Bipolar disorder often considered a mood disorder that characterized by impairing episodes of depression and mania. For the most part, the onset of this disorder occurs either in adolescence or early adulthood, even though there is a possibility that the disorder can occur later in life. Generally speaking, bipolar has a long life effect on patients’ life quality, health status, as well as functioning. The disorder affects approximately 0.02% of the globe’s population, with other forms of the disorder impacting another 0.02%. Even with the aid of treatment, nearly 0.37% of patients become depressed or experience manic episodes within one year, and about 0.6% within two years (Geddes & Miklowitz, 2013).
There are two types of bipolar disorder namely, bipolar I and bipolar II. Bipolar I is usually identified by mania presence and depression episodes. In contrast, bipolar disorder II is defined by episodes of hypomania and depression. Thus, the primary difference between the two types of bipolar is the severity of symptoms of mania. It is imperative to note that full mania leads to adverse functional impairment which can include psychosis symptoms and regularly requires hospitalization. Hypomania, on the other hand, is not harmful enough to cause notable impairment in both occupational and social functioning or to demand hospitalization. As indicated by Jann (2014), longitudinal studies suggest that individuals with either type of bipolar disorder experience symptoms of depression at least three times more often than symptomatic hypomania or mania. It should be noted that in the United States, the lifetime prevalence of the disorder is said to be 3.9%.
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The Clinical Spectrum of Bipolar Disorder
Markedly, the diagnosis of bipolar has changed from Emil Kraepelin’s explanation as manic-depressive insanity more than a century ago. In the decade of the 1950s and early 1960s, some researchers supported the division of affective disorders into unipolar and bipolar disorders. The most vital feature of bipolar is the manic episode. It is defined by at least a week of significantly irritable or elated mood. The elated mood is often followed by at least three of the following; pressured or rapid speech, racing thoughts, notable distractibility, heightened agitation or goal-oriented action, high-risk or impulsive behaviors such as hypersexuality and reckless spending (Barnett & Smoller, 2009). To qualify as an episode of mania, the signs must lead to significant occupational or social functioning, hospitalization or psychosis.
In most cases, most people with bipolar disorder experience episodes of depression even though it is not needed for the diagnosis. In the period of the 1970s, a further difference was made between bipolar I and bipolar II disorder. As mentioned earlier, hypomania is a less severe form of mania needing at least four days of symptoms with both an observable and uncharacteristic change in function but not distinct psychosis, impairment, or requirement for hospitalization. According to Barnett & Smoller (2009), episodes of mood in which criteria are met for both a major depressive and manic episodes are known as mixed episodes. Also, a rapid-cycling bipolar disorder is diagnosed when at least four or more mood episodes (hypomania, mania, mixed, or depression) take place within a one year period and episodes are distinguished either by full or partial remission for about two months.
The National Comorbidity Survey Replication recently conducted a survey which brought to light that the lifetime prevalence of bipolar type I disorder is 0.01%, with a further 0.011% prevalence of bipolar II. Interestingly, a more substantial part of the population displays subthreshold forms of the disorder. As per Barnett & Smoller (2009), women and men are roughly equally at risk, and the mean age of the onset of bipolar I is 18 years whereas the mean age for Bipolar II is 20 years. Equally important, other diagnoses in the Diagnostic Statistical Manual of Mental Disorders (DSM-V) bipolar spectrum consists of cyclothymia which is often characterized by at least 24 months of depressive and hypomania symptoms that fail to meet the standard for a depressive or manic episode.
Medical Burden in Bipolar Disorder
Bipolar disorder is associated with an increase in other medical conditions, for instance obesity, cardiovascular illness, diabetes/the resistance of insulin, arthritis, pain, as well as headache. Likewise, alcohol use disorders commonly known as (AUDs) are common in bipolar disorder. First, when it comes to insulin resistance/diabetes and obesity, most adults with bipolar are usually obese. In addition, epidemiologic data indicates mutually heightened prevalence of obesity and bipolar disorder (Goldstein, Kemp, Soczynska, & Mclntyre, 2009). In a similar fashion, the prevalence of diabetes is increased in bipolar, even after regulating for psychotropic medications.
Second, cardiovascular illness is another medical condition that is prevalent in individuals with bipolar disorder. For more than 25 years, various researchers have demonstrated elevated mortality as a result of cardiovascular illness in bipolar, with the most recent estimates showing standardized death ratios of 2.6 and 1.9 for women and men, respectively. Additionally, the onset of cardiovascular disease may be earlier than in the whole population. Third, there is scientific proof for increased burden of severe conditions of pain, including a backache, arthritis, and headache in bipolar I and II disorder (Goldstein, Kemp, Soczynska, & Mclntyre, 2009). Evidently, pathological pain is mediated by cytokines.
Finally, alcohol use and smoking are prevalent among the majority of patients with bipolar at a particular point during their lifetime. Notably, in bipolar disorder, alcohol is the most common substance of abuse. At the same time, bipolar disorder is unquestionably the Axis I mental disorder most strongly linked to AUDS. Goldstein, Kemp, Soczynska, & Mclntyre (2009), note that epidemiologic data brings to light that the lifetime prevalence of daily smoking among persons with bipolar disorder is 0.825%, more than two times higher than that of individuals with no psychiatric illness (0.391%). According to Goldstein, Kemp, Soczynska, & Mclntyre (2009), the figure is higher than that of individuals with lifetime depression (0.59%). Sadly, the rate of cessation for people with bipolar (0.166%) is substantially minimal than that for persons with no psychiatric illness (0.425%) or those with depression (0.381%).
Diagnosis of Bipolar Disorder
Essentially, the diagnosis of bipolar disorder is apparent when an individual presents with florid mania. However, it becomes challenging when the first presentation involves symptoms of depression; research, in general, reports that 0.5% or more of patients initially present with symptoms of depression mainly because unipolar depression is more prevalent than bipolar depression. More so, bipolar disorder does not have pathognomonic characteristics. Hence it is regular incorrectly identified as unipolar depression.
Among people who are later on diagnosed with bipolar, nearly 0.7% report being initially misdiagnosed and more than 0.33% remain with their incorrect diagnosis for ten years or more (Jann, 2014). More specifically, delay in diagnosis is a specific issue among women with bipolar II disorder as hypomania symptoms may not be very evident. Further, during the period of postpartum, misdiagnosis is common; in research involving 56 women having postpartum depression, 0.54% of them were later re-diagnosed with bipolar disorder.
Following Jann (2014), the delayed awareness of bipolar disorder has severe healthcare and clinical cost aftermath. From the perspective of a clinician, individuals with bipolar disorder who are only treated with antidepressants are less likely to have a suitable response. In addition, they are at high risk of a manic switch or cycle acceleration. To put it more simply, cycle acceleration is elevated frequency of mood episodes over a period.
Jann (2014), acknowledges that from a health economic side, there is a high probability that care will be more costly in people with a delayed diagnosis of bipolar than in those who are diagnosed early. According to an examination by the California Medicaid program, two patient groups with bipolar were compared; those whose diagnosis was delayed during a six-year follow-up and those who were appropriately diagnosed with bipolar at the first presentation (Jann, 2014). From the findings, patients with a delayed diagnosis were almost twice as many cases as those with initially diagnosed bipolar. Also, the yearly total cost per person in the deferred category was $2316 higher during the sixth year as compared with the cost for persons whose illness was initially recognized as bipolar disorder (Jann, 2014).Furthermore, the patient costs with bipolar disorder and a delayed diagnosis rose by $10 monthly before the appropriate diagnosis and it consequently reduced by $1 afterward. Therefore, putting into account the likelihood of bipolar in patients with depressive episodes is crucial in enhancing outcomes and minimizing the healthcare costs of patients with bipolar disorder.
Notably, screening patients for a history of hypomania and mania on their first presentation of symptoms of depression is an important step towards the identification of bipolar disorder. In fact, validated instruments that can be employed include the Composite International Diagnostic Interview, Mood Disorder Questionnaire, as well as the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (Jann, 2014). More importantly, clinical screening can be amplified with electronic health record (HER)-based findings, in which the data gathered by a healthcare assistant or self-report is recorded into the HER and is further screened for probable signs of bipolar disorder.
Admittedly, the tools mentioned above assist in ensuring that the clinician identifies patients who have a high possibility of having bipolar disorder (Jann, 2014). Moreover, they help in directing the clinical interview and can instigate active follow-up for any arising symptoms of the disorder. In research modeling the cost-effectiveness and clinical outcome over five years of giving out the Mood Disorder Questionnaire to all individuals initially demonstrating symptoms of unipolar depression, screening consequently led to a rise in accuracy in diagnosis for bipolar disorder and with a further 38 cases recognized per 1000 patients examined (Jann, 2014). Furthermore, a total of $1937 savings was saved per patient, and in a year, about $1.9 million was saved.
Treatment of Bipolar Disorder
Mood Stabilizers
Generally, lithium has been considered to be the treatment foundation of bipolar disorder for over six decades. Nonetheless, its efficacy in the treatment and prevention of bipolar depression is restricted, and it is not highly effective for severe mania. It should be noted that lithium remains the only mood stabilizer approved to minimize the risk for suicide in bipolar patients. On the other hand, sodium valproate is the most commonly utilized antiepileptic mood stabilizer for bipolar patients. However, in most cases, lithium has proved to be more effective as compared to valproate in treating bipolar disorder (Jann, 2014). Another mood stabilizer is lamotrigine, and it has the most suitable evidence for bipolar depression prophylaxix. Notably, published research on the utilization of lamotrigine for severe depression in bipolar disorder patients is inconsistent. Nevertheless, a meta-analysis found marked efficiency for a higher dose of 200 mg/day.
Inherently, the mood stabilizers mentioned earlier present essential safety problems. Firstly, lithium has a narrow therapeutic window that results in the need for frequent monitoring of the concentrations of serum. Additionally, it can be lethal in overdose and is connected with accelerating hypothyroidism and renal insufficiency (Jann, 2014). Secondly, valproate is linked to hepatotoxicity while lamotrigine is associated with Stevens-Johnson-Like syndrome and rash (Jann, 2014). Equally, lithium and valproate are both considered to be teratogenic.
Atypical Antipsychotics
Many researchers and clinicians support the utilization of atypical antipsychotics in treating bipolar disorder. The most developed role for this drug is in treating acute mania. Evidently, all authorized atypical antipsychotics apart from lurasidone are efficacious in the treatment of manic episodes of bipolar. On the contrary, only quetiapine has the highest level of proof for efficiency as monotherapy for both bipolar I and II depression (Jann, 2014). Recently, quetiapine was also indicated to decrease depression symptoms in severe mixed episodes of hypomania. However, atypical antipsychotics are widely known to contribute to metabolic risk in bipolar patients, and strategies for monitoring have been advocated to minimize, prevent, or detect the early signs of metabolic risk so that suitable measures can be taken.
Antidepressants
The utilization of antidepressants as pharmacotherapy for bipolar has given rise to a lot of controversies. Antidepressants, in essence, are not approved by the FDA for the treatment of the disorder, even though they are regularly prescribed to bipolar patients in clinical practice. However, olanzapine in combination with fluoxetine can be employed in the treatment of bipolar.
Major Challenges in the Treatment of Bipolar Disorder
Treatment Nonadherence
Over time, treatment nonadherence has become the most significant factor that contributes to poor outcome in bipolar patients. Treatment adherence is typically assessed by medication possession ratio (MPR) (Jann, 2014). MPR refers to the number of days ratio that an antipsychotic medication, for instance, was filled, in comparison to the total number of days during the period of follow-up. An MPR ratio of 1 shows that for a medication given to a patient over a given time frame, prescriptions were, in turn, filled 100% of that period. It is imperative to note that MPR thresholds of 70% to 80% have been put in place to indicate adherence versus nonadherence. Thus, a limit of 80% or 75% significantly represents an adherence level that is connected with better results in bipolar patients (Jann, 2014).
Psychiatric Comorbidities
Chiefly, bipolar patients are affected by other cormobid psychiatric disorders at higher rates as compared to patients with other mental disorders. Jann, (2014) asserts that drug or alcohol dependence and anxiety disorders are especially prevalent comorbidities, with significant consequences for the outcome of treatment and high cost. Undoubtedly, comorbidity is the rule instead of the exception in bipolar, with roughly 0.66% of patients having one comorbid diagnosis of mental health and nearly 0.66% having two other conditions (Jann, 2014). Notably, these comorbid psychiatric conditions are linked to more extended episodes of bipolar disorder; polypharmacy, with the likelihood for interactions with drugs; shorter remission time; and a rise in related issues, such as suicidality as well as reduced compliance of treatment (Goldstein, Kemp, Soczynska, & Mclntyre, 2009).
General Medical Comorbidities
In addition, bipolar patients have a high rate of other medical comorbidities such as obesity, cardiovascular disease, migraine, diabetes, as well as hepatitis C virus (HCV) infection. Many reasons can probably account for this high burden of medical diseases. To begin with, there is shared biological predisposition, for example, migraine. Second, there is comorbid substance misuse (HCV), and lastly, there are harmful impacts of treatment which can explain diabetes and obesity (Jann, 2014). It is not surprising to hear that medical comorbidities are affiliated with a marked rise in the total cost of healthcare.
Suicide
For the most part, suicide is more common among bipolar patients than among patients with other mental or general medical disorders. In fact, suicide among bipolar patients is approximated to take place at a yearly rate of 4% which is more than the number of suicide rates that occur in the U.S population (Breznokov, 2012). The Epidemiologic Catchment Area database is one of the best databases in America in regards to the epidemiology of mental disorders. The database revealed that the rate of suicide attempts in a lifetime for individuals with bipolar disorder was almost 29.2%, which is nearly twice the rate of unipolar disorder.
Inherently, suicide attempts are very costly. According to a study utilizing information from the PharMetrics Integrated Outcomes Database, the total cost for three hundred and fifty-two bipolar patients who attempted to take away their own lives was contrasted between the years before and after the first attempt of suicide. The results indicated that the mean cost of healthcare for the one year after the attempt of suicide was $25,012 versus $11,476 for a year before (Jann, 2014). During the month immediately after the suicide attempt, a significant increase was reported in emergency and inpatient services, followed by lasting long-term rises in outpatient and medication costs as well.
Conclusion
In summary, bipolar disorder is one of the most prevalent mental disorders in the society today. It is generally characterized by manic and depressive episodes as well. Overall, mood stabilizers, Atypical Antipsychotics, and antidepressants are prescribed for the treatment of bipolar. Nonetheless, as previously mentioned, bipolar patients are susceptiple to other medical illnesses such as diabetes, migrains, cardiovascular diseases, obesity, alcohol abuse and even suicidal tendencies. As such, it is challenging to adequately treat bipolar disorder. Also, the costs of healthcare for bipolar patients and their caregivers are enormous. Therefore, it the duty of healthcare professionals to minimize the strain of bipolar disorder.
References
Barnett, J. H., & Smoller, J. W. (2009). The Genetics of Bipolar Disorder. PubMed Central , 331-343. doi:10.1016/j.neuroscience.2009.03.080
Breznokov, D. (2012). Bipolar Disorder and Suicide. Bipolar Disorder - A Portrait of a Complex Mood Disorder . doi:10.5772/34396
Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of Bipolar Disorder. PubMed Central , 381. doi:10.1016/S0140-6736(13)60857-0
Goldstein, B. I., Kemp, D. E., Soczynska, J. K., & Mclntyre, R. S. (2009). Inflammation and the Phenomenology, Pathophysiology, Cormobidity, and Treatment of Bipolar Disorder: A systematic Review of the Literature. Journal of Clinical Psychiatry, 70 (8), 1078-1090. Retrieved from https://www.researchgate.net/profile/Joanna_Soczynska/publication/26267489_Inflammation_and_the_Phenomenology_Pathophysiology_Comorbidity_and_Treatment_of_Bipolar_Disorder_A_Systematic_Review_of_the_Literature/links/5994b7540f7e9b98953afc39/Inflammation-a
Jann, M. W. (2014, December). Diagnosis and Treatment of Bipolar Disorders in Adults: A Review of the Evidence on Pharmacologic Treatments. American Health and Drug Benefits, 7 (9), 489-499. Retrieved April 20, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296286/
