Bipolar disorder treatment
A diagnosis of bipolar affective disorder (manic-depressive disorder) is made if a person has had at least two affective phases, one of which must be a mania, a hypomania or a combined condition. Hypomania is characterized by the same symptoms as mania but in a milder form. Typically, the person does not feel ill and therefore does not seek bipolar disorder treatment.
In a combined condition there are both depressive and manic symptoms in the same illness phase. Previously it was thought that the lifetime risk of bipolar affective disorder was about 1% (which means that about 55,000 Danes develop this illness). However, new studies indicate that the frequency of previous hypomanic phases in those who are depressive is significantly higher than previously assumed. Furthermore, some people with recurring depressions develop manic symptoms.
It is therefore reasonable to assume that about 50% of those who have a depression should be placed within the bipolar spectrum. The diagnosis is difficult, because people often see their earlier hypomanic phases as a period of their life in which they were well-functioning and productive and did not feel ill.
Early diagnosis of bipolar affective disorder
The bipolar illness is characterized by an unstable mood and may be accompanied by varying degrees of sleep problems and anxiety. The illness is basically about periods with depressive symptoms, periods with hypomanic and manic symptoms or combined conditions in which there are both increases and reductions in energy, mood and cognitive function. These are the symptoms that have traditionally been watched for in order to make the bipolar affective disorder diagnosis, and many refuse to make the diagnosis until there are positive signs of both depression and mania.
The problem with this strategy is that depression and mania are often the last symptoms of the bipolar illness to appear. Symptoms such as sleep disturbances, anxiety, eating disorders or a high tolerance for alcohol are more frequently being viewed as the first signs of illness. Combined with high creativity, a need for or benefit from structure and exercise, and the existence of other family members with mental disorders all serve to increase the suspicion of a possible bipolar illness with development of depressive and hypomanic/manic symptoms in later life.
During the past 10-20 years there has therefore been an increased focus on what we call the bipolar spectrum. Instead of waiting to see the degree of depression or mania that has traditionally been required in order to make the diagnosis, a diagnosis within the bipolar spectrum is used to initiate an earlier bipolar disorder treatment and to work with prevention. Treatment for a patient who is suspected of being within the bipolar spectrum can very well differ from the treatment for a bipolar disorder.
Much of the treatment that is initiated in cases where there is only a suspicion of bipolar affective disorder is non-pharmacological and can in many cases stand alone as a preventive measure against further progression of the illness. This involves a focus on sleep, structure, exercise and caution with respect to alcohol and drugs.
Often the ”reward” for using the bipolar spectrum is that incorrect treatment may be avoided. This is especially true of patients who receive antidepressants as treatment for depression. It seems logical enough: the patient has not previously been manic, there are no immediate signs of hypomania, and the patient is clearly suffering because of the depressive symptoms.
The problem with antidepressants – and the reason why they must be handled with care – is that in patients with bipolar affective disorder it can result in mania. At an early stage of the disease progression, it is very likely that there have not yet been any clear signs of mania or hypomania, so how does one separate patients with a single depression from those who have the first depression of a bipolar disorder?
There are two different pharmacological treatments (antidepressants and mood-stabilizing medicine such as lithium). The non-pharmacological treatment is much the same, although it is probably most important for the bipolar patient, because it is to a high degree used to stabilize the mood and thereby prevent later fluctuations. It therefore makes a great deal of sense to focus on the non-pharmacological treatment and exercise caution regarding the use of antidepressants, because a sudden mania can be extremely unpleasant.
Antidepressants may not only be harmful when given to bipolar patients, it may also be difficult to phase out the treatment without causing unpleasant side effects (withdrawal symptoms). Lithium, on the other hand, does not have the same consequences when given to a person not suffering from bipolar disorder.
It may sound frightening to speak of bipolar disorder if one does not identify oneself as having depression and mania, but the diagnosis is important to the treatment. It may therefore be appropriate to speak of the bipolar spectrum at an early treatment stage, even though manias or depressions may not yet present themselves clearly, and even though the initiation of a pharmacological treatment may not yet be relevant. The bipolar spectrum is a more nuanced way of looking at the mental suffering, and can be of help if medicine must be considered as a treatment at some later point in time.