Treating Rapid-Cycling Bipolar Disorder: Mood Chart Covering 6 Months or a Year Provides a View of the Illness That Can Clarify Drug Choice

By Sherman, Carl | Clinical Psychiatry News, February 2007 | Go to article overview

Treating Rapid-Cycling Bipolar Disorder: Mood Chart Covering 6 Months or a Year Provides a View of the Illness That Can Clarify Drug Choice


Sherman, Carl, Clinical Psychiatry News


Bipolar disorder is a disease of variation, and one important variable is cycle frequency. At any time, a significant proportion of patients are rapid cyclers--20% in the Systematic Treatment Enhancement Program for Bipolar Disorder study--who have had four or more episodes in the preceding year (Am. J. Psychiatry 2004;161:1902-8).

Why four? "To a degree, it's arbitrary," said Dr. Christopher D. Schneck of the University of Colorado, Denver. The number is derived from old studies of lithium resistance and doesn't appear to represent any true cutoff point in disease characteristics. "There's nothing magical about that number," he said.

Cycling is frequently much more rapid. "In our controlled treatment trials of rapid cycling, the mean episode frequency was 8-10," said Dr. Joseph R. Calabrese, codirector of the Bipolar Disorders Research Center and director of the mood disorders program at University Hospitals Case Medical Center in Cleveland.

Rapid cycling appears to be more common in women than in men, in bipolar II than in bipolar I, and in early-than in late-onset cases.

Some studies find that the pattern persists, but there are data to the contrary. "In our long-term follow-up studies, four out of five cases resolve within a year or two, when rapid cycling is identified prospectively," said Dr. William H. Coryell, the George Winokur Professor of Psychiatry at the University of Iowa, Iowa City.

More episodes, in any case, mean worse disease. Drug response tends to be more erratic, episode intensity greater, and interepisode functioning poorer. "It's particularly demoralizing to patients," Dr. Schneck said. "If they're chronically depressed, they can deal with it better than being good one week, terrible the next. There are data showing higher suicide rates."

The goal of treatment, as for bipolar disorder generally, is to abolish cycling altogether. "For patients who are early in the disease process, we can often do this," Dr. Calabrese said. "But when, as in many instances, that fails to happen, we want to slow episode frequency and reduce episode amplitude."

A first step, Dr. Schneck said, is addressing "cycle-promoting" factors. These include medical conditions such as hypothyroidism and medications such as steroids and muscle relaxants. Psychosocial factors like shift work, frequent travel, and interpersonal conflict also deserve attention. Substance abuse or withdrawal may be implicated, along with anything that can disrupt sleep, which can mean untreated sleep apnea, too much caffeine, or an evening glass of wine.

Antidepressants are a prime suspect in cycle acceleration, but their role must be considered in the overall context of pharmacotherapy, which is complex.

"Rapid cycling is less likely than non-rapid-cycling bipolar disorder to respond to the first drug you try," Dr. Coryell said.

The frequent need for multiple medication trials is a reason for careful mood charting, said Dr. Joseph F. Goldberg of Mount Sinai School of Medicine, New York. "Pin down how the switch occurs. Is it gradual or rapid? If the patient cycles gradually after 6 weeks, you can wrongly conclude that what you did was effective. If a patient's cycles are abrupt and a week after starting a new atypical antipsychotic he is manic, you might wrongly conclude the drug is to blame."

A mood chart that covers 6 months or a year gives a panoramic view of the illness that can clarify drug choice, Dr. …

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