Academic journal article South African Journal of Psychiatry

Bipolar Disorder

Academic journal article South African Journal of Psychiatry

Bipolar Disorder

Article excerpt

1. Introduction

Bipolar disorder (BD) presents in different phases over time and is often complicated by comorbid conditions such as substance-use disorders and anxiety disorders. Treatment usually involves pharmacotherapy with combinations of different classes of medications and frequent medication revisions.

Since practice recommendations or treatment guidelines cannot fully summarise the myriad of presentations, they need to be used flexibly, taking into account the individual patient, the sociocultural context and the availability of treatment resources. The Medicines Control Council (MCC) in South Africa often lags behind other international regulatory agencies regarding the registration of medications with confirmed efficacy for indications in BD and therefore clinicians have to prescribe certain drugs off-label in the treatment of routine, difficult and treatment-resistant cases of BD.

In this guideline, levels of evidence derived from studies will be explored. [1] Evidence criteria include:

* Level 1: meta-analysis or replicated double-blind (DB), randomised controlled trial (RCT) with a placebo condition

* Level 2: at least one DB-RCT with active comparison condition or placebo

* Level 3: prospective uncontrolled trial with at least [greater than or equal to] 10 participants

* Level 4: anecdotal reports or expert opinion.

This guideline makes treatment recommendations: [1]

* First line: level 1 or level 2 evidence plus clinical support for safety and efficacy

* Second line: level 3 evidence or higher plus clinical support for safety and efficacy

* Third line: level 4 evidence or higher plus clinical support for safety and efficacy

* Not recommended: level 1 or level 2 evidence for lack of efficacy.

1.1 Epidemiology of bipolar disorder pertinent to the treatment guideline [2-5]

1.1.1 Epidemiological statistics

For bipolar I disorder, the mean reported age of the first mood episode is 18.2 years, while the lifetime prevalence is 1%. For bipolar II disorder, the mean reported age of first mood episode is 20.3 years, while the lifetime prevalence is 1.1%. Bipolar I disorder affects men and women equally, while bipolar II disorder is more common in women. [3,4]

1.1.2 Illness characteristics

The first symptoms of BD often present at 15-19 years of age. The most likely first episode, and also predominant phase in the later stages of the illness, is depression. Suicide is 15 times more likely in BD patients compared to the general population, with as many as 7-15% of all bipolar sufferers committing suicide. Suicide is most likely to occur during mixed or depressive episodes. [5]

2. Diagnosis and clinical characteristics

The diagnosis should be made with rigour. As the full spectrum of the disorder does not present itself at one point in time only, the diagnosis should be made over time. Table 1 summarises the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) [6] classification of bipolar subtypes. [7,8]

The International Society for Bipolar Disorders (ISBD) Diagnostic Guidelines Task Force made the following recommendations for the DSM-V and International Classification of Diseases 11th Revision (ICD-11) for BD. [1] For BD I, the DSM-V criteria for mania should remain similar, but for bipolar depression, the criteria should include a probabilistic approach acknowledging the presence of: (i) atypical depressive symptoms (hyperphagia, hypersomnia, or leaden paralysis); (ii) psychomotor disturbance; (iii) pathological guilt or psychotic features; and (iv) a positive family history of BD. It was suggested that the rapid-cycling specifier for BD I should be extended to BD II and BD not otherwise specified (NOS)(now known as Other Specified Bipolar and Related Disorder in the DSM-V. The Task Force also suggested modifications to the diagnostic criteria for BD II and BD NOS to improve the identification of bipolar spectrum disorders to include the following: (i) subthreshold hypomanic episodes, and (ii) other signs of bipolarity without manic or hypomanic episodes (also known as bipolar spectrum disorder). …

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