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Welcome to the Oxford University Psychiatry Podcast series brought to you by Charlotte Allen and Daniel Maun.

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We are advanced trainees in the Oxford Dictionary and today we're going to talk about bipolar disorder previously known as manic depression.

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So, Charlotte, maybe you could begin by telling us what the key features of bipolar disorder are.

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Bipolar disorder is a mood disorder characterised by unstable mood where patients

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have periods of high mood known as mania and low mood known as depression.

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What are the symptoms of mania? Mania is really elevated mood,

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which is too cheerful to be normal or might be seen as irritability or other symptoms of mania include increased energy,

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increased self-esteem, reduced concentration and changes in behaviour.

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So people might need a lot less sleep. They might have an increase in their sex drive and they might also have psychotic symptoms.

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Right. What about the symptoms of depression? Well, those are similar to depression in people who get unipolar depression.

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The core features are low mood and anhedonia, and it's accompanied again by changes in sleep.

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But it also appetite, appetite changes. You might get reduced appetite or increased appetite, weight changes and feelings of guilt,

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worthlessness and low self-esteem with a negative world view.

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And people often get very preoccupied by death and dying. Right.

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So two very distinct clinical pictures there.

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So what is the criteria for diagnosing bipolar disorder in ICD 10?

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That there needs to be at least two episodes of mood problems, one of which must be elevated mood.

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And there's got to be a complete recovery in between the episodes in DSM, you can actually diagnose bipolar disorder after a single manic episode.

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And DSM also has subclasses of bipolar disorder called bipolar one and bipolar two.

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Bipolar one is anybody who's had a manic episode.

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And Bipolar two is classified as at least one hypo manic episode, in addition to at least one depressive episode.

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Thank you. What's the difference between mania and hypomania, then?

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For a diagnosis of mania? The symptoms need to cause market disruption and functioning.

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So that's at work or at home or in somebody's social life and in mania.

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The symptoms need to be present for at least a week or a shorter period.

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If the symptoms lead to hospital admission, the hypomania, the symptoms need to be present for at least four days,

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but they shouldn't be severe enough to actually interfere with function.

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Right. So there's the time period which is crucial, but also the disturbance of function, which is another marker of mania.

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Yes, that's right. So people with bipolar disorder always experience these extremes of mood.

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Not always. It's possible to get a mixed affective state where the symptoms of mania and depression occur within the same episode.

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When making a diagnosis of bipolar disorder, are there any differential diagnosis you would need to consider?

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Well, there are several other things that you could consider.

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Cycler SAMEA is one, as well as schizoaffective disorder and borderline personality disorder.

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If someone presents with mania later on in life,

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you should also consider an organic cause and exclude that before making a diagnosis of bipolar disorder.

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OK, thanks. And just making another point about assessment,

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I think that it's really important to take an accurate history of somebody presenting with unipolar depression to exclude potential bipolar disorder.

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What do you think about that? I think that that's a good point,

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because people who are treated for unipolar depression actually may have had manic or hypo manic episodes in the past.

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And if you don't ask about that and don't recognise that, then the treatment is actually incorrect and people are unlikely to get fully better.

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Thank you. So how common is bipolar disorder?

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It has about one percent lifetime prevalence and it's equal in men and women.

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Most people develop the disorder in their late teens or early 20s.

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And as you just alluded to, I think it's important to recognise that it's probably underdiagnosed and it's

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probably more common and something we ought to be asking about a lot more.

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What causes bipolar disorder? There are a range of causes.

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Firstly, genetic factors are very important.

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So the risks of first degree relatives is between 10 and 15 percent, which is much higher than the risk in the general population.

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Other things include drugs, so street drugs can trigger particularly manic episodes and also antidepressants.

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And people with a predisposition to bipolar disorder can also trigger manic episodes.

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There are also environmental triggers. So work related stress, people who aren't sleeping very well, for example,

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due to shift work or possibly stress related hormonal responses can all trigger episodes.

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Right. So you've given us a clear understanding of what bipolar disorder is and what causes it.

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So if it's all right, we can move on to management. OK, starting with acute management, how should you manage mania?

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Well, first, you need to do a physical examination. It might not always be easy.

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If somebody has got florid manic symptoms, but it's important to exclude organic causes to start off with.

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If somebody is manic, particularly if they're aggressive or violent, then medication is likely to be important.

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And benzodiazepines and antipsychotics are the first line treatments for mania.

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Lithium is also licenced in acute mania, but it can take several days up to five or even longer amount of days to actually reach a therapeutic level.

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And because its action is slower, benzodiazepines and antipsychotics are often used in preference.

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And somebody with Manea is important to try and re-establish a normal pattern of sleep, and to do that, it might be necessary to use that drugs,

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things like superglue, and also to address any psychosocial stressors, anything that might be worrying the patient or contributing to the episode.

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Well, it's so actually when somebody presents with a cute Manea,

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you take the approach of polypharmacy using potentially both are not psychotic and some benzodiazepines potentially.

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But I'd always be cautious about polypharmacy and I'd start off with one medication first and add in the second only if it was really necessary.

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Some clinicians talk about the importance of sleep in the acute phase and that sleep is restorative

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and that it can be quite difficult getting patients who are acutely manic off to sleep.

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So maybe that extra medication is required in the hospital settings, for instance.

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That might be a good example of when two drugs are needed. You talked about how different the clinical picture was of depression in contrast to mania.

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And I'm just wondering how you would manage depression differently from what you've just outlined.

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A keep mania, OK,

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with depression really is the same principles of biopsychosocial psychosocial management that you would use for somebody with unipolar depression.

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I think the main difference is to be careful when initiating antidepressant treatments and using lower doses,

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perhaps to start off with and a careful titration to avoid the risk of a switch to mania.

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And ideally, you'd want to use antidepressants in conjunction with a mood stabiliser to reduce the risk of a manic switch.

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Right. So bipolar depression is thought of as quite a different entity to unipolar depression.

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Mm hmm. And you can't use the same treatments for the two conditions.

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That's an interesting point in bipolar disorder.

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What risks do you need to think about as part of your management?

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Well, there are potentially quite a lot of risks, and these obviously vary depending on the presentation,

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whether it's a manic presentation or presentation of depression in mania.

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You might consider the risk of self neglect, of overspending, of social embarrassment.

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If somebody is very disinhibited and doing things that they wouldn't usually do sexually,

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disinhibition would come into that or aggression towards other people.

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It's also important to think about driving and people who who have got manic symptoms.

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Obviously, this is not allowed by the DVLA and if somebody is driving,

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that can present a risk to themselves and also to other people in depression, the risk to others are often much less.

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But the risk of self neglect and suicide might be very high, and those are key risks that need to be considered.

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Thank you. It seems it's very important to do a comprehensive risk assessment, both for key mania and depression.

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That's right, yes. So you've helpfully outlined the medications that are used in the acute setting for both mania and depression.

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Are there any medications that are useful in the medium to long term to prevent relapse?

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Yes, there are. These are the anti manics or mood stabilisers.

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And this includes lithium, sodium valproate and other drugs, things like energy.

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Could you say a bit more about the use of lithium?

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Because as I understand it, that's the the sort of the the oldest mood stabiliser potentially the most frequently used, is that right?

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That's right. Yes. It's a very effective drug for long term prophylaxis of bipolar disorder.

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And it's particularly useful at preventing the manic episodes,

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if it's used in needs to be used with careful monitoring because of potential side effects.

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In the short term, patients need to have regular lithium levels while stabilising the dose.

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And you also need to warn patients about the risk of poly urea weight gain and tremor, which can all happen fairly soon after starting the drug.

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There are long term side effects of the lithium as well, and those are things like renal disease and hypothyroidism.

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So it's important to warn patients about that and to continue monitoring in the long

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term to be aware of if these problems are starting and to be able to intervene early.

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The other thing about lithium is that although it very effective,

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there is a risk of toxicity so it can interact with other medications and patients need to be warned about that.

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And if somebody gets dehydrated, for example, and they're on lithium,

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then there is a risk of toxicity and patients need to know what to do to other things that are important.

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One is that if somebody stops lithium, suddenly there is a risk of manic relapse.

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So that's not advisable and it's something to warn people about. And in women, there's a risk of teratogenic city.

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So again, something to mention at the start of treatment. OK, there's quite a lot of information there about lithium you'd need to give to patients.

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And I understand that the the NHS have designed a pack that they give patients when they start lithium.

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Yes. Which is actually really good, because if you're giving all this information to somebody in clinic, it's a lot to take in.

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And it's important that people do take that information in and take it on board.

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So, yeah, you're right, the lithium pack, which has got all that information,

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is very useful and that people can refer back to it and know what to do if there's a problem or if they're concerned.

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Thank you. Could you say a bit more about treatment with valproate then?

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Yes. So this is also an effective mood stabiliser. It has a different side effect profile to lithium.

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Things like nausea and vomiting are very common, can also cause abnormal liver function tests.

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So that's something to monitor like lithium.

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It can cause weight gain. And there are also some other rarer things like leukaemia and thrombocytopenia that can be found with Belpre weight.

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It is teratogenic as well. And actually the risk of terror in a city with valproate is even higher than it is with lithium.

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Right. So you've covered lithium and valproate,

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which are potentially the two most common mood stabilisers used in the long term prophylaxis of people with bipolar disorder.

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But what what options do we have for patients who have maybe tried these and they haven't been effective?

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Or for those who really don't want to take the risks or can't cope with the side effects, what other options are there out there?

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Well, there are lots of other options. First, if one, if either lithium mobile hasn't been effective on their own, they can actually be used together.

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And in some patients, that's a very good combination.

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But for people who don't want to take this class of drugs at all, then another option is to use antipsychotic medication.

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So olanzapine or risperidone can be used as long term prophylaxis against bipolar disorder.

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And thirdly, there are other mood stabilisers, such as carbamazepine or LaMotte's gene,

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which can also be very useful and in the right patients, very effective. So there's quite a battery of different medications that we have available.

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That's right. It's psychological therapy helpful in the management of bipolar disorder.

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Yes, psychological therapy does have a place in the management of bipolar disorder.

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First of all, there's psycho education and this is about helping patients to learn about their disorder,

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learn about how it affects them, and to recognise the early warning signs that they might be developing mania or depression.

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And that's really important because then they can take medication early or intervene to actually stop an episode getting worse or becoming a problem.

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Psychological therapies also used to manage depressive symptoms, so CBT for depression can be really helpful.

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But overall, it doesn't reduce the number of episodes. It helps with symptomatic relief.

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Other therapies could also be considered. So family therapy might be indicated if there's difficulty in the family that needs help.

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Thank you. What about social interventions? There are a number of things that patients can do which can be really helpful.

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The first is trying to encourage a regular routine and having regular sleeping habits.

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Limiting drug and alcohol consumption can also be really useful because that can make episodes more frequent and much worse.

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If somebody is able to have regular employment that helps to reduce the number of episodes

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and that can be very stabilising and some people might benefit from their support.

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So there are groups such as the Bipolar Fellowship, which can provide help and support in a really useful way.

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You've mentioned both in psychological interventions and social interventions, the importance of reducing the risk of further relapse.

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And it seems that a lot of the management is geared towards that.

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And what are the chances are of someone with bipolar disorder having another having a relapse?

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The short answer is that the chances of relapse are actually quite high.

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So it's a recurrent disorder and patients who have one episode are likely to have another episode.

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But the frequency of episodes varies quite considerably between individuals.

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So some people might have many episodes in one year.

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Other people might have long gaps of up to 10 years between episodes.

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So it can be very variable. It's important to remember that in between episodes, mood and also cognitive function returns to normal.

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And even if people do have a pattern of recurrent episodes, they might still live very normal lives and have high profile jobs in between episodes.

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And in terms of thinking about prognosis for individuals, people who use alcohol,

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those who have very prominent psychotic symptoms and people who find it difficult to be compliant

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with treatments and don't have regular employment are all more likely to have a poor prognosis.

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The other thing that's worth mentioning is that actually 10 percent of people with bipolar disorder die through suicide.

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And so that's something to bear in mind, that there's a reason why the risk assessment is so important.

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That's a very significant percentage of people dying through society, isn't it?

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Yes, it really is. As I understand it as well, the nature of the disorder is that as the disorder progresses,

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as people get older, the relapses tend to become more frequent or or more severe.

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Is that is that correct? They can do, but not for everybody.

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So some people might actually have fewer episodes, right, when they get older?

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I think it really depends on the individual. OK, thank you.

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So you've really given us a very good insight into both the assessment and management of bipolar disorder.

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Could you recommend any further resources for people who are more interested in this condition?

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There are many resources available. First, there's the Royal College of Psychiatrists website, which has got further information on it,

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or there's more detailed information in standard textbooks such as the shorter Oxford textbook of psychiatry.

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And there's also the nice guidelines on bipolar disorder.

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And they give a very clear overview of the sort of treatment that patients should expect and that professionals should expect to deliver.

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From another perspective, there's a very interesting book, which is a biography by Kay Redfield Jamison called An Unquiet Mind,

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and she is a clinical psychologist who's got bipolar disorder.

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And I think her biography gives a really good insight into her experiences and of talking about what it's like to live with bipolar disorder.

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Thank you for listening to the Oxford University psychiatry podcast about bipolar disorder.

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We hope you found it useful and we hope that you listen again to another podcast.

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Thank you. Goodbye.