Assessment and Treatment of Patients With Bipolar Disorders

Introduction to bipolar disorders

Mental health has become an increasingly critical public health issue. In the united states, it is estimated that one in every five adults has a mental illness. This represents about 5.8 million citizens in the United States alone (Jian, 2023). Bipolar disorder is one of the most typical mental illnesses, and it refers to bipolar disorder as a mental illness that is marked by episodes of mania (abnormally elevated or irritable mood) and depression (extreme sadness or hopelessness) that interfere with daily functioning (Jain, 2023). Bipolar disorder is also known as manic-depressive illness and is a chronic and often lifelong condition.

Prevalence order bipolar disorders in the USA

Bipolar disorders are shared globally, although some regions experience higher prevalences than others. The National Comorbidity Survey Replication (NCS-R) estimates that in the United States of America, about 2.8% of the population suffers from bipolar disorders. However, the prevalence was slightly higher in males at 2.9%, compared to females at 2.8%. The report further indicates that 4.4% of adults suffer an episode of bipolar disorder once in their lifetime. Adolescents and adults between 18 and 35 are the most affected, while the elderly are the least affected. The number of people suffering from mental health disorders has gradually increased, especially after COVID-19. However, statistics show that less than 5% of the affected population is treated. The report also offers a significant deficit in knowledge of the signs and symptoms of bipolar disorder and the treatment course.

Bipolar I disorder

This is the most common type of bipolar disorder; the patient experiences full-blown maniac episodes accompanied by severe depression. The condition is also characterized by prolonged sleep periods and a noticeable change in the patient’s normal functioning regarding attendance to daily activities. This subtype varies from bipolar disorder II in that the episodes of mania are mild and do not involve psychosis and severe functional impairment. Additionally, maniac episodes are punctuated by powerful to mild symptoms of depression.

Epidemiology of bipolar I

The symptoms of bipolar I am usually chronic and sometimes lifelong. The age of onset of symptoms varies from childhood to adulthood, but most patients develop symptoms between 15 and 19 years and sometimes between 20 and 24 years(Patel et al., 2018). The disorder occurs equally in both genders.

Globally, the condition accounts for 0.6% of all bipolar disorders (Patel et al., 2018). In the United States, bipolar I have been diagnosed in 2.9% of all adolescents diagnosed with bipolar disorders. 2.6% suffer severe impairment.

Pathophysiology of bipolar I

The development of bipolar is a complex process involving neurobiological, neurotransmitter, neuroendocrine, and immune systems. Genetics has been implicated as a significant risk factor for the development of bipolar (Kato et al., 2019). Various studies have shown that patients exhibiting bipolar symptoms also have altered neurotransmitter levels in the brain. For example, dopamine and norepinephrine levels are increased and decreased, respectively. Increased dopamine levels are responsible for elevated mood, impulsivity, and hyperactivity.

The development of bipolar is a complex process involving neurobiological, neurotransmitter, neuroendocrine, and immune systems. Genetics has been implicated as a significant risk factor for the development of bipolar. Various studies have shown that patients exhibiting bipolar symptoms also have altered neurotransmitter levels in the brain. For example, dopamine and norepinephrine levels are increased and decreased, respectively (Espay et al., 2018). Increased dopamine levels are responsible for elevated mood, impulsivity, and hyperactivity. On the other hand, reduced norepinephrine levels, especially in the prefrontal cortex, are responsible for poor concentration and loss of interest in previously pleasurable activities.

Abnormalities in the serotonin transporter gene lead to serotonin dysfunction (Espay et al., 2018). This leads to reduced serotonin levels, leading to low mood and severe symptoms of depression. An abnormality is also observed in the hypothalamic-pituitary-adrenal axis, leading to increased cortisol production in response to stress and depression, and maniac episodes.

Diagnosis of bipolar I according to DSM-5 criteria

The Diagnostic and Statistical Manual Mental Disorders 5th edition, for the diagnosis of bipolar I disorder, the patient has to meet the following criteria (APA, 2015)

1. The person has to have experienced one major episode of mania, lasting for a week and accompanied by mood changes.
2. The mania episode must be accompanied by three or more of
3. Abnormally high self-esteem or grandiosity
4. Decreased need for sleep
5. More talkative than usual or pressured to keep talking
6. Flight of ideas or racing thoughts
7. Easily distracted
8. Increased goal-directed activity or psychomotor agitation
9. Excessive involvement in pleasurable activities that have a high potential for painful consequences
10. The symptoms must be severe enough to cause occupational, social, or cognitive impairment and often require hospitalization to prevent self-harm.
11. Medical conditions, substance abuse, or other mental disorders do not cause maniac episodes.

Diagnosis of bipolar disorders in children and adolescents (DSM-5)

Children and adolescents may present differently from adults (Grunze et al., 2022). However, the diagnostic criteria require either group to present with (APA, 2015)

1. Abnormally elevated or irritable mood, lasting for more than seven days, requires hospitalization and is accompanied by three or more of

a. Abnormally high self-esteem or grandiosity

b. Decreased need for sleep

c. More talkative than usual or pressured to keep talking

d. Flight of ideas or racing thoughts

e. Easily distracted

f. Increased goal-directed activity or psychomotor agitation

g. Excessive involvement in pleasurable activities that have a high potential for painful consequences

2. Symptoms of depression include very low moods, loss of interest in playing, loss of weight, loss of energy, feelings of worthlessness or excessive guilt, poor concentration, and suicidal ideation.

3. Significant impairment in academic, social, and other functions.

4. Medical or other mental disorders, including substance use, do not cause the symptoms.

Treatment of bipolar disorder I in adults and elderly group

The approach to patient management depends on the presenting condition and symptoms. Patients without severe functional impairment and maniac episodes are managed as outpatients. In contrast, those posing a danger to themselves or others, with marked delirium and loss of cognitive and social function, should be admitted and treated as inpatients(Severus, 2018).

When choosing pharmacologic therapy, the patient’s age is critical to consider. This is especially true in children and the elderly, who are prone to drug toxicity, reduced drug metabolic rate, and multiple drug interactions in the elderly (Post et al., 2021).

Acute bipolar episodes present with acute mania and depression. The FDA has approved the use of mood stabilizers, antipsychotics, valproate, and benzodiazepines to control agitation, aggression, and sleep disturbance. The first line gold standard treatment of bipolar I disorder is the use of Lithium.

Lithium

Lithium is considered the first-line treatment option for bipolar disorder because it prevents acute mania and depression (Girardi et al., 2019). It is also effective in reducing suicide tendencies in patients. Lithium is classified as a mood stabilizer and functions at the synapse by modulating the production of neurotransmitters, specifically GABA, dopamine, and glutamate. The drug is available as 150mg, 300mg, and 6oomg capsules of 300mg and 450mg extended-release tablets.

It has a narrow therapeutic window and should therefore be used with caution. Lithium levels should be occasionally monitored, at 12 hours, twice weekly, and then monthly during treatment to ensure therapeutic blood levels between 0.6-1.2 mmol/L. kidney function should also be closely monitored (Fountoulakis et al., 2022).

Potential side effects from lithium toxicity include severe nausea, vomiting, and diarrhoea, common in the first few weeks of treatment. Others include tremors, especially in the hands, increased urination, thirst, and seizures.

In adults, the dose is P.O LithiumLithium capsules 900mg every 8 hours for one week. Suppose the symptoms resolve and no toxicity is noted. In that case, the maintenance dose can be increased or maintained using sustained-release tablets such as P.O Lithium-ER Tablets 900mg every 12 hours for four weeks. In children, dosing is weight-based at 15mg/kg/ day, but the initial dose should be at most 600mg. For example, a child less than 30 kg and more than seven years but less than 12 years will receive a P.O. Lithium capsule 300mg every 12 hours for a week and maintained based on response (Cichon et al., 2020).

Selective serotonin Reuptake Inhibitors (SSRIs)

This medication class inhibits serotonin reuptake, thereby reducing depression by alleviating mood. Examples of FDA-approved brands include Fluoxetine, Citalopram, Paroxetine, Sertraline and Fluvoxamine. Fluoxetine is commonly used and is available in 20 mg capsules. The recommended dose is 20mg once daily, titrated based on response and side effects. In elderly patients, the drug can lead to toxicity and hypernatremia and should therefore be used after kidney function, and electrolyte levels are assessed. The recommended dose is P.O. Fluoxetine tabs 20mg before bedtime for one week.

Conclusion

Bipolar disorder is a mental condition characterized by severe depression and episodes of mania. There are several types, but Bipolar I is the most common and affects all age groups and gender equally. The condition is diagnosed based on the DSM-5 manual, and management is by use of mood stabilizers such as LithiumLithium and also the use of SSRIs. Regular kidney function tests should be performed in the elderly and children using LithiumLithium due to the risk of toxicity.

References

American Psychiatric Association. (2015). Depressive disorders: DSM-5® selections. American Psychiatric Pub.

Cichoń, L., Janas-Kozik, M., Siwiec, A., & Rybakowski, J. K. (2020). Clinical picture and treatment of bipolar affective disorder in children and adolescents. Obraz kliniczny i leczenie choroby afektywnej dwubiegunowej u dzieci i młodzieży. Psychiatria polska, 54(1), 35–50. https://doi.org/10.12740/PP/OnlineFirst/92740

Fountoulakis, K. N., Tohen, M., & Zarate, C. A., Jr (2022). Lithium treatment of Bipolar disorder in adults: A systematic review of randomized trials and meta-analyses. European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology, 54, 100–115. https://doi.org/10.1016/j.euroneuro.2021.10.003

Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations. Drugs in R&D, 16(4), 293–302. https://doi.org/10.1007/s40268-016-0139-7

Grunze, A., Born, C., Fredskild, M. U., & Grunze, H. (2021). How Does Adding the DSM-5 Criterion Increased Energy/Activity for Mania Change the Bipolar Landscape? Frontiers in psychiatry, 12, 638440. https://doi.org/10.3389/fpsyt.2021.638440

Jain, A., & Mitra, P. (2023). Bipolar Disorder. In StatPearls. StatPearls Publishing.

Kato T. (2019). Current understanding of bipolar disorder: Toward an integration of biological basis and treatment strategies. Psychiatry and clinical neurosciences, 73(9), 526–540. https://doi.org/10.1111/pcn.12852

Patel, R. S., Virani, S., Saeed, H., Nimmagadda, S., Talukdar, J., & Youssef, N. A. (2018). Gender differences and comorbidities in U.S. adults with bipolar disorder. Brain sciences, 8(9), 168.

Post, R. M., & Grunze, H. (2021). The Challenges of Children with Bipolar Disorder. Medicine (Kaunas, Lithuania), 57(6), 601. https://doi.org/10.3390/medicina57060601

Severus, E., & Bauer, M. (2018). Diagnosing bipolar disorders in DSM-5. International journal of bipolar disorders, 1(1), 1–3.