Bipolar Disorder

   BIPOLAR DISORDER
Nurmiati Amir

Bipolar disorder is a mental disorder characterized by changes in mood (mood). Mood change is usually accompanied by a change of mind, energy, and behavior. There are five types of mood episodes that can occur in people with bipolar disorder: episodes of mania, hypomania, depression, mix, and Euthymia.
   

•        Mania episode: characterized by excessive joy, very excited or energized and many activities. Another sign is irritable or grumpy, talk a lot and fast (hard interrupted) and jump from one topic to another. His attention is distracted and his confidence increased and grandiosity, such as believing himself as an important person or great. Reduced of sleeping needs. He still feels fresh despite not sleep at night. People with bipolar disorder also wasteful, sexuality increases or explore many things related to sex. He is often unable to control himself. Power value is reduced and the perception of him is inaccurate. As a result, he can engage in risky behavior without realizing the consequences. For example, spending money, speeding on the highway, and to engage in unsafe sex, or involved legal issues. He also could have delusion and trust that is incompatible with the fact which has demonstrated clear evidence of the associated confidence. Hallucinations, such as hearing voices or seeing visions may also occur. Episodes of mania lasting for at least one week.
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•        Hypomania episode: the manifestation of symptoms similar with mania but lighter and shorter duration, and disturbance function is not flashy. His mood look "up" but not "sick". Hypomania is characterized by unrealistic optimism, irritability, decreased need for sleep, increased speech and activity, as well as hypersexuality. All these symptoms are seen not so extreme. During this period, people with bipolar disorder can conveniently indicates an increase in creativity and / or poor power value. Hypomania episode lasts at least four days.  
•        Depression episode: the mood is characterized by sadness, melancholy, anhedonia (inability to feel pleasure), loss of interest in usually enjoyable activities and loss of power. Other symptoms are guilt, regret, sinful, inferiority, shameful, do not want to hang out, reduced appetite, disturbed sleep, decreased memory, slow thinking, hesitation, and feeling hopeless. In severe circumstances, depressed people with bipolar disorder often have suicidal ideas and sometimes commit suicide. Episode of depression lasting for at least two weeks
•        Mix episode: a condition which is characterized by the occurrence of mania and depression simultaneously. When the episode mix, people with bipolar disorder will potentially trapped in a very dangerous condition with excessive force but the mood is very sad. He may experience agitation, edgy, increased energy, continuous anxiety and at the same time there is a feeling of worthlessness and want to do harm to themselves. The risk of suicide is higher in a mixed state because people with bipolar disorder have the power to carry out the ideas of suicide. Mix episode lasting for at least one week.  
•        Euthymia episode: the mood is in stable condition. In most people with bipolar disorder, euthymia is a fragile situation. They can recur in the form of mania, hypomania, mixed or depressed episodes. Some people with bipolar disorder can continuously experiencing mild hypomania or mild depression during the phase of "stabilization". Although the mood could be in euthymia, cognitive deficits (i.e. , difficulty of maintaining attention) continues to interfere the euthymic mood state of people with bipolar disorder.

   

Bipolar Disorder Types

Bipolar disorder is a spectrum disease with a very wide variation manifestations. Almost all people with bipolar disorder will experience one or more episodes of mania during their lives. The frequency and pattern of episodes may vary widely among the people with bipolar disorder.
   

•        Bipolar-I Disorder shows the classic picture of bipolar disorder. It is mania (either euphoria or irritable) and the degree of the depression episode is usually severe. People with Bipolar-I Disorder can experience hypomania episodes. Around 50% of the time people with Bipolar-I Disorder was filled with the symptoms. About three-quarters of the time is filled with depression. Approximately one fifth of the time show mania. In other words, the episode of depression is the predominant state.

•        Bipolar-II Disorder is less noticeable when compared to Bipolar-I Disorder because it is not easy to identify hypomania. In addition, people with Bipolar-II Disorder rarely seek for treatment. Although it is not as severe as Bipolar-I Disorder, Bipolar-II Disorder remains a serious disturbance. Episode of depression in Bipolar-II Disorder as severe as in Bipolar-I Disorder, and even more severe on Bipolar-II Disorder when compared to Bipolar-I Disorder. Therefore, Bipolar-II Disorder could not be considered milder than Bipolar-I Disorder.

•        About one-third of people with cyclothymia will eventually developed into Bipolar-1 Disorder or Bipolar-II Disorder.

   
Pathogenesis of Bipolar Disorder

Bipolar disorder (BD) is a chronic illness, episodic, often recurrent and usually lifelong. The first episode can be depression, mania, hypomania, or mixed. Depression is the most common first episode. People with bipolar disorder can be in a state of normal mood (Euthymia) in the long term but that does not mean the healing Euthymia. Symptoms can come back at any time without any signs (warning).

Bipolar disorder is a unique disease. It can hide (go underground) in the long term. It could be described like a bomb or walking on a rope. Concern of the emergence of a new episode always present for entire life.

Bipolar disorder is progressive disease. Every episode stimulates brain emerging next episode or recurrences. Recurrence can be triggered by unidentified reason. Every recurrence affects physiologic and neuron of patients. In other word, BD destroys neurons or neurodegenerative.

Bipolar disorder manifests differently in each people with bipolar disorder. Sometimes, the mood episode follows the specific pattern in a particular people with bipolar disorder. For example, Mania is followed by depression and then followed by euthymic period. Although many variations occur, most of the people with bipolar disorder mood doesn’t follow a specific pattern. For example, they have depression period longer than manic period.

The length of time between Euthymic episodes is also vary. It could be started in several hours or days up to years. In the early phase of the disease, the time between episodes could be longer and shorter as more progressive of the disease. The onset can occur suddenly (mostly in mania) or gradually (mostly in depressive)

   

   
Onset
The most frequent onset is between 15-24 years. Onset can be happened in geriatric. Onset after 60 years old can be triggered by physical disorder.
Formerly considered that bipolar disorder has never occurred before adolescence. Since five years ago, this concept has changed. Bipolar disorder can emerge from infant. The manifestation of Bipolar disorder in young people is different from adult. Therefore, early onset is still unknown. The early onset of BP is often characterized by an ultra-rapid cycle such as anger, against, irritable, and mild hyperactivity. They are diagnosed as an attention deficit/hyperactivity disorder (ADHD).

Epidemiology
Bipolar disorder may affect all races, ethnics, and social life. Prevalence of each type of bipolar is different. The World Mental Health Survey Initiative conducts an epidemiological survey of Bipolar Disorder (for entire life /last 12 months) involving 61.392 subjects.
   The results are:

1.        Bipolar disorder –I is {0.6% (0.4%)}, in adult population. Prevalence between men and women is same   
2.        Bipolar disorder –II is {0.4% (0.3%)}. Prevalence in woman is higher than man.  
3.        Bipolar Disorder Subambang is {1.4% (0.8%)}

   
Bipolar Disorder Spectrum
The actual prevalence of bipolar disorder is higher than ever expected. Bipolar disorder is undiagnosed. For example, depression in Bipolar disorder is mostly diagnosed as unipolar depressive disorder. Diagnosis of bipolar disorder is currently tight. Mild bipolar disorder is still undiagnosed. Actually, there are type of bipolar disorder which unclassified. If this happened, the prevalence of BD could be higher, such as 3%-8% in adult.
   

   
Management of Bipolar Disorder
Bipolar disorder therapy will be effective when managed comprehensively. Comprehensive procedures include psychopharmacology therapy, psycho-education, psychotherapy, electroconvulsive therapy (ECT) and rehabilitation. Management therapy has been adapted individually.

Psychopharmacology
The outcome of these pharmacotherapy is achieving complete remission, not only response. To get the outcome, we should use drugs which has been proven effectively over the years. None of drugs is totally effective but do not give up. Pharmacotherapy for bipolar disorder has already complex. Most of the patients are taking the drugs at least two to three types of drugs simultaneously. There are drugs which are used continuously, but some of them are intermittent.

Preferred drugs should be the best, such as :
   

1.        Safe and well tolerated   
2.        The most convenient (for patients)   
3.        The easiest management (for doctor)

   
For the best result, the instruments should be used to measure the symptomatic outcomes of BD. The instruments are Young Mania Rating Scale (YMRS) and Montgomery Asberg Depression Rating Scale (MADRS).

   The different between mania therapy and depressive therapy will be quite difficult. In many cases, drugs for a particular mood may induced another mood. For example, antidepressant can be a trigger of manic. First generation antipsychotic will trigger depression. Therefore, physician should determine the strategy of therapy carefully.

   Some factors which can be considered are :

1.        Appearance of symptoms (type and severity of episodes)   
2.        Pattern of previous cycles   
3.        A history of previous treatment response  
4.        The duration of a particular drug should be used to obtain benefits.  
5.        Comorbid diagnosis (psychiatric and physical) 
6.        Family history, such as the family's response to psychotropic drugs   
7.        Other medical conditions that exist in a patient which influence drug choice  
8.        Side effects   
9.        Age, gender, and psychosocial; history of patients
10.        Drugs that are consumed by patients for other diseases (side effects and drug interactions)

   
Choosing a drug is not easy. Drugs can be initiated or be modified when needed to get a response or well tolerability. Having enough time to try a drug is also important because, sometimes, an adequate response to new drugs will be obtained after few weeks. The doctor can assess the patient's response to drugs based on the report, the mental status examination, and the input from the family. Assessing procedures continuously are very important.

Bipolar Disorder Drugs

There are several drugs which have been used for acute mania, acute depressive or both. Moreover, there are several drugs which have been used for maintenance therapy.
   

   

References
   

1.        Akiskal HS. Mood Disorder: Clinical Features. Dalam: Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Sadock BJ, Sadock VA, Editors. 8th Ed. Lipincott Williams & Wiliknsf. 2004: hal.1611-1651.  
2.        American Psychiatric Association. Dalam:  Diagnostic and Statistical Manual of Mental Disorders. 5th Ed. 2013:123-154.  
3.        Angst, Gamma A, Benazzi F, Ajdacic V, Eich D, Rossler W. Diagnostic issues in bipolar disorder. Eur Neuropsychopharmacol. 2003; 13 (suppl 2): S 43-S50   
4.        Ketter TA. Diagnostic features, prevalence, and impact of bipolar disorder. J Clin Psychiatry 2010; 71(6): e 14.  
5.        Stahl SM. Antipsychotics Agents. Dalam: Stahl’s Essential Psychopharmacology. Camb nridge University Press, 4th Ed. 2013; 129-210.  
6.        Yatham LN, Kennedy SH, Parikh SV, dkk. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disorders 2013, hal. 1-44