PsychoTropical Research - Dr Ken Gillman, Serotonin Syndrome, Mirtazapine, Dual Action Drugs. Bipolar Disorder - Management of.

PsychoTropicalResearch, serotonin and serotonin syndrome research.

Bipolar Disorder - Management of

Bipolar Disorder - Management of

Date Created: 14/01/1999   Last Modified: 11/02/2003   Last Checked: 11/02/2003

Bipolar Disorder is frequently unrecognised and it is useful to enquire about family history and whether any close relatives have been treated, especially with Lithium. Any signs of spells of diminished need for sleep and strong feelings of well being may be significant pointers.

The recognition of potential bipolarity is worthwhile, indeed important, because it changes the treatment indications, both for maintenance treatment and for the depressive phase. There is now evidence that some treatments can exacerbate the illness and promote rapid cycling (ie more frequent episodes of illness). See note on 'Bipolar Disorder, consensus treatment guidelines'

This potential for causing a worsening of the whole course of the illness is a serious matter. Sub-optimal treatment can possibly make the course of the illness worse.

In my opinion such factors suggest the wisdom and prudence of referring all bipolar, or suspected bipolar, cases for specialist management. (Management guidelines recently published endorse that view).

Try to keep reminding yourself that at least 25% of patients presenting with major (endogenous) depression will turn out to have bipolar disorder (manic depressive illness). Indications of bipolarity are:-

  • first illness in 20’s vs 40’s (ave age at onset, bipolar 29, unipolar 46),
  • post-partum major depression
  • episodes of major depression lasting less than 3 months
  • > 3 episodes of major depression, or any episode of psychotic depression
  • antidepressant induced 'hypomania'
  • lack of response to 2 or more adequate trials of drugs for 'major depression'
  • high socio-economic group for patient (and close relatives),
  • family history of bipolar disorder and depression of early onset (see above),
  • family or personal history of panic disorder or migraine.
  • the presence of migraine in the patient or first degree relatives

Angst's 30 year follow up data (below) are a reminder of the real risks in this group; most striking is the greatly raised Standard Mortality Ratio; that is 27 (twenty seven) times for depression.

Angst, J. Long-term FU
Uni-polar Bi-polar
Recovered 25 16
Recurrent 49 62
Suicide 14 8.2
Onset, age 46 29
St Mortality R (1) 27 12
Suicide % 7 / 18 5 / 13
(Rx / No Rx)