Bipolar affective disorder

Specialties > Mental health

Background knowledge 🧠

Definition

Bipolar affective disorder (BPAD) is a chronic mental health condition characterized by recurrent episodes of mood disturbances that range from mania/hypomania to depression.
Formerly known as manic-depressive illness.
Affects mood, energy levels, and ability to function.
Mood episodes can last weeks to months.

Epidemiology

Lifetime prevalence is approximately 1-2% globally.
Equal prevalence in males and females.
Onset typically occurs between ages 15-30.
Higher prevalence in high-income countries.
Genetic predisposition is significant.

Aetiology and pathophysiology

Multifactorial: genetic, neurobiological, and environmental factors.
Imbalance in neurotransmitters (e.g., serotonin, dopamine).
Genetic factors: first-degree relatives have a 10-fold increased risk.
Stressful life events can trigger episodes.
Structural brain abnormalities: e.g., prefrontal cortex, amygdala.

Types

Bipolar I: characterized by at least one manic episode, often with major depressive episodes.
Bipolar II: characterized by at least one hypomanic episode and one major depressive episode.
Cyclothymic disorder: chronic, fluctuating mood disturbance with periods of hypomania and depressive symptoms that do not meet criteria for major depression.
Rapid cycling: four or more mood episodes within a year.
Mixed features: simultaneous symptoms of mania/hypomania and depression.

Clinical Features 🌡️

Symptoms

Manic symptoms: elevated mood, increased energy, reduced need for sleep, grandiosity, racing thoughts, impulsive behavior.
Depressive symptoms: low mood, anhedonia, fatigue, feelings of worthlessness, suicidal ideation.
Hypomanic symptoms: similar to mania but less severe; no psychosis.
Psychotic symptoms: may occur during severe episodes of mania or depression.
Cognitive impairment may persist between episodes.

Signs

Pressured speech.
Increased psychomotor activity.
Flight of ideas.
Distractibility.
Delusions or hallucinations (in severe cases).
Poor insight.

Investigations 🧪

Tests

Clinical diagnosis primarily based on history and mental state examination.
Mood questionnaires (e.g., Mood Disorder Questionnaire) may aid diagnosis.
Rule out organic causes: thyroid function tests, electrolytes, drug screening.
Imaging (e.g., MRI) not routinely indicated unless ruling out structural brain lesions.
Baseline investigations before starting medications: FBC, U&Es, LFTs, ECG.

Management 🥼

Management

Pharmacological: mood stabilizers (e.g., lithium, valproate), antipsychotics (e.g., quetiapine, olanzapine).
Antidepressants may be used cautiously with mood stabilizers.
Psychotherapy: CBT, psychoeducation, family therapy.
Lifestyle modifications: regular sleep, stress management, avoiding alcohol and recreational drugs.
Crisis intervention: may require hospitalization for severe episodes.
Long-term monitoring and follow-up are essential to manage relapses.

Complications

High risk of suicide: up to 20 times higher than the general population.
Substance abuse disorders are common.
Increased risk of cardiovascular disease.
Social and occupational impairment.
Adverse effects of long-term medication use (e.g., renal impairment from lithium).

Prognosis

Chronic and relapsing course; 60-70% of patients have recurrent episodes.
Early treatment and adherence improve outcomes.
Poor prognosis associated with mixed features, rapid cycling, and comorbid substance abuse.
Lifelong treatment often necessary to prevent relapse.
With effective treatment, many patients can achieve good functional recovery.

Key points

Early identification and treatment are crucial to improving outcomes.
Long-term follow-up with regular monitoring for mood changes and medication side effects.
Educating patients and families about the nature of the disorder can improve adherence and outcomes.
Interdisciplinary care (including GPs, psychiatrists, and psychologists) is key to successful management.

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