Psychiatric Annals

resident's viewpoint 

The Bipolar Roller Coaster

Sayali Kulkarni, MD

Abstract

Mood disorders have been described since ancient Greco-Roman times. It is interesting to know a little about the history of bipolar spectrum disorders, how the terms "melancholia" and "mania" were coined, and how they were linked together to give rise to bipolar spectrum disorders.

Greek physicians postulated the earliest biochemical etiology of any mental disorder. They believed that melancholia ("black bile") arose from a somber melancholic temperament in which black bile was secreted from the spleen under the influence of the planet Saturn. This black bile resulted in depressed mood through its influence on the brain. Mania, on the other hand, was described as a state of raving madness with exalted mood.

The relation of melancholy with mania was possibly noted in the first century BC, but this relation was later discounted. This connection was rediscovered 2,000 years later by French physician Jean-Pierre Falret, who coined the term "circular insanity." Similarly, much of the modern perspective on mood disorders can be traced back to those ancient concepts.

In the United States alone, approximately 4 million people are affected by bipolar disorder. It is a chronic, recurrent illness, but appropriate management can decrease the associated morbidity and mortality. Residents are taught that the goals of treatment are to decrease the frequency, severity, and psychosocial consequences of manic or depressive episodes, and to improve psychosocial functioning between episodes. Some patients with severe forms of the illness show chronic impairment and may require specific rehabilitative services.

The goals of practice management of bipolar disorder, according to the American Psychiatric Association, include establishing and maintaining a therapeutic alliance, monitoring the patient's psychiatric status, providing education regarding bipolar disorder, enhancing treatment compliance, promoting regular patterns of activity and wakefulness, promoting understanding of and adaptation to the psychosocial effects of bipolar disorder, identifying new episodes early, and reducing the morbidity and sequelae of bipolar disorder.

PHARMACOTHERAPY

Somatic treatment is an essential aspect in the treatment of patients with bipolar disorder. Research has proved medications to be effective in the treatment of acute episodes, as well as in the prevention of future episodes. The medications for bipolar disorder include those that treat the symptoms of mania or depression and those that act as a prophylaxis against future episodes. Lithium has historically been a mainstay of treatment in bipolar disorder. More recently, anticonvulsant mood stabilizers are considered first-line treatment in some situations.

New research suggests that many of the atypical antipsychotic medications may be effective as adjunct treatment and, in some cases, as primary treatment for the management of bipolar disorders. Electroconvulsive therapy is highly effective against acute mania despite the lack of controlled evidence and appears to be regaining some of its previous popularity.

However, more treatment options for bipolar depression are needed. Currently available antidepressants may increase the risk of mania and rapid cycling, and mood stabilizers appear to be less effective in treating depression than mania. Preliminary data suggest lamotrigine, an established antiepileptic drug, may be effective for both the depression and mania associated with bipolar disorder and may reduce future rapid cycling.

The pharmacology of bipolar disorder is also changing with regard to monopharmacy versus polypharmacy. As we develop more pharmacologic treatments and characterize them better, we are beginning to develop a sense of which medications are more effective for which symptoms and which phase of the illness, rather than using one mood stabilizer for all symptoms at all times. Some medications may be better for acute illness or for prophylaxis, and some may be better for mania or depression. Fish oils appear to be a promising but untested treatment. One of my patients…

Mood disorders have been described since ancient Greco-Roman times. It is interesting to know a little about the history of bipolar spectrum disorders, how the terms "melancholia" and "mania" were coined, and how they were linked together to give rise to bipolar spectrum disorders.

Greek physicians postulated the earliest biochemical etiology of any mental disorder. They believed that melancholia ("black bile") arose from a somber melancholic temperament in which black bile was secreted from the spleen under the influence of the planet Saturn. This black bile resulted in depressed mood through its influence on the brain. Mania, on the other hand, was described as a state of raving madness with exalted mood.

The relation of melancholy with mania was possibly noted in the first century BC, but this relation was later discounted. This connection was rediscovered 2,000 years later by French physician Jean-Pierre Falret, who coined the term "circular insanity." Similarly, much of the modern perspective on mood disorders can be traced back to those ancient concepts.

In the United States alone, approximately 4 million people are affected by bipolar disorder. It is a chronic, recurrent illness, but appropriate management can decrease the associated morbidity and mortality. Residents are taught that the goals of treatment are to decrease the frequency, severity, and psychosocial consequences of manic or depressive episodes, and to improve psychosocial functioning between episodes. Some patients with severe forms of the illness show chronic impairment and may require specific rehabilitative services.

The goals of practice management of bipolar disorder, according to the American Psychiatric Association, include establishing and maintaining a therapeutic alliance, monitoring the patient's psychiatric status, providing education regarding bipolar disorder, enhancing treatment compliance, promoting regular patterns of activity and wakefulness, promoting understanding of and adaptation to the psychosocial effects of bipolar disorder, identifying new episodes early, and reducing the morbidity and sequelae of bipolar disorder.

PHARMACOTHERAPY

Somatic treatment is an essential aspect in the treatment of patients with bipolar disorder. Research has proved medications to be effective in the treatment of acute episodes, as well as in the prevention of future episodes. The medications for bipolar disorder include those that treat the symptoms of mania or depression and those that act as a prophylaxis against future episodes. Lithium has historically been a mainstay of treatment in bipolar disorder. More recently, anticonvulsant mood stabilizers are considered first-line treatment in some situations.

New research suggests that many of the atypical antipsychotic medications may be effective as adjunct treatment and, in some cases, as primary treatment for the management of bipolar disorders. Electroconvulsive therapy is highly effective against acute mania despite the lack of controlled evidence and appears to be regaining some of its previous popularity.

However, more treatment options for bipolar depression are needed. Currently available antidepressants may increase the risk of mania and rapid cycling, and mood stabilizers appear to be less effective in treating depression than mania. Preliminary data suggest lamotrigine, an established antiepileptic drug, may be effective for both the depression and mania associated with bipolar disorder and may reduce future rapid cycling.

The pharmacology of bipolar disorder is also changing with regard to monopharmacy versus polypharmacy. As we develop more pharmacologic treatments and characterize them better, we are beginning to develop a sense of which medications are more effective for which symptoms and which phase of the illness, rather than using one mood stabilizer for all symptoms at all times. Some medications may be better for acute illness or for prophylaxis, and some may be better for mania or depression. Fish oils appear to be a promising but untested treatment. One of my patients benefited from them when everything else appeared to fail.

Another challenge in the management of bipolar disorder is comorbid substance abuse. One of my patients with bipolar disorder and alcohol dependence could not be optimally treated until his cravings for and consumption of alcohol were reduced by using topiramate. Research continues to find newer agents that are effective for this difficult-to-treat group, and we are hopeful that by the time we graduate, we will have a strong armamentarium of medications.

PSYCHOTHERAPY

Even as residents, we observe that a combination of pharmacotherapy and psychotherapy is usually more effective in treating bipolar disorder than either of them alone. Individual psychotherapy, including psychodynamic, interpersonal, behavioral, and cognitive therapies, can be very helpful, encouraging adherence to treatment and enabling the individual to develop insight into the illness, as well as offering coping strategies to manage the many issues that arise with such a complex disorder. One of my patients who had a poor course initially due to poor insight and compliance, which resulted in multiple hospitalizations due to rapidcycling, responded to cognitive behavioral therapy. Other modalities that can be helpful in this respect include couples therapy, family therapy, and group therapy. Research is in progress to demonstrate empirical evidence as to the tiveness of these treatments.

GENETICS

I had the opportunity to attend the XI World Congress on Psychiatric Genetics in Quebec City, Quebec, Canada, in October 2003, and it opened my eyes to a whole new world of genetics in psychiatry. An extensive body of evidence from family, twin, and adoption studies demonstrates the importance of genes in the pathogenesis of bipolar disorder. Recent advances in molecular genetics have made it possible to identify these susceptibility genes. Regions of interest include chromosomes 4pl6, 12q23q24, 16pl3, 21q22, and Xq24-q26. Candidate-geneassociation studies are in progress.

The science of human genomics has moved us closer to finding specific genes responsible for pathology in patients with bipolar disorder. Once we determine the products of those genes, we may be able to develop more specific and immediate treatments, and perhaps even talk about actual cures through genetic altering with gene therapy. Many residents, I am sure, will be attracted to this field in psychiatry as it probably holds the answers to most of our questions.

NEUROIMAGING

At the Third International Conference on Bipolar Disorder in Pittsburgh, Pennsylvania, June 17-19, 1999, it was shown that recent studies using advanced magnetic resonance techniques have provided important new insights into the neuropathophysiology of bipolar disorder and its effective treatment. Highresolution, structuralimaging studies using three-dimensional volumetric magnetic resonance imaging combined with advanced computer segmentation techniques allow for quantitative assessment of the volume of specific brain structures.

Studies using these techniques have recently documented abnormalities in specific regions of the frontal cortex and the temporal lobe in subjects with bipolar disorder. Importantly, these structural and neurochemical studies are beginning to elucidate the circuitry and biochemical pathways involved in bipolar disorder and its treatment, information that is key to the development of novel and more effective therapeutic strategies for this devastating illness.

Like genetics, neuroimaging will entice many resident psychiatrists. Residents interested in these fields can make use of the various training opportunities made available by the National Institutes of Mental Health (NTMH) in these important aspects of psychiatry.

In conclusion, people with bipolar spectrum disorders constantly live life on a roller coaster, and it is both a challenge and a gratifying experience for the psychiatrist to manage this group of patients. The disease takes them as low as it takes them high, and both the extremes are just as dangerous. We, as mental health professionals, have to do our best to help them attain an emotional equilibrium.

10.3928/0048-5713-20040101-10

Sign up to receive

Journal E-contents