorder

02 Periods of high stress, such as

the death of a loved one or
another traumatic event

03 Drug or alcohol abuse

 COMPLICATIONS
Left untreated, bipolar disorder can
result in serious problems that affect
every area of your life, such as:

• Problems related to drug

and alcohol use
• Suicide or suicide attempts
• Legal or financial problems
• Damaged relationships
• Poor work or school
performance
 CO-OCCURRING
CONDITIONS
If you have bipolar disorder, you may also have
another health condition that needs to be
treated along with bipolar disorder. Some
conditions can worsen bipolar disorder
symptoms or make treatment less successful.
Examples include:

• Anxiety disorders
• Eating disorders
• Attention-deficit/hyperactivity
disorder (ADHD)
• Alcohol or drug problems
• Physical health problems,
such as heart disease, thyroid
problems, headaches or
obesity
EPIDEMIOLOGY
 01
Mortality/Morbidity
 Bipolar disorder has significant mortality and morbidity rates.
02
 Approximately 25-50% of individuals with bipolar disorder
attempt suicide, and 11% commit suicide.
03
Race
 No racial predilection exists. 04

Sex 05
 Bipolar I disorder occurs equally in both sexes; rapid-cycling
bipolar disorder (4 or more episodes a year) is more common in 06
women than in men.
 Incidence of bipolar II disorder is higher in females than in males.
 01
Age
 The age of onset of bipolar disorder varies greatly.
02
 The age range for both bipolar I and bipolar II is from childhood
to 50 years, with a mean age of approximately 21 years, (15-19
years), (20-24 years). 03
 Onset of mania in people older than 50 years should lead to an
investigation for medical or neurological disorders such as 04
cerebrovascular disease.
05
Seasonal variation
 Depression more common in spring and autumn 06
 Mania more common in summer
 01

02

03

04

05

Epidemiological studies have suggested a lifetime prevalence of

06
around 1% for bipolar type I in the general population. A large cross-
sectional survey of 11 countries found the overall
lifetime prevalence of bipolar spectrum disorders was 2.4%, with
a prevalence of 0.6% for bipolar type I and 0.4% for bipolar type II.
 01

02

03

04

05

06
An estimated 2.8% of U.S. adults had bipolar disorder in the past
year. Past year prevalence of bipolar disorder among adults was
similar for males (2.9%) and females (2.8%).
Epidemiology of geriatric bipolar disorder:
- Bipolar disorder affects 0.5% to 1% of older adults.
- Bipolar disorder is approximately one-third (1/3) as common in older
persons as in younger persons.
- While there is no “official” cutoff, most literature suggests that first-time
mania or hypomania in persons older than 50 years is considered late-
onset.
- Misdiagnosis is common in both younger and ang geriatric persons with
bipolar disorder.
Pathogenesis
Bipolar disorder is a serious psychiatric disorder, with
a high heritability and unknown pathogenesis. Recent
genome-wide association studies have identified the
first loci, implicating genes such as CACNA1C and
ANK3. The genes highlight several pathways, notably
calcium signaling, as being of importance.
Pathophysiology
• 80% genetic contribution.
Complex genetic disorder, multiple different common
disease alleles.
16 different chromosomal regions.

• Two particular genes, ANK3 (ankyrin G) and CACNA1C (alpha 1 C

subunit of L-type voltage-gated calcium channel).

• ANK3 is an adaptor protein found at axon initial segments that

regulates the assembly of voltage-gated sodium channels and
both ANK3 and subunits of the calcium channel are down-
regulated in mouse brain in response to lithium, indicating a
possible therapeutic mechanism of action of one of the most
effective treatments for bipolar disorder.
• Diacylglycerol kinase eta (DGKH) gene. DGKH is a key protein
in the lithium-sensitive phosphatidyl inositol pathway.
• Glycogen Synthase Kinase 3-beta (GSK3B). Lithium-mediated
inhibition of GSK3B is thought to result in down-regulation of
molecules involved in cell death and upregulation of
neuroprotective factors.
-GSK3B is a central regulator of the circadian clock and
lithium-mediated modulation of circadian periodicity is
thought to be a critical component of its therapeutic effect.
• COMT gene (Catechol-O-Methyltransferase) has important role
in Intelligence, BP, Schizophrenia.
• CLOCK gene (Circadian Locomotor Output Cycles Kaput) is a
dominant negative mutation in the CLOCK gene normally
contributing to circadian periodicity in humans results in manic-
like behavior in mice.
CLINICAL FEATURES
(PRESENTATION)
Signs and Symptoms of Bipolar Disorder
Bipolar disorder begins with an acute phase of symptoms, followed by a repeating
course of remission and relapse. Remissions are often complete, but many patients
have residual symptoms, and for some, the ability to function at work is severely
impaired. Relapses are discrete episodes of more intense symptoms that are manic,
depressive, hypomanic, or a mixture of depressive and manic features.

Episodes last anywhere from a few weeks to 3 to 6 months; depressive episodes

typically last longer than manic ones.

Cycles—time from onset of one episode to that of the next—vary in length among
patients. Some patients have infrequent episodes, perhaps only a few over a lifetime,
whereas others have rapid-cycling forms (usually defined as ≥ 4 episodes/yr). Only a
minority alternate back and forth between mania and depression with each cycle; in
most, one or the other predominates to some extent.

Patients may attempt or commit suicide. Lifetime incidence of suicide in patients with
bipolar disorder is estimated to be at least 15 times that of the general population.
Mania
A manic episode is defined as ≥ 1 week of a persistently elevated, expansive,
or irritable mood and persistently increased goal-directed activity or energy
plus ≥ 3 additional symptoms:

• Inflated self-esteem or grandiosity

• Decreased need for sleep
• Greater talkativeness than usual
• Flight of ideas or racing of thoughts
• Distractibility
• Increased goal-directed activity
• Excessive involvement in activities with high potential for painful
consequences (eg, buying sprees, foolish business investments)
Mania
Manic patients may be inexhaustibly, excessively, and impulsively involved in
various pleasurable, high-risk activities (eg, gambling, dangerous sports,
promiscuous sexual activity) without insight into possible harm. Symptoms
are so severe that they cannot function in their primary role (occupation,
school, housekeeping). Unwise investments, spending sprees, and other
personal choices may have irreparable consequences.

Patients in a manic episode may be exuberant and flamboyantly or

colorfully dressed and often have an authoritative manner with a rapid,
unstoppable flow of speech. Patients may make clang associations (new
thoughts that are triggered by word sounds rather than meaning). Easily
distracted, patients may constantly shift from one theme or endeavor to
another. However, they tend to believe they are in their best mental state.
Mania
Lack of insight and an increased capacity for activity often lead to intrusive
behavior and can be a dangerous combination. Interpersonal friction results
and may cause patients to feel that they are being unjustly treated or
persecuted. As a result, patients may become a danger to themselves or to
other people. Accelerated mental activity is experienced as racing thoughts
by patients and is observed as flights of ideas by the physician.

Manic psychosis is a more extreme manifestation, with psychotic symptoms

that may be difficult to distinguish from schizophrenia. Patients may have
extreme grandiose or persecutory delusions (eg, of being Jesus or being
pursued by the FBI), occasionally with hallucinations. Activity level increases
markedly; patients may race about and scream, swear, or sing. Mood lability
increases, often with increasing irritability. Full-blown delirium (delirious
mania) may appear, with complete loss of coherent thinking and behavior.
Hypomania
A hypomanic episode is a less extreme variant of mania involving a distinct
episode that lasts ≥ 4 days with behavior that is distinctly different from the
patient’s usual nondepressed self and that includes ≥ 3 of the additional
symptoms listed above under mania.

During the hypomanic period, mood brightens, the need for sleep decreases,
and psychomotor activity accelerates. For some patients, hypomanic
periods are adaptive because they produce high energy, creativity,
confidence, and supernormal social functioning. Many do not wish to leave
the pleasurable, euphoric state. Some function quite well, and in most,
functioning is not markedly impaired. However, in some patients, hypomania
manifests as distractibility, irritability, and labile mood, which the patient and
others find less attractive.
Depression
A depressive episode has features typical of major depression; the episode
must include ≥ 5 of the following during the same 2-week period, and one of
them must be depressed mood or loss of interest or pleasure:

• Depressed mood most of the day

• Markedly diminished interest or pleasure in all or almost all activities for most
of the day
• Significant (> 5%) weight gain or loss or decreased or increased appetite
• Insomnia (often sleep-maintenance insomnia) or hypersomnia
• Psychomotor agitation or retardation observed by others (not self-reported)
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate or indecisiveness
• Recurrent thoughts of death or suicide, a suicide attempt, or specific plan for
suicide
Psychotic features are more common in bipolar depression than in unipolar
depression.
Mixed Features
An episode of mania or hypomania is designated as having mixed features if
≥ 3 depressive symptoms are present for most days of the episode. This
condition is often difficult to diagnose and may shade into a continuously
cycling state; the prognosis is worse than that in a pure manic or hypomanic
state.
Risk of suicide during mixed episodes is particularly high.
Depressive Symptoms
Major depressive episode must have at least four of the
following symptoms. They should be new or suddenly
worse, and must last for at least two weeks:
- changes in appetite or weight, sleep, or
psychomotor activity
decreased energy
- feelings of worthlessness or guilt
- trouble thinking, concentrating, or making
decisions
- thoughts of death or suicidal plans or attempts
Manic Symptoms
“distinct period of abnormally and persistently
elevated, expansive, or irritable mood.” The episode
must last at least a week. The mood must have at
least three of the following symptoms:

- high self-esteem
- little need for sleep
- increased rate of speech (talking fast)
- flight of ideas
- getting easily distracted
- an increased interest in goals or activities
psychomotor agitation (pacing, hand wringing,
etc.)
- increased pursuit of activities with a high risk
of danger
DIAGNOSIS
A diagnostic exam for bipolar disorder generally consists
of the following:
Psychological evaluation – The doctor or bipolar disorder specialist will
conduct a complete psychiatric history. You will answer questions about your
symptoms, the history of the problem, any treatment you’ve previously
received, and your family history of mood disorders.

Medical history and physical – There are no lab tests for identifying bipolar
disorder, but your doctor should conduct a medical history and physical
exam in order to rule out illnesses or medications that might be causing your
symptoms. Screening for thyroid disorders is particularly important, as
thyroid problems can cause mood swings that mimic bipolar disorder.
Medical conditions and medications that can mimic the
symptoms of bipolar disorder include:

• Thyroid disorders
• Neurological disorders
• Vitamin B12 deficiency
• Drugs for Parkinson’s Disease
• Corticosteroids
• Antidepressants
• Anti-Anxiety Drugs
• Adrenal disorders (e.g. Addison’s disease, Cushing’s syndrome)
INVESTIGATIONS
There are no specific blood tests or brain scans to
diagnose bipolar disorder. Even so, your doctor may
perform a physical exam and order lab tests, including
a thyroid function test and urine analyses. These tests
can help determine if other conditions or factors could
be causing your symptoms.
A thyroid function test is a blood test that measures how well
your thyroid gland functions. The thyroid produces and secretes
hormones that help regulate many bodily functions. If your
body doesn’t receive enough of the thyroid hormone, known
as hypothyroidism, your brain may not function properly. As a
result, you may have problems with depressive symptoms or
develop a mood disorder.

Sometimes, certain thyroid issues cause symptoms that are

similar to those of bipolar disorder. Symptoms may also be a
side effect of medications. After other possible causes are ruled
out, your doctor will likely refer you to a mental health specialist.
NATURAL HISTORY
(COURSE)
Onset:
Most cases of bipolar disorder commence when individuals are aged 15–
19 years. The second most frequent age range of onset is 20–24 years.
Some patients diagnosed with recurrent major depression may indeed
have bipolar disorder and go on to develop their first manic episode when
older than 50 years.

Progression:
Generally, although there are exceptions, the illness develops
imperceptibly during adolescence, a stage already known for its proclivity
to emotional instability, and reaches its splendor in adult age, in the form
of a depressive or even a hypomanic/manic phase.
Duration:
The median duration of bipolar I mood episodes was 13 weeks, and the
probability of recovery was significantly decreased for cycling episodes,
mood episodes with severe onset, and subjects with greater cumulative
morbidity. Bipolar I disorder is usually characterized by recurrent mood
episodes.

Severity:
Bipolar I disorder is the most severe form of
the illness. Bipolar II disorder is characterized by predominantly
depressive episodes accompanied by occasional hypomanic episodes.
Hypomanic episodes are milder than manic episodes but can still impair
functioning.
Complications:
Left untreated, bipolar disorder can result in serious problems that affect
every area of your life, such as:
• Problems related to drug and alcohol use
• Suicide or suicide attempts
• Legal or financial problems
• Damaged relationships
• Poor work or school performance

The main complications of bipolar disorder, or manic-depressive illness

(MDI), are suicide, homicide, and addictions.
Mortality:
Bipolar disorder is associated with
high mortality, and people with
this disorder on average may die 10-
20 years earlier than the general
population.

The rate of all-cause mortality in

individuals with bipolar disorder was
210.34 per 10 000 person-years at-
risk (PYAR, 95% CI 199.07–222.25).
Trends in bipolar disorder
mortality rate suggested a
reduction over follow-up time.
Course of Bipolar Disorder
Bipolar disorder typically develops in late adolescence or early adulthood.
The average age of onset for Bipolar Disorder I is 18 and for Bipolar
Disorder II is the mid-20s for both men and women. However, there is some
variation in the age of onset. Some people have their first bipolar disorder
symptoms during childhood, and some develop them later in life. The
symptoms are often not recognized as a bipolar disorder right away.
People may suffer for years before the condition is properly diagnosed and
treated.

Bipolar disorder is ongoing condition. More than 90% of individuals who

have a single manic episode go on to have future episodes. About 60-70%
of manic or hypomanic episodes occur before or after a major depressive
episode. The frequency of swings during a lifetime is typically increased in
those with bipolar II disorder compared to other bipolar conditions.
Approximately, 5-15% of these patients become rapid-cyclers with a poorer
treatment outcomes.
Course of Bipolar Disorder
Females with Bipolar Disorder I tend to have more rapid cycling and
mixed feature episodes than males do. Females also tend to have co-
occurring eating disorders. Females with bipolar I and bipolar II are more
likely than males to experience depressive episodes, have a higher risk of
alcohol use disorder.

Once bipolar disorder signs have established themselves, episodes of

mania and depression often recur across the life span. Bipolar disorders
have no cure and are chronic, long-term conditions. The risk of suicide is
high among those with bipolar disorder. The rate is estimated to be at
least 15 times the rate of those in the general population without bipolar
disorder. According to the DSM, bipolar disorder may account for 25% of
all completed suicides. Bipolar patients are also at heightened risk for
engaging in impulsive and risky acts other than suicide such as violent
outbursts, domestic abuse, substance abuse, etc.
Course of Bipolar Disorder
Fortunately, the worst (e.g., most dangerous) symptoms can be
controlled and stabilized in most cases provided that proper bipolar
disorder medications are prescribed and taken regularly. Approximately
20-30% of individuals with bipolar I disorder and 15% of individuals with
bipolar II disorder will continue to show changing moods and challenges
with school, work and relationships despite following treatment guidelines.
Ongoing protective treatment is generally recommended for patients
even when they have not shown evidence of mood swings for extended
periods of time. This can help prevent the possible recurrence of suicidal
thoughts and other risky, impulsive self-destructive behaviors.
Aims
• Symptomatic Relief: Treatment of bipolar disorder conventionally
focuses on acute stabilization, in which the goal is to bring a patient with
mania or depression to a symptomatic recovery with euthymic (stable)
mood; and on maintenance, in which the goals are relapse prevention,
reduction of subthreshold symptoms, and enhanced social and
occupational functioning.

• Reverse Disease (Cure): Although bipolar disorder has no cure, people

with the condition can experience long periods during which they are free
of symptoms. With ongoing treatment and self-management, people
with bipolar disorder can maintain a stable mood for extended periods.
During intervals of recovery, they may have few or no symptoms.
Aims
Prevent Disease: There's no sure way to prevent bipolar disorder. However,
getting treatment at the earliest sign of a mental health disorder can help
prevent bipolar disorder or other mental health conditions from worsening.
If you've been diagnosed with bipolar disorder, some strategies can help prevent
minor symptoms from becoming full-blown episodes of mania or depression:

• Pay attention to warning signs. Addressing symptoms early on can prevent

episodes from getting worse. You may have identified a pattern to your
bipolar episodes and what triggers them. Call your doctor if you feel you're
falling into an episode of depression or mania. Involve family members or
friends in watching for warning signs.
• Avoid drugs and alcohol. Using alcohol or recreational drugs can worsen
your symptoms and make them more likely to come back.
• Take your medications exactly as directed. You may be tempted to stop
treatment — but don't. Stopping your medication or reducing your dose on
your own may cause withdrawal effects or your symptoms may worsen or
return.
Duration
Treatment Mode
• Early diagnosis and treatment of acute mood episodes improve
prognosis by reducing the risk of relapse and doubling the rate of
response to medications. Medication selection depends on the presenting
phase of illness and its severity. Treatment should continue indefinitely
because of the risk of relapse, which occurs in one-third of patients in the
first year after presentation and in more than 70 percent of patients
within five years. Comanagement with a psychiatrist is often required
because of relapse, treatment resistance, comorbid psychiatric
conditions, and the risk of patients harming themselves or others.
Women of childbearing age should be educated about the teratogenic
effects of most mood stabilizers and the importance of using reliable
contraception while taking these medications. Monotherapy with
antidepressants is contraindicated in patients with mixed states, manic
episodes, or bipolar I disorder.
Treatment Mode
• Electroconvulsive therapy can be effective for mania and
psychotic depression. Behavioral interventions (e.g., cognitive
behavior therapy, caregiver support, psychoeducation regarding
the early warning signs of mood relapse) are considered first-
line adjuncts to pharmacotherapy to improve social function and
reduce the need for medications, number of hospitalizations, and
relapse rates. Early warning signs of a mood relapse include
sleep disturbance, agitation, increased goal orientation, and a
disruption in usual routine. The risk of suicide is lowered with
increased satisfaction with care, lithium therapy, and treatment
of alcohol and tobacco abuse.
• Mood stabilizers (eg, lithium,
certain anticonvulsants), a 2nd-
generation antipsychotic, or both
• Support and psychotherapy
Treatment of bipolar disorder usually
has 3 phases:
• Acute: To stabilize and control the
initial, sometimes severe
manifestations
• Continuation: To attain full
remission
• Maintenance or prevention: To
keep patients in remission
Although most patients with
hypomania can be treated as
outpatients, severe mania or
depression often requires inpatient
management.
Drugs for bipolar disorder include
• Mood stabilizers: Lithium and certain anticonvulsants, especially
valproate, carbamazepine, and lamotrigine
• 2nd-generation antipsychotics:
Aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone and
cariprazine.
These drugs are used alone or in combination for all phases of treatment, although at
different dosages.
Choice of drug treatment for bipolar disorder can be difficult because all drugs have
significant adverse effects, drug interactions are common, and no drug is universally
effective. Selection should be based on what has previously been effective and well-
tolerated in each patient. If the patient has not previously been given drugs to treat
bipolar disorder (or drug history is unknown), choice is based on the patient’s medical
history (vis-à-vis the adverse effects of the specific mood stabilizer) and the severity of
symptoms.
Specific antidepressants (eg, selective serotonin reuptake inhibitors [SSRIs]) are
sometimes added for severe depression, but their effectiveness is controversial; they
are not recommended as sole therapy for depressive episodes.
Other treatments
• Electroconvulsive therapy (ECT) is sometimes used for depression
refractory to treatment and is also effective for mania.
• Phototherapy can be useful in treating seasonal bipolar I or bipolar II
disorder (with autumn-winter depression and spring-summer
hypomania). It is probably most useful as augmentative therapy.

Education and psychotherapy

Enlisting the support of loved ones is crucial to preventing major episodes.
• Group therapy is often recommended for patients and their partner;
there, they learn about bipolar disorder, its social sequelae, and the
central role of mood stabilizers in treatment.
• Individual psychotherapy may help patients better cope with problems
of daily living and adjust to a new way of identifying themselves.
Patients, particularly those with bipolar II disorder, may not adhere to mood-stabilizer
regimens because they believe that these drugs make them less alert and creative. The
physician can explain that decreased creativity is relatively uncommon because mood
stabilizers usually provide opportunity for a more even performance in interpersonal,
scholastic, professional, and artistic pursuits.

Patients should be counseled to avoid stimulant drugs and alcohol, to minimize sleep
deprivation, and to recognize early signs of relapse.

If patients tend to be financially extravagant, finances should be turned over to a

trusted family member. Patients with a tendency to sexual excesses should be given
information about conjugal consequences (eg, divorce) and infectious risks of
promiscuity, particularly AIDS.

• Support groups (eg, the Depression and Bipolar Support Alliance [DBSA]) can help
patients by providing a forum to share their common experiences and feelings.
Lithium:
The first mood stabilizer for bipolar disorder
Mood stabilizers are medications that help control the highs and
lows of bipolar disorder. They are the cornerstone of treatment,
both for mania and depression. Lithium is the oldest and most well-
known mood stabilizer and is highly effective for treating mania.
Lithium can also help bipolar depression. However, it is not as
effective for mixed episodes or rapid cycling forms of bipolar
disorder. Lithium takes from one to two weeks to reach its full effect.
Common side effects of lithium
Some of these common side effects may go away as your body adapts to
the medication.
• Weight gain
• Drowsiness
• Tremor
• Weakness or fatigue
• Excessive thirst; increased urination
• Stomach pain
• Thyroid problems
• Memory and concentration problems
• Nausea, vertigo
• Diarrhea

If you take lithium, it’s important to have regular blood tests to make sure your dose is
in the effective range. Doses that are too high can be toxic. When you first start taking
it, your doctor may check your blood levels once or twice a week. When the right dose
has been determined and your levels are steady, it’s still important to get blood tests
every two to three months, since many things can cause your lithium levels to change.
Even taking a different brand of lithium can lead to different blood levels.
Anticonvulsant mood stabilizers for
bipolar disorder
Originally developed for the treatment of epilepsy, anticonvulsants
have been shown to relieve the symptoms of mania and reduce
mood swings.

Valproic acid (Depakote)

Valproic acid, also known as divalproex or valproate, is a highly
effective mood stabilizer. Common brand names include Depakote
and Depakene. Valproic acid is often the first choice for rapid
cycling, mixed mania, or mania with hallucinations or delusions. It is
a good bipolar medication option if you can’t tolerate the side
effects of lithium.
Common side effects of Valproic Acid :
• Drowsiness
• Weight gain
• Dizziness
• Tremor
• Diarrhea
• Nausea

Other anticonvulsant medications for

bipolar disorder
• Carbamazepine (Tegretol)
• Lamotrigine (Lamictal)
• Topiramate (Topamax)
Treating bipolar depression with mood
stabilizers
The new focus in bipolar depression treatment is on optimizing the
dose of mood stabilizers. If you can stop your mood cycling, you
might stop having depressive episodes entirely. If you are able to
stop the mood cycling, but symptoms of depression remain, the
following medications may help:

• Lamictal (lamotrigine)
• Seroquel (quetiapine)
• Zyprexa (olanzapine)
• Symbyax (a pill that combines olanzapine with the
antidepressant fluoxetine)
Antipsychotic medications for bipolar
disorder
If you lose touch with reality during a manic or depressive episode,
an antipsychotic drug may be prescribed. They have also been
found to help with regular manic episodes. Antipsychotic
medications may be helpful if you have tried mood stabilizers
without success. Often, antipsychotic medications are combined with
a mood stabilizer such as lithium or valproic acid.
Antipsychotic medications used for bipolar disorder include:
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ariprazole (Abilify)
• Ziprasidone (Geodon)
• Clozapine (Clozaril)
Common side effects of antipsychotic
medications for bipolar disorder
• Drowsiness
• Weight gain
• Sexual dysfunction
• Dry mouth
• Constipation
• Blurred vision
Other medications for bipolar disorder
Other medications your doctor may recommend include
benzodiazepines, calcium channel blockers, and thyroid
medications.

Benzodiazepines
Mood stabilizers can take up to several weeks to reach their full
effect. While you’re waiting for the medication to kick in, your doctor
may prescribe a benzodiazepine to relieve any symptoms of
anxiety, agitation, or insomnia. Benzodiazepines are fast-acting
sedatives that work within 30 minutes to an hour. Because of their
high addictive potential, however, benzodiazepines should only be
used until your mood stabilizer or antidepressant begins to work.
Those with a history of substance abuse should be particularly
cautious.
Calcium channel blockers
Traditionally used to treat heart problems and high blood pressure,
they also have a mood stabilizing effect. They have fewer side
effects than traditional mood stabilizers, but they are also less
effective. However, they may be an option for people who can’t
tolerate lithium or anticonvulsants.

Thyroid medication
People with bipolar disorder often have abnormal levels of thyroid
hormone, especially rapid cyclers. Lithium treatment can also cause
low thyroid levels. In these cases, thyroid medication may be added
to the drug treatment regimen. While research is still ongoing,
thyroid medication also shows promise as a treatment for bipolar
depression with minimal side effects.
Bipolar disorder medication alone is not
enough
Bipolar medication is most effective when used in combination
with other bipolar disorder treatments, including:

Therapy. People who take medication for bipolar disorder tend to

recover much faster and control their moods much better if they
also get therapy. Therapy gives you the tools to cope with life’s
difficulties, monitor your progress, and deal with the problems
bipolar disorder is causing in your personal and professional life.

Exercise. Getting regular exercise can reduce bipolar disorder

symptoms and help stabilize mood swings. Exercise is also a safe
and effective way to release the pent-up energy associated with
the manic episodes of bipolar disorder.
Stable sleep schedule. Studies have found that insufficient sleep can
precipitate manic episodes in bipolar patients. To keep symptoms and
mood episodes to a minimum maintain a stable sleep schedule. It is also
important to regulate darkness and light exposure as these throw off
sleep-wake cycles and upset the sensitive biological clock in people with
bipolar disorder.

Healthy diet. Omega-3 fatty acids may lessen the symptoms of bipolar
disorder. Weight gain is a common side effect of many bipolar
medications, so it’s important to adopt healthy eating habits to manage
your weight. Avoid caffeine, alcohol, and drugs as they can adversely
interact with bipolar medications.

Social support network. Living with bipolar disorder can be challenging and
having a solid support system in place can make all the difference in your
outlook and motivation. Participating in a bipolar disorder support group
can give you the opportunity to share your experiences and learn from
others. Support from loved ones also makes a huge difference, so reach
out to your family and friends. They care about you and want to help.
Psychotherapy
The types of psychotherapy used to treat bipolar disorder include:

• Behavioral therapy. This focuses on behaviors that decrease stress.

• Cognitive therapy. This type of approach involves learning to identify
and modify the patterns of thinking that accompany mood shifts.
• Interpersonal Therapy. This involves relationships and aims to reduce
strains that the illness may place upon them.
• Social rhythm therapy. This helps you develop and maintain a normal
sleep schedule and more predictable daily routines.
Support Groups
also help people with bipolar disorder. You receive encouragement, learn
coping skills, and share concerns. You may feel less isolated as a result.
Family members and friends may also benefit from a support group. They
can gain a better understanding of the illness, share their concerns, and
learn how to best support loved ones with bipolar disorder.
Education
Education is another integral part of treatment for you and your family.
People with bipolar disorder (and their families) often benefit from learning
about the disorder -- its symptoms, early signs of an episode, and types of
treatment. This type of education can also help to come up with a plan in
case your insight or ability to see if system is compromised.
Also, taking these steps may help you cope with bipolar disorder:

• Establish routines. Regular sleep, eating, and activity appear to help

people with bipolar disorder manage their moods.
• Identify symptoms. Even though the early warning signs of an
approaching episode vary from person to person, together with a
psychiatrist you can identify what behavior changes signal the onset of
an episode for you. It may be needing less sleep to feel rested, buying
things you can’t afford or don't need, or becoming suddenly involved in
religion or new activities and interests.
Education
• Adapt. This can help you avoid embarrassing behavior during manic
episodes and set realistic goals for treatment. Your doctor can help you
prepare for possible future episodes and manage fear about having
more. A key part of adapting is to understand the types of stressors that
might increase the risk for manic or depressive episodes and the lifestyle
changes that can reduce them.
• Maintain a regular sleep pattern. Go to bed and wake up around the
same times each day. Changes in sleep can disrupt the normal
functioning of brain circuits involved in the processing of emotions,
potentially triggering mood episodes.
• Do not use alcohol or street drugs. These substances can trigger or
mimic mood episodes. They can also interfere with the effectiveness of
medication.
The importance of therapy for bipolar disorder
Research indicates that people who take medications for bipolar
disorder are more likely to get better faster and stay well if they also
receive therapy. Therapy can teach you how to deal with problems your
symptoms are causing, including relationship, work, and self-esteem
issues. Therapy will also address any other problems you’re struggling
with, such as substance abuse or anxiety.

Three types of therapy are especially helpful in the treatment of

bipolar disorder:
1. Cognitive-behavioral therapy
2. Interpersonal and social rhythm therapy
3. Family-focused therapy
Cognitive-behavioral therapy
In cognitive-behavioral therapy (CBT), you examine how your
thoughts affect your emotions. You also learn how to change
negative thinking patterns and behaviors into more positive ways of
responding. For bipolar disorder, the focus is on managing
symptoms, avoiding triggers for relapse, and problem-solving.
Interpersonal and social rhythm therapy
Interpersonal therapy focuses on current relationship issues and helps you
improve the way you relate to the important people in your life. By
addressing and solving interpersonal problems, this type of therapy reduces
stress in your life. Since stress is a trigger for bipolar disorder, this
relationship-oriented approach can help reduce mood cycling.

Social rhythm therapy is often combined with interpersonal therapy is often

combined with social rhythm therapy for the treatment of bipolar disorder.
People with bipolar disorder are believed to have overly sensitive biological
clocks, the internal timekeepers that regulate circadian rhythms. This clock is
easily thrown off by disruptions in your daily pattern of activity, also known
as your “social rhythms.” Social rhythm therapy focuses on stabilizing social
rhythms such as sleeping, eating, and exercising. When these rhythms are
stable, the biological rhythms that regulate mood remain stable too.
Family-focused Therapy
Living with a person who has bipolar disorder can be difficult,
causing strain in family and marital relationships. Family-focused
therapy addresses these issues and works to restore a healthy and
supportive home environment. Educating family members about the
disease and how to cope with its symptoms is a major component
of treatment. Working through problems in the home and improving
communication is also a focus of treatment.
Family-focused Therapy
Living with a person who has bipolar disorder can be difficult,
causing strain in family and marital relationships. Family-focused
therapy addresses these issues and works to restore a healthy and
supportive home environment. Educating family members about the
disease and how to cope with its symptoms is a major component
of treatment. Working through problems in the home and improving
communication is also a focus of treatment.
Complementary treatments for bipolar disorder
Most alternative treatments for bipolar disorder are complementary
treatments, meaning they should be used in conjunction with medication,
therapy, and lifestyle changes. Here are a few of the options that show
promise:

Light and dark therapy. Like social rhythm therapy, light and dark therapy
focuses on the sensitive biological clock in people with bipolar disorder. This
easily disrupted clock throws off sleep-wake cycles, a disturbance that can
trigger symptoms of mania and depression. Light and dark therapy
regulates these biological rhythms—and thus reduces mood cycling— by
carefully managing your exposure to light. The major component of this
therapy involves creating an environment of regular darkness by restricting
artificial light for ten hours every night.
Mindfulness meditation. Research has shown that mindfulness-based
cognitive therapy and meditation help fight and prevent depression, anger,
agitation, and anxiety. The mindfulness approach uses meditation, yoga, and
breathing exercises to focus awareness on the present moment and break
negative thinking patterns.

Acupuncture. Some researchers believe that acupuncture may help people

with bipolar disorder by modulating their stress response. Studies on
acupuncture for depression have shown a reduction in symptoms, and there
is increasing evidence that acupuncture may relieve symptoms of mania
also.
 MONITORING
Clinicians should measure bipolar
symptoms and be alert for
psychiatric adverse events of
treatment such as suicidality and
mood elevation. Self-assessments
tools like the PHQ-9 and MDQ and
other strategies can be used to
assess symptom severity
and monitor symptomatic
improvement in busy primary care
settings.
MONITORING
Medical monitoring should assess adverse effects of medication
such as sedation and weight gain and metabolic, endocrine, and
cardiovascular problems. Many patients with bipolar disorder can
be diagnosed in primary care. Less complex cases (with more
stable mood, less psychiatric comorbidity, and less complex
medication regimens) may also be effectively treated in primary
care, although more complex cases (with unstable mood, complex
comorbidities, and complicated medication regimens) may need
psychiatric referral.
Bipolar disorder is often diagnosed in young people, typically first
appearing in the late teen years or early adulthood. It is a lifelong,
incurable condition, but symptoms can usually be successfully
managed with medication, such as antidepressants, mood stabilizers,
and antipsychotics, as well as therapy or some form of counseling.
The prognosis for bipolar disorder varies depending on which type of
bipolar disorder you have.

Bipolar I is considered more severe, with episodes of mania or

depression that can require hospitalization. About 70 to 80% of
people with Bipolar I are treated successfully. However, 20 to
30% will continue to have symptoms, including mood swings,
and may have more trouble maintaining relationships and
keeping jobs.
• Bipolar II is considered less severe, with no full-blown manic
episodes. Treatment is about 85% effective for this
condition. However, about 15% of affected individuals
continue to have symptoms. About 5 to 15% of bipolar II
patients may experience rapid cycling between mania and
depression. This bipolar disorder complication results in a
poorer prognosis.

Also affecting prognosis: having another mental health disorder along

with bipolar disorder, such as an anxiety or eating disorder. Such
patients have a higher likelihood of relapse than individuals without co-
occurring conditions.
People with bipolar disorders are at a relatively high risk for
suicide. Annually, about 10 to 17% percent of those with a bipolar
disorder diagnosis commit suicide. Many more attempt it.

Psychiatrists often recommend medication even when symptoms

have abated, in order to prevent recurrence. However, some
people with bipolar disorder prefer no medication, especially when
they are feeling well. Some treatments that don’t involve
medication are available as an alternative, such as transcranial
magnetic stimulation (a noninvasive procedure that stimulates
nerve cells in the brain).

In general, experts say those who can follow a long-term

treatment plan, usually including medication, therapy and a
healthy lifestyle, can live well.
 ROLE OF
PHARMACISTS
Pharmacists have a role in promoting the importance of medication
adherence and educating patients about how to recognize triggers for their
mood episodes. Pharmacists can use motivational interviewing techniques to
help patients become comfortable with their diagnosis, educate them about
the effectiveness and adverse effects of their medications, and encourage
them to take responsibility for managing their condition. Reviewing optimal
administration times and potential side effects with patients will help
pharmacists improve adherence in patients and reduce the number of
hospital visits.

Pharmacists play a role in ensuring proper dosing regimens, checking for

drug interactions, and monitoring for potential drug toxicity. When counseling
patients, pharmacists should review optimal administration times and
potential side effects to make certain that the patient has a comprehensive
understanding of how to manage symptoms.
COUNSELING POINTS
The primary goal of all bipolar therapy is remission from episodes of
mania and depression to enable the patient to lead a functional life. The
first line of defense in treating bipolar disorder is pharmacologic
intervention. Medications generally are prescribed specifically for the
treatment of both manic and depressive episodes. Currently, several
medications are used to treat bipolar episodes.
Pharmacists can have an impact on patient adherence in any disease state by
providing education through consultation with their patients.

The importance of counseling patients cannot be stressed enough, especially in

a population that uses mental health medications. The side effects and strict
regimens associated with these medications can often deter patients from their
use. However, it is our job as pharmacists to inform these patients of what to
expect while taking these medications.
Side effects associated with medications can have a significant impact on
patient adherence and should also be explained during patient consultation.
Patients should be informed of what to expect when taking a medication and
the importance of following the entire prescribed regimen. Often, patients
begin to feel better and decide that the medication is no longer needed to
help them. What they may not comprehend is that this is a result of their
medication, and that by stopping the medication prematurely, they will revert
to their usual behavior.
Therefore, it is extremely important that patients are informed to continue
taking the medication even if they do start to feel better. The abrupt
discontinuation of certain medications that require dose tapering could also
have a negative impact on patients. Patients should also be aware that
stopping these medications “cold turkey” could produce unwanted side
effects. Our goal as pharmacists is to improve patient health and quality of
life, so counseling patients on these important side effects is an example of
how we can achieve that goal.
Click the video: Bipolar Disorder