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Bipolar Disorder

Bipolar Disorder

Bipolar Disorder a used to be called manic-depressive disorder. We don't use that term now. The key thing about bipolar disorder is that there are changes in the person's mood, which go in a cycle. There can be periods of very high mood we call Mania and low periods of mood we call Major Depression. When somebody is experiencing a period of mania they might feel overly happy but they also might feel extremely irritable. Behavioural changes can be seen such as the person talking very quickly and their thinking appearing to jump from one idea to another. Sometimes people describe their thoughts as racing. They might take on new projects increase the level of activities they do. They often describe feeling restless. Often there are sleeping problems, usually a reduced need for sleep. The person may be able to stay up all night and not feel tired the next day. Sometimes a person might believe that they are special or have special powers. Taking high risks in behaviour and acting on impulse are also features of mania.

In recent times there has been growing consensus among psychiatrists that there are more people on the bipolar spectrum than thought before. Some researchers believe it is possible that as many as 50% of people who suffer with major depression could be on the bipolar spectrum. Is important to bear this in mind when treating people with major depression. Is necessary for the doctor to watch for any symptoms of person's mood becoming excessively high. It is important not to over diagnose bipolar disorder. It may take time for the doctor to arrive at an accurate diagnosis. Patients who have clear symptoms of major depressive disorder or bipolar disorder are relatively easy to diagnose. It is the patients that fall in between that are difficult to diagnose. Sometimes patients may present with symptoms of major depressive disorder and manic symptoms at the same time. These episodes are call mixed episodes.

Gene studies suggest that abnormalities of cell membrane molecules and secondary messenger molecules in nerve cells are implicated in the pathology of bipolar disorder.

A thorough history detailing the mood patterns over the person's lifetime is very important. A detailed family history is also a key part of helping the doctor to get the diagnosis right.

The use of validated diagnostic scales such as the mood disorder questionnaires such as the Montgomery Asberg Depression Rating Scale (MADRS), Hypomania Mania Symptom Checklist HCL 32, and Young Mania rating scale can be very helpful in the initial assessment and monitoring of the persons condition thereafter.

Early treatment of the acute manic or mixed affective state is important to prevent harm. If the symptoms are severe a period of in-patient care may be required. Acute depressive episodes also need to be managed in good time. The presentation of an episode may be complicated comorbid substance misuse and this will need special attention.

The mainstay of pharmacological treatment is with mood stabilising medication. Antidepressant medication may be required in depressive phases and antipsychotic drugs when there are psychotic symptoms or severe behavioural disturbance.

Long-term treatment is another aspect of care, which needs careful planning. Preparing the patient to self-manage their condition is an important process. Involvement of family members and friends in the patient's recovery process is an important aspect in the overall care package. One key aspect is educating the patient and their family about the nature of the condition and its treatment. Individual therapy is usual in the form of Cognitive Behaviour Therapy. Group therapy can also be helpful for some patients.

Helping the patient to look for stressful events and how to possibly reduce the frequency of them occurring and managing their impact more effectively is important. Anxiety management can be really useful as quite often anxiety can be more disabling than the mood symptoms. Looking at the impact of sleep deprivation and fine-tuning of the awareness of early signs of relapse are other areas, which are addressed. The patient is also made aware of the need for regular patterns of daily activity. Dealing with any interpersonal relationship problems can often be another factor, which assists the recovery process.

Lithium Carbonate Treatment

To date lithium carbonate remains the only drug specifically targeted for bipolar disorder. It works by modulating the actions of messenger proteins within nerve cells. A recent study looked at all the drugs that have been used to treat bipolar disorder. Although most of the drugs used were more efficacious than placebo, and generally well tolerated, the authors advised that differences in the quality of evidence and the side-effect profiles should be taken into consideration by clinicians and patients.

The study concluded that lithium should remain the first-line treatment when prescribing a relapse-prevention drug in patients with bipolar disorder. The superior efficacy of lithium carbonate in prevention of both manic episode and depressive episode relapse or recurrence was also confirmed. Lithium reduces the incidence of suicide in patients with bipolar disorder by approximately 80%. Recently NICE guidelines have been published regarding the use of lithium in bipolar disorder. One key change in the advice is not to treat patients with rapid cycling disorder differently to other patients with bipolar disorder.

It is important when initiating lithium treatment to keep a very close eye on a measure of kidney function called glomerular filtration rate (GFR) over the first few months of treatment. Unfortunately the drug companies are generally not investing money into exploring more closely how lithium works and perhaps finding a more refined drug, which has fewer side effects.

Sodium Valproate and Depakote Treatment

A very informative study (BALANCE) has suggested that the combination of lithium carbonate and sodium valproate combination in the long-term produced outcomes which were better than each drug being used individually although the results were not statistically significant.

Bipolar Depression Treatment

The latest NICE guidelines advise that when treating bipolar depression, Fluoxetine in combination with Olanzapine or Quetiapine is recommended, with the addition of lamotrigine if there is no response. We are still awaiting the publication of the results of the CEQUEL study, based in Oxford, which is was designed to evaluate the efficacy of Lamotrigine and Quetiapine alone and combined.

Future Developments

Research is planned which will be looking at functional MRI (magnetic resonance imaging) and MEG (magnetoencephalography) imaging in bipolar patients receiving lithium for the first time. This may give us some insight into exactly what lithium is doing. Insights from new mathematical models of managing big data will hopefully be able to understand better the fluctuations that we see in mood in bipolar patients on a day-to-day basis.

Adult ADHD

Adult ADHD

This condition quite often occurs in patients with mood disorders such as bipolar disorder. It has many features in common with bipolar disorder so it is important to establish if one or both conditions are present in an individual patient. There is also increased incidence of drug and alcohol misuse with this condition, which may make diagnosis more difficult to make.
ADHD is normally diagnosed in childhood or adolescence. For some people however the diagnosis is not made until adulthood. The prevalence of this condition in adults is probably around 2.5 to 4%.

Diagnosis involves a very thorough history taking and going back through personal records and talking to families and examining things like school reports. Successful treatment of the condition can help with mood disorders and substance misuse. A small but not insignificant number of patients with Adult ADHD may have another co-existing mental health problem in which they are experiencing psychotic symptoms. It is really important for the psychiatrist assessing patients who may have Adult ADHD to ask about these possible symptoms.

The Adult ADHD Self–Report Scale is used to screen for this condition. As yet there is no neuropsychological battery that can be used on its own to make the diagnosis. The condition in adults is gaining increased recognition by health professionals and neuroscientists.

Treatment in adults is often with stimulant medication. Methylphenidate (Ritalin) is one such stimulant drug. As some stimulant drug stimulate dopamine receptors it is possible that psychotic symptoms could arise, so it is important to monitor patients carefully particularly when treatment is initiated. There are a few adult case reports where patients with ADHD, who may also be experiencing psychotic symptoms due to another mental health condition, have been treated with methylphenidate successfully. This sort of treatment would take place in a specialist treatment unit under very careful supervision.

Atomoxetine is another drug used to treat Adult ADHD. Atomoxetine It is a selective Noradrenaline reuptake inhibitor and it leads to increased stimulation of Noradrenaline receptors. It can take months to see it's full treatment potential. It is probably safer to use in patients experiencing psychotic symptoms than drugs like Methylphenidate.