Monday, November 5, 2007

The Anxiety-Bipolar Connection

Department of Psychiatry, Pharmacology, Neurobiology and Bio-technology,
University of Pisa, via Roma 67, 56100 Pisa, Italy.

BACKGROUND: The present study examined whether specific types of comorbid
anxiety disorders, namely panic disorder (PD), social phobia (SP) and
obsessive-compulsive disorder (OCD) are differentially associated with course
variables and insight into bipolar illness. METHOD: The sample consisted of 151
consecutively hospitalized patients with bipolar I disorder. They were assessed
in the week prior to discharge using the Structured Clinical Interview for
DSM-III-R (SCID-P), the Brief Psychiatric Rating Scale (BPRS), the Global
Assessment of Functioning Scale (GAF) and the Hopkins Symptom Checklist
(HSCL-90). Level of insight was assessed with the Scale to assess Unawareness of
Mental Disorders (SUMD). RESULTS: Of the 151 bipolar subjects, 92 had no PD, SP
and OCD comorbidity, 35 had PD and 24 had SP and/or OCD. The three groups
differed significantly on the current awareness of illness and treatment
response scores and the retrospective awareness of illness and treatment
response scores. Post-hoc analyses revealed that, compared with bipolar patients
without PD/SD/OCD and those with comorbid PD, patients with comorbid SP and/or
OCD had better insight on current awareness of illness, current awareness of
treatment response, retrospective awareness of illness and retrospective
awareness of treatment response. The regression analysis showed that the
presence of no panic type anxiety comorbidity was a predictor of good insight.
CONCLUSIONS: These data indicate the value of identifying comorbid anxiety
disorders in patients with bipolar illness. The results could be interpreted as
evidence of discrete disorders within the bipolar spectrum, one that is
characterized by, among other things, SP and/or OCD with good insight, another
characterized by PD with poor insight.

Antidepressants in bipolar disorder: the case for caution

Bipolar Disorder Research Program, Cambridge Hospital, Cambridge, MA and Harvard Medical School, Boston, MA 02139, USA.

The 2002 American Psychiatric Association (APA) guidelines for the treatment of bipolar disorder recommended more conservative use of antidepressants. This change in comparison with previous APA guidelines has been criticized, especially from some groups in Europe. The Munich group in particular has published a critique of assumptions underlying the conservative recommendations of the recent APA treatment guidelines. In this paper, we re-examine the argument put forward by the Munich group, and we demonstrate that indeed, conceptually and empirically, there is a strong rationale for a cautious approach to antidepressant use in bipolar disorder, consistent with, and perhaps even more strongly than, the APA guidelines. This rationale is based on support for the following four propositions: (i) The risk of antidepressant induced mood-cycling is high, (ii) Antidepressants have not been shown to definitively prevent completed suicides and reduce mortality, whereas lithium has, (iii) Antidepressants have not been shown to be more effective than mood stabilizers in acute bipolar depression and have been shown to be less effective than mood stabilizers in preventing depressive relapse in bipolar disorder and (iv) Mood stabilizers, especially lithium and lamotrigine, have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes. We therefore draw three conclusions from this interpretation of the evidence: (i) There are significant risks of mania and long-term worsening of bipolar illness with antidepressants, (ii) Antidepressants should generally be reserved for severe cases of acute bipolar depression and not routinely used in mild to moderate cases and (iii) Antidepressants should be discontinued after recovery from the depressive episode, and maintained only in those who repeatedly relapse after antidepressant discontinuation (a minority we judge to represent only about 15-20% of bipolar depressed patients).

When to Seek Medical Care

Generally, people with severe bipolar disorder symptoms will not seek medical care on their own. A family member or close friend is usually the one seeking help for the person. The person needs to be seen by a medical professional in these situations:

  • When changes in personality, including extreme moodiness, start to affect a person's life, ruin relationships with others, or threaten basic health, the person should be seen by a medical professional. Medical conditions such as diabetes and thyroid disorders can cause mood swings. These are relatively easy to detect and treat. They are the starting point of an evaluation of mood swings.

  • When changes in sleep and appetite begin to affect health, the person needs to be evaluated. Some people may not want any help. If they fear the stigma of having a mental illness, they need to know that many other things could be responsible for the changes in their behavior. This is especially true for anyone older than 40 years who develops signs of bipolar disorder.

  • When the mood swings have become so severe that a person cannot function at home or work

  • When a person has thoughts of suicide, especially with a specific plan as to how to take his or her own life

  • If the person might be a danger to self or others, he or she should be seen in a hospital emergency department.

  • Suicidal patients are hospitalized until their mood can be stabilized.

  • If the person refuses to go to the hospital, you may need assistance in getting him or her there. Call 911 if the situation is dangerous.

  • Above all, be sure of your own safety first. A person with bipolar disorder is probably not thinking clearly when in severe mania or depression. He or she may feel that the person calling for help is a traitor.

  • With a suicide attempt, call 911 so that the person can be treated in the emergency department. Don't try to take a person who has attempted suicide to the hospital by yourself.

  • Homicidal thoughts, threats, or behaviors require immediate intervention. Assure your own safety and then call 911 for help.

Bipolar Disorder Overview

Bipolar disorder (BD) is a type of mood disorder. Bipolar disorder was called manic depression in the past, and that term is still used by some people. It is a psychiatric illness that causes major disruptions in lifestyle and health.
Everyone has occasional highs and lows in their moods. But people with bipolar disorder have extreme mood swings. They can go from feeling very sad, despairing, helpless, worthless, and hopeless (depression) to feeling as if they are on top of the world, hyperactive, creative, and grandiose (mania). This disease is called bipolar disorder because the mood of a person with bipolar disorder can alternate between two completely opposite poles, euphoric happiness and extreme sadness.

Symptoms of both mania and depression sometimes occur together, in what is called "mixed state."

The extremes of mood usually occur in cycles. In between these mood swings, people with bipolar disorder are able to function normally, hold a job, and have a normal family life. The episodes of mood swings tend to become closer together with age.

When a person is in the grip of this disease, chaos can occur. Bipolar disorder can cause major disruption of family and finances, loss of job, and marital problems.

Severe depression can be life-threatening. It may be associated with thoughts of suicide, actual acts of suicide, and even acts of homicide in some cases.

Extreme mania can lead to aggressive behavior, potentially dangerous risk-taking behaviors, and homicidal acts.

A number of people with bipolar disorder may turn to drugs and alcohol to "self-treat" their emotional disorder, resulting in substance abuse and dependence.

Most people start showing signs of bipolar disorder in their late teens (the average age of onset is 21 years). These signs may be dismissed as "growing pains" or normal teenage behavior. On occasion, some people have their first symptoms during childhood, but the condition can often be misdiagnosed at this age and improperly labeled as a behavioral problem. Bipolar disorder may not be properly diagnosed until the sufferer is 25-40 years old, at which time the pattern of symptoms may become clearer.

Bipolar disorder occurs in both men and women. About 5.7 million people in the United States have the disorder. There is no racial group that is more afflicted by this disease.

Because of the extreme and risky behavior that goes with bipolar disorder, it is very important that the disorder be identified. With proper and early diagnosis, this mental condition can be treated. Bipolar disorder is a long-term illness that will require proper management for the duration of a person's life.

Bipolar Disorder Symptoms

In adults, mania is usually episodic with an elevation of mood and increased energy and activity. In children, mania is commonly chronic rather than episodic, and usually presents in mixed states with irritability, anxiety and depression. In adults and children, during depression there is lowering of mood and decreased energy and activity. During a mixed episode both mania and depression can occur on the same day.

Bipolar I Disorder

Bipolar I Disorder is a life-long disease and runs in families but has a complex mode of inheritance. Family, twin and adoption studies suggest genetic factors. The concordance rate for monozygotic (identical) twins is 43%; whereas it is only 6% for dizygotic (nonidentical) twins. About half of all patients with Bipolar I Disorder have one parent who also has a mood disorder, usually Major Depressive Disorder. If one parent has Bipolar I Disorder, the child will have a 25% chance of developing a mood disorder (about half of these will have Bipolar I or II Disorder, while the other half will have Major Depressive Disorder). If both parents have Bipolar I Disorder, the child has a 50%-75% chance of developing a mood disorder. First-degree biological relatives of individuals with Bipolar I Disorder have elevated rates of Bipolar I Disorder (4%-24%), Bipolar II Disorder (1%-5%), and Major Depressive Disorder (4%-24%).

The finding that the concordance rate for monozygotic twins isn't 100% suggests that environmental or psychological factors likely play a role in causation. Certain environmental factors (e.g., antidepressant medication, antipsychotic medication, electroconvulsive therapy, stimulants) or certain illnesses (e.g., multiple sclerosis, brain tumor, hyperthyroidism) can trigger mania. Mania can be triggered by giving birth, sleep deprivation, and major stressful life events.