SummaryBipolar affective disorder – previously referred to as manic depression – is a psychiatric disorder affecting at least 1% of the UK population, and depending on the definition used, may affect as many as 5% of the population. A recent World Health Organization analysis of the major global causes of disability, economic and social burden, indicated that bipolar affective disorders are ranked in the top ten, and account for 2.5% of total years lost to disability across all age groups.
Bipolar affective disorder – previously referred to as manic depression – is a psychiatric disorder affecting at least 1% of the UK population, and depending on the definition used, may affect as many as 5% of the population. A recent World Health Organization analysis of the major global causes of disability, economic and social burden, indicated that bipolar affective disorders are ranked in the top ten, and account for 2.5% of total years lost to disability across all age groups.
It was initially thought that, in comparison with schizophrenia, the outcome for bipolar affective disorder was very good. However, this concept has increasingly been shown to be false. Whilst the outcome in bipolar affective disorder is slightly better than schizophrenia, it is a chronic condition with a lifetime prevalence of suicide in the order of 20%.
The various phases of illness in bipolar affective disorder – acute mania/hypomania, mixed episodes, depressive episodes, rapid-cycling bipolar disorder – have long been recognised, although consistent evidence-based treatment to manage the different phases of the illness has proved to be a more elusive goal. There has also been an increased recognition of bipolar affective disorder as a serious mental illness, which has followed on from an increase in research into the causes and treatments for the disorder.
For many years, lithium has been considered to be the mainstay for acute and chronic treatment of classical bipolar affective disorder (bipolar I disorder), and in particular for managing episodes of acute mania. Bipolar I disorder, however, is only part of the illness. Initially, tricyclic antidepressants (TCAs) were used to treat the depressive episodes of the disorder, principally on the basis that they were effective in treating unipolar depression. However, their use has now significantly decreased with the recognition that TCAs actually increase the risk of a switch into a manic/hypomanic state coupled with the advent of alternative non-TCA antidepressant drugs which have a lower risk of this switch. Where selective serotonin reuptake inhibitors (SSRIs) are used to treat the depressive phase in bipolar disorder, they should only be used in combination with an antimanic agent and not as monotherapy.
Since the mid-to-late 1980s, it has become increasingly clear that antipsychotics treat psychotic symptoms regardless of the underlying mood state, and that lithium is relatively ineffective for the psychotic symptoms that occur in bipolar affective disorder. This has led to the increasing use of antipsychotics in the management of bipolar affective disorder, not only in its acute stages but also as chronic prophylaxis. There is now an increasing evidence base for the use of antipsychotics in these indications and the advent of newer atypical antipsychotics has allowed new controlled clinical trials to be carried out to address some of the current treatment issues in bipolar affective disorder, particularly in patients with difficult-to-treat bipolar depression.
The widening of this evidence base, along with variation in prescribing practice when managing bipolar affective disorder has provided the impetus for the formulation of a series of national and international guidelines, which have the objective of aiding the clinician in the management of this difficult-to-treat disorder.
It is known that the majority of patients with bipolar affective disorder can suffer for years before receiving a correct diagnosis. Furthermore, when bipolar affective disorder is considered as a whole, patients spend longer in the depressive phase of the illness than any other. During these periods, patients are less likely to seek medical attention, and if they do it is likely to be in primary care. Therefore, it is absolutely essential that appropriate treatment is given at this stage. As such, recognition of the condition itself and a thorough understanding of the treatment options available will establish a therapeutic alliance between patient and practitioner, with ensuing benefits for both parties.
Over the coming years one of the major challenges in the management of bipolar affective disorder will be the recognition that many patients previously diagnosed with other psychiatric disorders will in fact have a variant of bipolar disorder. The recognition of these patient groups, both clinically and biologically, is critical to furthering our understanding of the condition and will also inform future decisions about treatment. The evidence base that we currently have will expand in years to come, with increasing information about the mood-stabilising effects of the newer antipsychotic medications and the identification of novel therapeutic targets for the pharmacological treatment of bipolar affective disorder.
Whilst this evidence base is building, each individual clinician will continue to make their own treatment choices based partially on consensus guidelines but also on their own clinical judgement of what is the right treatment for a specific individual at any particular time. This experience, if appropriately harnessed, can inform the development of newer treatments and the design of new clinical trials in specific patient groups that will allow a more targeted and rational management of bipolar affective disorder across all of its phases.
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This Editorial has been written by the specialist opinion leader, Dr Michael J Travis,
Consultant Psychiatrist and Honorary Senior Lecturer, Section of Clinical Neuropharmacology, Division of Psychological Medicine, Institute of Psychiatry, London and published in the latest issue of the serial publication, Drugs in Context.
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