Bipolar Disorder Research Program, Cambridge Hospital, Cambridge, MA and Harvard Medical School, Boston, MA 02139, USA. ghaemi@hms.harvard.edu
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).
Showing posts with label Bipolar. Show all posts
Showing posts with label Bipolar. Show all posts
Monday, November 5, 2007
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.
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.
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.
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