The medical management of bipolar disorder

Rebecca Henry MRPharmS, MCMHP

Senior Pharmacist Mental Health
Southern Health NHS Foundation Trust 

Royal South Hants Hospital, Southampton, UK

Bipolar disorder, previously known as manic depression,

is a cyclical mood disorder involving periods of profound disruption to the mood and behaviour interspersed with periods of recovery. With appropriate treatment and support, patients in recovery appear no different from those without the illness. However, during the extreme mood fluctuations behaviour can be erratic, uncharacteristic and place the sufferer and others at risk. The key features of bipolar disorder include episodes of mania or hypomania with periods of euthymia (normal mood) or depression. Symptoms of mania include a persistently elevated mood, increased energy and activity, pressure of speech, distractibility and a loss of normal social inhibitions which may result in reckless or inappropriate behaviour. Hypomania presents as similar symptoms to those in mania but to a lesser severity and without the significant disruption to functioning. Symptoms of depression are the same as those seen in unipolar depression and include low energy, lack of interest and enjoyment in everyday activities and a persistent low mood. A simple five minute screening tool such as the Mood Disorder Questionnaire (MDQ) is useful to identify those who need more comprehensive investigations with mental health services.¹

The lifetime prevalence of bipolar disorder is between 1% and 3% depending on the diagnostic criteria used. The first episode usually occurs before the age of 30 (although there is often a significant delay before diagnosis), and some evidence points to a slightly higher rate of bipolar disorder in women and black and minority ethnic groups.²

The exact cause of the illness is unknown; however, there is probably a large genetic component which may account for neurotransmitter and brain structure abnormalities. 

Adverse social factors are also important and may trigger episodes or cause an earlier age of onset of the illness.² Physical conditions such as thyroid disease can mimic symptoms, while drugs such as antidepressants, L-dopa, corticosteroids and stimulants (both prescribed and illicit) can induce symptoms of mania.³

Treatment

The treatment of bipolar disorder aims to treat the correct phase of the illness in the short term and to prevent symptoms returning in the long term. 

Prescribers and other healthcare professionals should be aware that some of the medicines recommended for use in bipolar disorder do not have current UK product licences for the condition or particular phases of the condition.
In view of this, the rationale for using
a medicine