Bipolar disorder: new understandings, emerging treatments

The role of general practitioners in managing bipolar disorder is gaining increasing recognition

David J Castle MD, FRANZCP, FRCPsych · Michael Berk MB BCh, FRANZCP, PhD · Barbara M Hocking BSc(Hons), DipEd, DipHEd

Bipolar disorders are cyclical mood disorders with clinical features including distinct sustained periods of mood elevation. Briefer (4 days or more), mild episodes of mood elevation define bipolar II disorder; lengthier (7 days or more), more severe episodes (or those requiring hospitalisation), with or without psychotic features, define bipolar I disorder. Depressive periods are more common and lengthier than manic or hypomanic states, and are the main cause of disability. Bipolar depression may respond poorly to antidepressants and these medications may destabilise the illness. The diagnosis of bipolar disorder should be considered when a patient with depression is treatment resistant. Irritability is a common symptom in bipolar disorder, particularly during mixed states (during which patients have features of mood elevation and depression concurrently) or when there is rapid cycling of mood (more than four episodes of mood disorder per year). Alcohol misuse and use of illicit drugs may simulate mood changes in bipolar disorder. Accurate diagnosis and assessment of bipolar disorder is essential for clinical decision making and determining prognosis and treatments.

John W G Tiller MD, FRACP, FRANZCP · Isaac Schweitzer MD, DPM, FRANZCP

General practitioners are often consulted for first presentations of bipolar disorder and are well placed to coordinate patient care. They can assist with early identification of bipolar disorder and monitoring for manic and depressive episodes. Delayed and incorrect diagnoses are common in bipolar disorder, and unipolar depression is a frequent misdiagnosis. Characteristics that can be used to distinguish bipolar I depression from unipolar depression (when no clear prior manic episodes are evident) include the course of illness, symptoms, mental state signs and family history. Manic episodes can be caused by poor adherence to medication, substance misuse, antidepressants and stressful events, and are often preceded by early warning signs. Early warning signs are less commonly observed for depressive episodes. Daily mood charts are useful for providing an overview of patient progress and for identifying and managing early warning signs. Families and carers can also play an active role in supporting patients with bipolar disorder.

Philip B Mitchell AM, MB BS, MD, FRANZCP, FRCPsych · Colleen K Loo MB BS, MD, FRANZCP · Bronwyn M Gould AM, MB BS, DipPaed, MPsycholMed

General practitioners are involved in the continuing care and shared care of patients with chronic mental illness, including bipolar disorder. Psychiatrists are particularly reliant on GPs to monitor and treat comorbidities as well as the psychiatric condition itself. Management of chronic mental illness is compromised by a number of factors, including problems with diagnosis, physical comorbidity, erratic attendance and poor compliance with treatment. Diagnosis of bipolar disorder is often delayed, and differential diagnoses to be considered include unipolar depression, anxiety disorder, drug and alcohol dependence, personality disorder, attention deficit hyperactivity disorder, and general medical and central nervous system diseases. New Medicare items have been introduced under the Better Access to Mental Health Care initiative. However, uptake for patients with chronic psychiatric illness, including bipolar disorder, is low. Patients with bipolar disorder may be prone to a range of comorbid psychological, social and physical problems, and GPs need to be vigilant to detect and manage comorbidity and social problems as part of the overall plan. This includes assistance with certification for sickness and unemployment benefits. GPs may become involved during crises affecting patients and this may pose significant problems for GPs who need to provide ongoing care following patient discharge from hospital. Despite these difficulties, opportunities exist for GPs to play a vital and ongoing role in the management of patients with bipolar disorder.

Leon Piterman MD, MMed, FRACGP · Kay M Jones BSW, MT+D, PhD · David J Castle MD, FRANZCP, FRCPsych

Rates of conditions comorbid with bipolar disorder are very high, with anxiety disorders, impulse-control disorders, and drug and alcohol problems being the most distinctly over-represented conditions. Although the high rates of comorbid conditions may be overestimates — owing to measurement distortions in community surveys, and because definitions of comorbidity generally include antecedent and consequential conditions (not merely coterminous ones) — they are clinically distinctive. Clinical comorbidity can be explained by at least four different models, which each have clinical management implications. If the bipolar disorder and the comorbid conditions are deemed to be interdependent, two broad approaches are appropriate: hierarchical management strategies and sequential management strategies. Successful management of bipolar disorder often involves the development of a wellbeing plan that addresses comorbid issues iterative to the bipolar disorder.

Gordon B Parker MD, PhD, FRANZCP

Bipolar affective disorders carry significant risks to the patient and sometimes others. The form of the illness relapse needs to be determined, and high-risk features such as psychosis and suicide considered. Gathering collateral information from others is invaluable. Mania brings particular risks of disinhibition, poor judgement, risk taking and sometimes aggression. Depression carries notable risks of suicidal behaviour, poor self-care and homicide. Both mania and depression bring risks of substance misuse and disrupted relationships. Management requires an optimal therapeutic alliance with good communication, appropriate treatment and sometimes compulsory care during crises. Preventive strategies are invaluable.

Darryl L Bassett MB BS, FRANZCP, DipPsychother

Objective: To provide a practical overview of the pharmacological management of adults with bipolar disorder in primary care and the role of general practitioners in the pharmacotherapy of this complex disorder.Data sources: Published guidelines for the treatment of bipolar disorder, plus Cochrane reviews, meta-analyses, review articles and reports from randomised controlled trials that were published up to May 2009.Study selection: Over 500 articles on the treatment of bipolar disorder were reviewed, with an emphasis on meta-analyses and systematic reviews of randomised controlled trials. Where evidence was more limited, open trials and non-controlled data were also reviewed.Data extraction: Key recommendations relevant to GPs were synthesised and rated according to National Health and Medical Research Council levels of evidence.Data synthesis: Lithium, valproate and atypical antipsychotics are first-line treatment options for acute mania, and monotherapy is ideal if it produces an adequate response. For depressive episodes, recommendations are less definitive and the use of antidepressants is controversial. Most patients require maintenance treatment, during which pharmacotherapy should be used to prevent relapse, and psychological and social interventions should be considered.Conclusions: Bipolar disorder is a lifelong episodic illness that affects 1%–2% of the population, many of whom are principally managed by their GPs. Pharmacological treatment with mood-stabilising agents is the primary form of management, although this is ideally provided in conjunction with psychosocial interventions.

Gin S Malhi FRCPsych, FRANZCP, MD · Danielle Adams BSc(Psych)(Hons), MPsych(Clin) · Michael Berk MB BCh, FRANZCP, PhD

Adjunctive psychosocial interventions for bipolar disorder target many of the issues that are not addressed by medication alone, including non-adherence, efficacy–effectiveness gap and functionality. Psychosocial interventions have been found to reduce relapse, particularly for the depressive pole, and improve functionality. Approaches such as psychoeducation, cognitive behaviour therapy, interpersonal and social rhythm therapy, and family therapy have shown benefits as adjunctive treatments. Each of the various psychosocial interventions has a unique emphasis, but they share common elements. These include: providing information and education; developing a personal understanding of the illness, such as triggers and early warning signs; having prepared strategies in place for early intervention, should symptoms of illness develop; and promoting a collaborative approach. Evidence to date supports the use of adjunctive psychosocial interventions in the management of bipolar disorder.

Sue D Lauder MPsych(Clinical) · Michael Berk MB BCh, FRANZCP, PhD · David J Castle MD, FRANZCP, FRCPsych · Seetal Dodd BSc, MSc, PhD · Lesley Berk MA(ClinPsych)