Bipolar Disorder

Bipolar Mood Disorders

Three major types of bipolar disorder are described by the DSM-5 (APA, 2013): bipolar I,
bipolar II, and cyclothymia. Bipolar I disorder (BD I), which was previously known as manic
depression, is characterized by a single or recurrent manic episode. A person with bipolar
disorder often experiences mood states that vacillate between depression and mania; that is,
the person’s mood is said to alternate from one emotional extreme to the other (in contrast to
unipolar, which indicates a persistently sad mood). A depressive episode is not necessary but
commonly present for the diagnosis of bipolar I disorder.

Bipolar I, Bipolar II, and Cyclothymic Disorder

Bipolar II disorder is characterized by single (or recurrent) hypomanic episodes and
depressive episodes, instead of the more severe manic episodes characteristic of bipolar I
disorder.
Another type of bipolar disorder is cyclothymic disorder, characterized by numerous
and alternating periods of hypomania and depression, lasting at least two years. To qualify for
cyclothymic disorder, the periods of depression cannot meet the full diagnostic criteria for a
diagnosis of major depressive disorder; the person must experience symptoms at least half the
time with no more than two consecutive, symptom-free months, and the symptoms must cause
significant distress or impairment.

Factors Contributing to Bipolar Disorder

1.1 Genetics
Bipolar disorder often runs in families, with 80 to 90 percent of affected individuals having
relatives with mood disorders, demonstrating a strong genetic link24. Family history increases
the likelihood of developing the disorder4.

1.2 Environmental Factors

Stressful life events, such as relationship breakdowns, abuse, or the death of a loved one, can
trigger episodes, particularly in those with a genetic predisposition24.

1.3 Neurotransmitter Imbalances

Chemical imbalances involving neurotransmitters like norepinephrine, serotonin, and dopamine
may contribute to the disorder's symptoms6.

1.4 Other Contributing Factors

Factors such as sleep disturbances, substance misuse, and physical health issues can
exacerbate or trigger bipolar symptoms

Non-Psychiatric Illnesses Associated with Bipolar Disorder

Several non-psychiatric illnesses can mimic or overlap with bipolar disorder, including:
● Endocrine Diseases: Conditions like thyroid disorders can present symptoms similar to
mood swings.
 ● Neurological Conditions: Disorders such as epilepsy and multiple sclerosis may exhibit
mood-related symptoms.
● Vitamin Deficiencies: Low levels of certain vitamins, particularly B12 or folate, can
affect mood and energy.

Connections Between Bipolar Disorder and Other Conditions

Bipolar disorder frequently co-occurs with various mental and physical health conditions, such
as:
● Mental Health Disorders: Common comorbidities include anxiety disorders,
attention-deficit/hyperactivity disorder (ADHD), and substance use disorders.
● Physical Health Conditions: Those with bipolar disorder may experience higher rates
of gastric ulcers, heart disease, and autoimmune disorders like rheumatoid arthritis.

Risk Factors for Bipolar Disorder (Global Context)

Bipolar disorder is considerably less common than major depressive disorder. In the United
States, one out of every 167 people meets the criteria for bipolar disorder each year, and one
out of 100 meets the criteria within their lifetime (Merikangas et al., 2011). The rates of BD are
higher in men than in women, and about half of those with this disorder report onset before the
age of 25 (Merikangas et al., 2011). Around 90% of those with bipolar disorder have a comorbid
disorder, most often an anxiety disorder or a substance abuse problem. Unfortunately, close to
half of the people suffering from bipolar disorder do not receive treatment (Merikangas & Tohen,
2011). Suicide rates are extremely high among those with bipolar disorder: around 36% of
individuals with this disorder attempt suicide at least once in their lifetime (Novick, Swartz, &
Frank, 2010), and between 15–19% complete suicide (Newman, 2004).

Philippines
According to the World Health Organization (2020), 1,145,871 Filipinos suffer from Major
Depressive Disorder, 520,614 are diagnosed with Bipolar Disorder, and annually, 5,570 suicide
rates are completed. These statistics are crucial in providing proper treatment and implementing
prevention programs for each mental disorder. However, a clear exigency in mental health
professionals is evident in spite of the existence of primary care services in the Philippine health
care system. It was found that among 100 million Filipino people, there are only about 133
practicing psychologists, 516 psychiatric nurses, and 548 psychiatrists in the country [1].

Epidemiology of Bipolar Disorders

Bipolar disorder is the sixth leading cause of disability worldwide and has a lifetime
prevalence of about 1%-3% in the general population. However, a reanalysis of data from the
National Epidemiological Catchment Area survey in the United States suggested that 0.8% of
the population experience a manic episode at least once (the diagnostic threshold for Bipolar I)
and a further 0.5% have a hypomanic episode (the diagnostic threshold for bipolar II or
cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a
short time period, an additional 5.1% of the population, adding up to a total of 6.4%, were
classified as having a bipolar spectrum disorder. A more recent analysis of data from a second
U.S. National Comorbidity Survey found that 1% met lifetime prevalence criteria for Bipolar I,
1.1% for Bipolar II, and 2.4% for subthreshold symptoms.

A recent cross-national study sample of more than 60,000 adults from 11 countries,
estimated the worldwide prevalence of BD at 2.4%, with BD I constituting 0.6% of this rate
(Merikangas et al., 2011). In this study, the prevalence of BD varied somewhat by country.
Whereas the United States had the highest lifetime prevalence (4.4%), India had the lowest
(0.1%). Variation in prevalence rates was not necessarily related to socioeconomic status
(SES), as in the case of Japan, a high-income country with a very low prevalence rate of BD
(0.7%).

Treatment for Bipolar Disorder

Psychotherapy aims to assist a person with bipolar disorder in accepting and
understanding their diagnosis, coping with various types of stress, improving their interpersonal
relationships, and recognizing prodomal symptoms before full-blown recurrence. Cognitive
behavioral therapy, family-focused therapy, and psychoeducation have the most evidence for
efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and CBT
appear the most effective in regard to residual depressive symptoms. Most studies have been
based only on Bipolar I, however, and treatment during the acute phase can be a particular
challenge. Some clinicians emphasize the need to talk with individuals experiencing mania to
develop a therapeutic alliance in support of recovery.

Medication
Lithium (Lithobid, Eskalith) is effective at stabilizing mood and preventing the extreme
highs and lows of bipolar disorder. Periodic blood tests are required because lithium can cause
thyroid and kidney problems. Common side effects include restlessness, dry mouth, and
digestive issues. Lithium levels should be monitored carefully to ensure the best dosage and
watch for toxicity. Lithium is used for continued treatment of bipolar depression and for
preventing relapse. There is evidence that lithium can lower the risk of suicide but the FDA has
not granted approval specifically for this purpose.

Other mood-stabilizing medications and anticonvulsants (generally used to treat

seizures) are recommended for treating bipolar disorder. Common side effects include weight
gain, dizziness, and drowsiness. But sometimes, certain anticonvulsants cause more serious
problems, such as skin rashes, blood disorders or liver problems.

Valproic acid and carbamazepine are used to treat mania. These drugs, also used to
treat epilepsy, were found to be as effective as lithium for treating acute mania. They may be
better than lithium in treating the more complex bipolar subtypes of rapid cycling and dysphoric
mania.

Lamotrigine is used to delay occurrences of Bipolar I. Lamotrigine does not have FDA
approval for treatment of the acute episodes of depression or mania. Studies of lamotrigine for
treatment of acute bipolar depression have produced inconsistent results.
Second-Generation Antipsychotics (SGAs)
Second-generation antipsychotics (SGAs) are commonly used to treat the symptoms of
bipolar disorder and are often paired with other medications, including mood stabilizers. They
are generally used for treating manic or mixed episodes. Second-generation antipsychotics
(SGAs) are often prescribed to help control acute episodes of mania or depression. Finding the
right medication is not an exact science; it is specific to each person. Currently, only quetiapine
and the combination of olanzepine and fluoxetine (Symbax) are approved for treating bipolar
depression. Regularly check with the FDA website, as side effects can change over time.

Standard Antidepressants
Antidepressants present special concerns when used in treating bipolar disorder, as they
can trigger mania in some people. A National Institute of Mental Health (NIMH) study showed
that taking an antidepressant in addition to a mood stabilizer is no more effective than using a
mood stabilizer alone for Bipolar I. This is an essential area to review treatment risks and
benefits.
The aim of management is to treat acute episodes safely with medication and work with
the patient in long-term maintenance to prevent further episodes and optimize functioning using
a combination of pharmacological and psychotherapeutic techniques. Hospitalization may be
required especially with the manic episodes present in Bipolar I. This can be voluntary or (local
legislation permitting) involuntary. Long-term inpatient stays are now less common due to
deinstitutionalism, although these stays can still occur. Following (or in lieu of) a hospital
admission, support services available can include drop-in centers, visits from members of a
community mental health team or an Assertive Community Treatment team, supported
employment, patient-led support groups, and intensive outpatient programs. These are
sometimes referred to as partial-inpatient programs.

References:
https://courses.lumenlearning.com/wm-abnormalpsych/chapter/mood-disorders/
https://www.healthline.com/health/bipolar-disorder/bipolar-causes#genetics
https://www.healthline.com/health/bipolar-disorder/bipolar-causes#genetics
https://www.aseanjournalofpsychiatry.org/articles/dsm5based-diagnosis-and-demographics-of-th
e-philippine-mental-health-association-incs-psychiatric-outpatients.pdf