August, 2004 PSYCHOPHARMACOLOGY UPDATE Volume 4 Number 4
Diagnosis and Treatment of Bipolar Disorder
In 1976 Dunner and colleagues proposed two categories of bipolar disorder (manic-depressive illness). These categories were named bipolar I and bipolar II.
Diagnosis of Bipolar I Disorder:
Bipolar I disorder is characterized by depressive episodes alternating with manic episodes. A manic episode is associated with grandiose psychotic features and danger to the self and, perhaps, to others. The severity of the symptoms usually demands that the patient be hospitalized for treatment.
Diagnosis of Bipolar II Disorder
Bipolar II disorder is characterized by depressive episodes alternating with hypomanic episodes. There exists some confusion regarding the term "hypomania" (below mania). A hypomanic episode is unassociated with psychotic features. Instead, a hypomanic episode is characterized by a 4-day (or more) period of persistently elevated, expansive, or irritable mood. The symptoms of hypomania can be characterized by the acronym DIGFAST:
- D = Distractibility
- I = Insomnia
- G = Grandiosity
- F = Flight of ideas
- A = Activity in unexplained burst of energy
- S = Speech that is fast, pressured, hyperverbal or interrupting
- T = Thoughtlessness that leads of risk taking behavior such as inappropriate sexual liaisons, spending more money than suitable or driving fast/recklessly.
Distinguishing between Recurrent Unipolar Depression and Bipolar II Depression
Because bipolar II patients often demonstrate several episodes of depression before an initial hypomanic episode, patients with bipolar II depression may be falsely diagnosed as having recurrent unipolar depression. When compared to unipolar depressed patients, bipolar II depressed patients are more likely to have the following characteristics:
1. Family history of mania, bipolar illness or substance abuse
2. Earlier age of onset of depression (adolescence or early 20s)
3. A higher number of depressive episodes
4. Mood swings
5. Non-response or agitation on antidepressants
Rapid Cycling
Rapid cycling, defined as the presence of 4 or more mood swings in a year, is much more prevalent in bipolar II patients than bipolar I patients. Brief, frequent episodes of depression are highly suggestive of rapid cycling bipolar II disorder. Antidepressants can exacerbate rapid cycling. Antidepressants can also precipitate a manic crisis in depressed patients that have undiagnosed bipolar illness.
Treatment
Depakote possesses antimanic effects, but more moderate antidepressant effects.
Lamictal is effective in the treatment of depression in bipolar disorder.
Lamictal + Depakote may be required in combination to stabilize rapid cycling.
Lithium functions poorly in rapid cycling patients; and because the therapeutic dose of lithium is close to the toxic dose, lithium treatment must be used with caution, if at all.
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