Welcome to the Oxford University Psychiatry Podcast series brought to you by Charlotte Allen and Daniel Maun.
We are advanced trainees in the Oxford Dictionary and today we're going to talk about bipolar disorder previously known as manic depression.
So, Charlotte, maybe you could begin by telling us what the key features of bipolar disorder are.
Bipolar disorder is a mood disorder characterised by unstable mood where patients
have periods of high mood known as mania and low mood known as depression.
What are the symptoms of mania? Mania is really elevated mood,
which is too cheerful to be normal or might be seen as irritability or other symptoms of mania include increased energy,
increased self-esteem, reduced concentration and changes in behaviour.
So people might need a lot less sleep. They might have an increase in their sex drive and they might also have psychotic symptoms.
Right. What about the symptoms of depression? Well, those are similar to depression in people who get unipolar depression.
The core features are low mood and anhedonia, and it's accompanied again by changes in sleep.
But it also appetite, appetite changes. You might get reduced appetite or increased appetite, weight changes and feelings of guilt,
worthlessness and low self-esteem with a negative world view.
And people often get very preoccupied by death and dying. Right.
So two very distinct clinical pictures there.
So what is the criteria for diagnosing bipolar disorder in ICD 10?
That there needs to be at least two episodes of mood problems, one of which must be elevated mood.
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.
And DSM also has subclasses of bipolar disorder called bipolar one and bipolar two.
Bipolar one is anybody who's had a manic episode.
And Bipolar two is classified as at least one hypo manic episode, in addition to at least one depressive episode.
Thank you. What's the difference between mania and hypomania, then?
For a diagnosis of mania? The symptoms need to cause market disruption and functioning.
So that's at work or at home or in somebody's social life and in mania.
The symptoms need to be present for at least a week or a shorter period.
If the symptoms lead to hospital admission, the hypomania, the symptoms need to be present for at least four days,
but they shouldn't be severe enough to actually interfere with function.
Right. So there's the time period which is crucial, but also the disturbance of function, which is another marker of mania.
Yes, that's right. So people with bipolar disorder always experience these extremes of mood.
Not always. It's possible to get a mixed affective state where the symptoms of mania and depression occur within the same episode.
When making a diagnosis of bipolar disorder, are there any differential diagnosis you would need to consider?
Well, there are several other things that you could consider.
Cycler SAMEA is one, as well as schizoaffective disorder and borderline personality disorder.
If someone presents with mania later on in life,
you should also consider an organic cause and exclude that before making a diagnosis of bipolar disorder.
OK, thanks. And just making another point about assessment,
I think that it's really important to take an accurate history of somebody presenting with unipolar depression to exclude potential bipolar disorder.
What do you think about that? I think that that's a good point,
because people who are treated for unipolar depression actually may have had manic or hypo manic episodes in the past.
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.
Thank you. So how common is bipolar disorder?
It has about one percent lifetime prevalence and it's equal in men and women.
Most people develop the disorder in their late teens or early 20s.
And as you just alluded to, I think it's important to recognise that it's probably underdiagnosed and it's
probably more common and something we ought to be asking about a lot more.
What causes bipolar disorder? There are a range of causes.
Firstly, genetic factors are very important.
So the risks of first degree relatives is between 10 and 15 percent, which is much higher than the risk in the general population.
Other things include drugs, so street drugs can trigger particularly manic episodes and also antidepressants.
And people with a predisposition to bipolar disorder can also trigger manic episodes.
There are also environmental triggers. So work related stress, people who aren't sleeping very well, for example,
due to shift work or possibly stress related hormonal responses can all trigger episodes.
Right. So you've given us a clear understanding of what bipolar disorder is and what causes it.
So if it's all right, we can move on to management. OK, starting with acute management, how should you manage mania?
Well, first, you need to do a physical examination. It might not always be easy.
If somebody has got florid manic symptoms, but it's important to exclude organic causes to start off with.
If somebody is manic, particularly if they're aggressive or violent, then medication is likely to be important.
And benzodiazepines and antipsychotics are the first line treatments for mania.
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.
And because its action is slower, benzodiazepines and antipsychotics are often used in preference.
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,
things like superglue, and also to address any psychosocial stressors, anything that might be worrying the patient or contributing to the episode.
Well, it's so actually when somebody presents with a cute Manea,
you take the approach of polypharmacy using potentially both are not psychotic and some benzodiazepines potentially.
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.
Some clinicians talk about the importance of sleep in the acute phase and that sleep is restorative
and that it can be quite difficult getting patients who are acutely manic off to sleep.
So maybe that extra medication is required in the hospital settings, for instance.
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.
And I'm just wondering how you would manage depression differently from what you've just outlined.
A keep mania, OK,
with depression really is the same principles of biopsychosocial psychosocial management that you would use for somebody with unipolar depression.
I think the main difference is to be careful when initiating antidepressant treatments and using lower doses,
perhaps to start off with and a careful titration to avoid the risk of a switch to mania.
And ideally, you'd want to use antidepressants in conjunction with a mood stabiliser to reduce the risk of a manic switch.
Right. So bipolar depression is thought of as quite a different entity to unipolar depression.
Mm hmm. And you can't use the same treatments for the two conditions.
That's an interesting point in bipolar disorder.
What risks do you need to think about as part of your management?
Well, there are potentially quite a lot of risks, and these obviously vary depending on the presentation,
whether it's a manic presentation or presentation of depression in mania.
You might consider the risk of self neglect, of overspending, of social embarrassment.
If somebody is very disinhibited and doing things that they wouldn't usually do sexually,
disinhibition would come into that or aggression towards other people.
It's also important to think about driving and people who who have got manic symptoms.
Obviously, this is not allowed by the DVLA and if somebody is driving,
that can present a risk to themselves and also to other people in depression, the risk to others are often much less.
But the risk of self neglect and suicide might be very high, and those are key risks that need to be considered.
Thank you. It seems it's very important to do a comprehensive risk assessment, both for key mania and depression.
That's right, yes. So you've helpfully outlined the medications that are used in the acute setting for both mania and depression.
Are there any medications that are useful in the medium to long term to prevent relapse?
Yes, there are. These are the anti manics or mood stabilisers.
And this includes lithium, sodium valproate and other drugs, things like energy.
Could you say a bit more about the use of lithium?
Because as I understand it, that's the the sort of the the oldest mood stabiliser potentially the most frequently used, is that right?
That's right. Yes. It's a very effective drug for long term prophylaxis of bipolar disorder.
And it's particularly useful at preventing the manic episodes,
if it's used in needs to be used with careful monitoring because of potential side effects.
In the short term, patients need to have regular lithium levels while stabilising the dose.
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.
There are long term side effects of the lithium as well, and those are things like renal disease and hypothyroidism.
So it's important to warn patients about that and to continue monitoring in the long
term to be aware of if these problems are starting and to be able to intervene early.
The other thing about lithium is that although it very effective,
there is a risk of toxicity so it can interact with other medications and patients need to be warned about that.
And if somebody gets dehydrated, for example, and they're on lithium,
then there is a risk of toxicity and patients need to know what to do to other things that are important.
One is that if somebody stops lithium, suddenly there is a risk of manic relapse.
So that's not advisable and it's something to warn people about. And in women, there's a risk of teratogenic city.
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.
And I understand that the the NHS have designed a pack that they give patients when they start lithium.
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.
And it's important that people do take that information in and take it on board.
So, yeah, you're right, the lithium pack, which has got all that information,
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.
Thank you. Could you say a bit more about treatment with valproate then?
Yes. So this is also an effective mood stabiliser. It has a different side effect profile to lithium.
Things like nausea and vomiting are very common, can also cause abnormal liver function tests.
So that's something to monitor like lithium.
It can cause weight gain. And there are also some other rarer things like leukaemia and thrombocytopenia that can be found with Belpre weight.
It is teratogenic as well. And actually the risk of terror in a city with valproate is even higher than it is with lithium.
Right. So you've covered lithium and valproate,
which are potentially the two most common mood stabilisers used in the long term prophylaxis of people with bipolar disorder.
But what what options do we have for patients who have maybe tried these and they haven't been effective?
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?
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.
And in some patients, that's a very good combination.
But for people who don't want to take this class of drugs at all, then another option is to use antipsychotic medication.
So olanzapine or risperidone can be used as long term prophylaxis against bipolar disorder.
And thirdly, there are other mood stabilisers, such as carbamazepine or LaMotte's gene,
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.
That's right. It's psychological therapy helpful in the management of bipolar disorder.
Yes, psychological therapy does have a place in the management of bipolar disorder.
First of all, there's psycho education and this is about helping patients to learn about their disorder,
learn about how it affects them, and to recognise the early warning signs that they might be developing mania or depression.
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.
Psychological therapies also used to manage depressive symptoms, so CBT for depression can be really helpful.
But overall, it doesn't reduce the number of episodes. It helps with symptomatic relief.
Other therapies could also be considered. So family therapy might be indicated if there's difficulty in the family that needs help.
Thank you. What about social interventions? There are a number of things that patients can do which can be really helpful.
The first is trying to encourage a regular routine and having regular sleeping habits.
Limiting drug and alcohol consumption can also be really useful because that can make episodes more frequent and much worse.
If somebody is able to have regular employment that helps to reduce the number of episodes
and that can be very stabilising and some people might benefit from their support.
So there are groups such as the Bipolar Fellowship, which can provide help and support in a really useful way.
You've mentioned both in psychological interventions and social interventions, the importance of reducing the risk of further relapse.
And it seems that a lot of the management is geared towards that.
And what are the chances are of someone with bipolar disorder having another having a relapse?
The short answer is that the chances of relapse are actually quite high.
So it's a recurrent disorder and patients who have one episode are likely to have another episode.
But the frequency of episodes varies quite considerably between individuals.
So some people might have many episodes in one year.
Other people might have long gaps of up to 10 years between episodes.
So it can be very variable. It's important to remember that in between episodes, mood and also cognitive function returns to normal.
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.
And in terms of thinking about prognosis for individuals, people who use alcohol,
those who have very prominent psychotic symptoms and people who find it difficult to be compliant
with treatments and don't have regular employment are all more likely to have a poor prognosis.
The other thing that's worth mentioning is that actually 10 percent of people with bipolar disorder die through suicide.
And so that's something to bear in mind, that there's a reason why the risk assessment is so important.
That's a very significant percentage of people dying through society, isn't it?
Yes, it really is. As I understand it as well, the nature of the disorder is that as the disorder progresses,
as people get older, the relapses tend to become more frequent or or more severe.
Is that is that correct? They can do, but not for everybody.
So some people might actually have fewer episodes, right, when they get older?
I think it really depends on the individual. OK, thank you.
So you've really given us a very good insight into both the assessment and management of bipolar disorder.
Could you recommend any further resources for people who are more interested in this condition?
There are many resources available. First, there's the Royal College of Psychiatrists website, which has got further information on it,
or there's more detailed information in standard textbooks such as the shorter Oxford textbook of psychiatry.
And there's also the nice guidelines on bipolar disorder.
And they give a very clear overview of the sort of treatment that patients should expect and that professionals should expect to deliver.
From another perspective, there's a very interesting book, which is a biography by Kay Redfield Jamison called An Unquiet Mind,
and she is a clinical psychologist who's got bipolar disorder.
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.
Thank you for listening to the Oxford University psychiatry podcast about bipolar disorder.
We hope you found it useful and we hope that you listen again to another podcast.
Thank you. Goodbye.