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Bipolar disorder: Strategies for the lifelong illness

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Current Psychosis & Therapeutics Reports

Abstract

Bipolar disorder has a lifelong course. Our understanding of the illness is not complete enough to detect it before the first manic or hypomanic episode. Treatment of bipolar disorder has three phases. The continuation phase comprises the transition between symptomatic improvement after correct diagnosis and effective treatment of an episode and functional recovery. This phase requires continuation of effective pharmacologic treatments combined with nonpharmacologic treatments that will provide the basis for education, monitoring, and anticipation of relapse. The maintenance phase begins when pre-episode function has been regained. Placebo-controlled data for mania support lithium, olanzapine, and divalproex in patients whose most recent episode responded to one of these treatments. Carbamazepine lacks placebo-controlled studies but appears to have response predictors that are complementary to those of lithium. For prevention of depressive episodes, which are at least twice as frequent as mania, placebo-controlled data support lithium, lamotrigine, and divalproex. Treatment response may depend upon the course of illness. There are relatively little data about long-term treatment response in bipolar II disorder or rapid-cycling. Although current treatments are effective, especially when combined with appropriate nonpharmacologic treatments, more definitive strategies require a better understanding of the physiologic processes underlying the recurrent nature of bipolar disorder.

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References and Recommended Reading

  1. First MB, Spitzer RL, Gibbon M, Williams JB:Structured Clinical Interview for DSM-IV Axis I Disorders Patient Edition. New York: New York State Psychiatric Institute; 1996.

    Google Scholar 

  2. Perugi G, Micheli C, Akiskal HS, et al.: Polarity of the first episode, clinical characteristics, and course of manic depressive illness: systematic retrospective investigation of 320 bipolar I patients.Compr Psychiatry 2000,41:13–18.

    Article  PubMed  CAS  Google Scholar 

  3. Lish JD, Dime-Meenan S, Whybrow PC, et al.: The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members.J Affective Disord 1994,31:281–294.

    Article  CAS  Google Scholar 

  4. Swann AC, Geller B, Post RM, et al.: Practical clues to early recognition of bipolar disorder: a primary care approach.Prim Care Companion J Clin Psychiatry 2005,7:15–21.

    Article  PubMed  Google Scholar 

  5. Suppes T, Dennehy EB, Hirschfeld RM, et al.: The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder.J Clin Psychiatry 2005,66:870–886.

    PubMed  Google Scholar 

  6. Post RM, Denicoff KD, Leverich GS, et al.: Morbidity in 258 bipolar outpatients followed for 1 year with daily prospective ratings on the NIMH life chart method.J Clin Psychiatry 2003,64:680–690.

    Article  PubMed  Google Scholar 

  7. Judd LL, Akiskal HS: Depressive episodes and symptoms dominate the longitudinal course of bipolar disorder.Curr Psychiatry Rep 2003,5:417–418.

    Article  PubMed  Google Scholar 

  8. Post RM, Leverich GS, Nolen WA, et al.: A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation Bipolar Network.Bipolar Disord 2003,5:396–406.

    Article  PubMed  Google Scholar 

  9. Frye A, Gitlin MJ, Altshuler LL: Unmet needs in bipolar depression.Depress Anxiety 2004,19:199–208.

    Article  PubMed  Google Scholar 

  10. Bauer MS, Altshuler L, Evans DR, et al.: Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder.J Affect Disord 2005,85:301–315.

    Article  PubMed  Google Scholar 

  11. Kraepelin E:Manic-depressive Illness and Paranoia. Edinburgh, Scotland: E & S Livingstone; 921.

    Google Scholar 

  12. Cutler NR, Post RM: Life course of illness in untreated manic-depressive patients.Compr Psychiatry 1982,23:101–115.

    Article  PubMed  CAS  Google Scholar 

  13. Turvey CL, Coryell WH, Solomon DA, et al.: Long-term prognosis of bipolar I disorder.Acta Psychiatr Scand 1999,99:110–119.

    Article  PubMed  CAS  Google Scholar 

  14. Swann AC, Bowden CL, Calabrese JR, et al.: Differential effect of number of previous episodes of affective disorder on response to lithium or divalproex in acute mania.Am J Psychiatry 1999,156:1264–1266.

    PubMed  CAS  Google Scholar 

  15. Gelenberg AJ, Kane JM, Keller MB: Comparison of standard and low serum levels of lithium for maintenance treatment of bipolar disorders.N Engl J Med 1989,321:1489–1493.

    Article  PubMed  CAS  Google Scholar 

  16. Coryell W, Endicott J, Keller M: Rapidly cycling affective disorder. Demographics, diagnosis, family history, and course.Arch Gen Psychiatry 1992,49:126–131.

    PubMed  CAS  Google Scholar 

  17. Maj M, Pirozzi R, Formicola AM, Tortorella A: Reliability and validity of four alternative definitions of rapid-cycling bipolar disorder.Am J Psychiatry 1999,156:1421–1424.

    PubMed  CAS  Google Scholar 

  18. Coryell W, Solomon D, Turvey C, et al.: The long-term course of rapid-cycling bipolar disorder.Arch Gen Psychiatry 2003,60:914–920.

    Article  PubMed  Google Scholar 

  19. Calabrese JR, Shelton MD, Rapport DJ, et al.: A 20-month, double-blind, maintenance trial of lithium versus divalproex in rapid-cycling bipolar disorder.Am J Psychiatry 2005,162:2152–2161.

    Article  PubMed  Google Scholar 

  20. Calabrese JR, Suppes T, Bowden CL, et al.: A double-blind, placebo-controlled, prophylaxis study of lamotrigine in rapid-cycling bipolar disorder. Lamictal 614 Study Group.J Clin Psychiatry 2000,61:841–850.

    Article  PubMed  CAS  Google Scholar 

  21. Judd LL, Akiskal HS, Schettler PJ, et al.: The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders?J Affect Disord 2003,73:19–32.

    Article  PubMed  Google Scholar 

  22. Quitkin FM, Rabkin JG, Prien RF: Bipolar disorder: are there manic-prone and depressive-prone forms?J Clin Psychopharmacol 1986,6:167–172.

    Article  PubMed  CAS  Google Scholar 

  23. Judd LL, Schettler PJ, Akiskal HS, et al.: Long-term symptomatic status of bipolar I vs. bipolar II disorders.Int J Neuropsychopharmacol 2003,6:127–137.

    Article  PubMed  Google Scholar 

  24. Dunner DL, Stallone F, Fieve RR: Lithium carbonate and affective disorders. V: a double-blind study of prophylaxis of depression in bipolar illness.Arch Gen Psychiatry 1976,33:117–120.

    PubMed  CAS  Google Scholar 

  25. Fieve RR, Kumbaraci T, Dunner DL: Lithium prophylaxis of depression in bipolar I, bipolar II, and unipolar patients.Am J Psychiatry 1976,133:925–929.

    PubMed  CAS  Google Scholar 

  26. Chengappa KN, Hennen J, Baldessarini RJ, et al.: Recovery and functional outcomes following olanzapine treatment for bipolar I mania.Bipolar Disord 2005,7:68–76.

    Article  PubMed  CAS  Google Scholar 

  27. Sachs GS, Yan LJ, Swann AC, Allen MH: Integration of suicide prevention into outpatient management of bipolar disorder.J Clin Psychiatry 2001,62(Suppl 25):3–11.

    PubMed  Google Scholar 

  28. Quanbeck CD, Stone DC, Scott CL, et al.: Clinical and legal correlates of inmates with bipolar disorder at time of criminal arrest.J Clin Psychiatry 2004,65:198–203.

    PubMed  Google Scholar 

  29. Perlis RH, Ostacher MJ, Patel JK, et al.: Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).Am J Psychiatry 2006,163:217–224.

    Article  PubMed  Google Scholar 

  30. Tohen M, Chengappa KN, Suppes T, et al.: Relapse prevention in bipolar I disorder: 18-month comparison of olanzapine plus mood stabiliser v. mood stabiliser alone.Br J Psychiatry 2004,184:337–345.

    Article  PubMed  Google Scholar 

  31. Faedda GL, Tondo L, Baldessarini RJ, et al.: Outcome after rapid vs gradual discontinuation of lithium treatment in bipolar disorders.Arch Gen Psychiatry 1993,50:448–455.

    PubMed  CAS  Google Scholar 

  32. Sachs GS: Bipolar mood disorder: practical strategies for acute and maintenance phase treatment.J Clin Psychopharmacol 1996,16(2 Suppl 1):32S-47S.

    Article  PubMed  CAS  Google Scholar 

  33. Altshuler L, Kiriakos L, Calcagno J, et al.: The impact of anti-depressant discontinuation versus antidepressant continuation on 1-year risk for relapse of bipolar depression: a retrospective chart review.J Clin Psychiatry 2001,62:612–616.

    Article  PubMed  CAS  Google Scholar 

  34. Altshuler L, Suppes T, Black D, et al.: Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up.Am J Psychiatry 2003,160:1252–1262.

    Article  PubMed  Google Scholar 

  35. Fava GA, Kellner R: Prodromal symptoms in affective disorders.Am J Psychiatry 1991,148:823–830.

    PubMed  CAS  Google Scholar 

  36. Lam D, Wong G, Sham P: Prodromes, coping strategies and course of illness in bipolar affective disorder—a naturalistic study.Psychol Med 2001,31:1397–1402.

    Article  PubMed  CAS  Google Scholar 

  37. Perry A, Tarrier N, Morriss R, et al.: Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment [see comments].BMJ 1999,318:149–153.

    PubMed  CAS  Google Scholar 

  38. Post RM, Roy Byrne PP, Uhde TW: Graphic representation of the life course of illness in patients with affective disorder.Am J Psychiatry 1988,145:844–848.

    PubMed  CAS  Google Scholar 

  39. Otto MW, Reilly-Harrington N, Sachs GS: Psychoeducational and cognitive-behavioral strategies in the management of bipolar disorder.J Affect Disord 2003,73:171–181.

    Article  PubMed  Google Scholar 

  40. Schmitz JM, Averill P, Sayre SL, et al.: Cognitive-behavioral treatment of bipolar disorder and substance abuse: a preliminary randomized study.Addict Disord Their Treat 2002;1:17–24.

    Article  Google Scholar 

  41. DeRubeis RJ, Hollon SD, Amsterdam JD, et al.: Cognitive therapy vs medications in the treatment of moderate to severe depression.Arch Gen Psychiatry 2005,62:409–416.

    Article  PubMed  Google Scholar 

  42. Simon NM, Otto MW, Wisniewski SR, et al.: Anxiety disorder comorbidity in bipolar disorder patients: data from the first 500 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).Am J Psychiatry 2004,161:2222–2229.

    Article  PubMed  Google Scholar 

  43. Frank E, Hlastala S, Ritenour A, et al.: Inducing lifestyle regularity in recovering bipolar disorder patients: results from maintenance therapies in bipolar disorder protocol.Biol Psychiatry 1997,41:1165–1173.

    Article  PubMed  CAS  Google Scholar 

  44. Frank E, Kupfer DJ, Thase ME, et al.: Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder.Arch Gen Psychiatry 2005,62:996–1004.

    Article  PubMed  Google Scholar 

  45. Lam DH, Hayward P, Watkins ER, et al.: Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years.Am J Psychiatry 2005,162:324–329.

    Article  PubMed  Google Scholar 

  46. Scott J, Pope M: Nonadherence with mood stabilizers: prevalence and predictors.J Clin Psychiatry 2002,63:384–390.

    PubMed  Google Scholar 

  47. Pope M, Scott J: Do clinicians understand why individuals stop taking lithium?J Affect Disord 2003,74:287–291.

    Article  PubMed  Google Scholar 

  48. Perlick D, Clarkin JF, Sirey J, et al.: Burden experienced by care-givers of persons with bipolar affective disorder.Br J Psychiatry 1999,175:56–62.

    Article  PubMed  CAS  Google Scholar 

  49. Perlick DA, Rosenheck RR, Clarkin JF, et al.: Impact of family burden and patient symptom status on clinical outcome in bipolar affective disorder.J Nerv Ment Dis 2001,189:31–37.

    Article  PubMed  CAS  Google Scholar 

  50. Michalak EE, Yatham LN, Wan DD, Lam RW: Perceived quality of life in patients with bipolar disorder. Does group psychoeducation have an impact?Can J Psychiatry 2005,50:95–100.

    PubMed  Google Scholar 

  51. Suppes T, Dennehy EB, Swann AC, et al.: Report of the Texas Consensus Conference Panel on medication treatment of bipolar disorder 2000.J Clin Psychiatry 2002,63:288–299.

    PubMed  Google Scholar 

  52. Perlis RH, Sachs GS, Lafer B, et al.: Effect of abrupt change from standard to low serum levels of lithium: a reanalysis of double-blind lithium maintenance data.Am J Psychiatry 2002,159:1155–1159.

    Article  PubMed  Google Scholar 

  53. Goldstein TR, Frye A, Denicoff KD, et al.: Antidepres-sant discontinuation-related mania: critical prospective observation and theoretical implications in bipolar disorder.J Clin Psychiatry 1999,60:563–567.

    Article  PubMed  CAS  Google Scholar 

  54. Suppes T, Baldessarini RJ, Faedda GL, Tohen M: Risk of recurrence following discontinuation of lithium treatment in bipolar disorder.Arch Gen Psychiatry 1991,48:1082–1088.

    PubMed  CAS  Google Scholar 

  55. Calabrese JR, Vieta E, el Mallakh R, et al.: Mood state at study entry as predictor of the polarity of relapse in bipolar disorder.Biol Psychiatry 2004,56:957–963.

    Article  PubMed  Google Scholar 

  56. Bowden CL, Swann AC, Calabrese JR, et al.: Maintenance clinical trials in bipolar disorder: design implications of the divalproex-lithium-placebo study.Psychopharmacol Bull 1997,33:693–699.

    PubMed  CAS  Google Scholar 

  57. Schou M: Forty years of lithium treatment.Arch Gen Psychiatry 1997,54:9–13.

    PubMed  CAS  Google Scholar 

  58. Bowden CL, Calabrese JR, Sachs G, et al.: A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder.Arch Gen Psychiatry 2003,60:392–400.

    Article  PubMed  CAS  Google Scholar 

  59. Calabrese JR, Bowden CL, Sachs G, et al.: A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently depressed patients with bipolar I disorder.J Clin Psychiatry 2003,64:1013–1024.

    Article  PubMed  CAS  Google Scholar 

  60. Goodwin GM, Bowden CL, Calabrese JR, et al.: A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder.J Clin Psychiatry 2004,65:432–441.

    Article  PubMed  CAS  Google Scholar 

  61. Bowden CL, Calabrese JR, McElroy SL, et al.: A randomized, lacebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Divalproex Maintenance Study Group [see comments ].Arch Gen Psychiatry 2000,57:481–489.

    Article  PubMed  CAS  Google Scholar 

  62. Tohen M, Greil W, Calabrese JR, et al.: Olanzapine versus lithium in the maintenance treatment of bipolar disorder: a 12-month, randomized, double-blind, controlled clinical trial.Am J Psychiatry 2005,162:1281–1290.

    Article  PubMed  Google Scholar 

  63. Quitkin FM, Kane J, Rifkin A, et al.: Prophylactic lithium carbonate with and without imipramine for bipolar 1 patients. A double-blind study.Arch Gen Psychiatry 1981,38:902–907.

    PubMed  CAS  Google Scholar 

  64. Kleindienst N, Greil W: Inter-episodic morbidity and drop-out under carbamazepine and lithium in the maintenance treatment of bipolar disorder.Psychol Med 2002,32:493–501.

    Article  PubMed  CAS  Google Scholar 

  65. Greil W, Kleindienst N, Erazo N, Muller-Oerlinghausen B: Differential response to lithium and carbamazepine in the prophylaxis of bipolar disorder.J Clin Psychopharmacol 1998,18:455–460.

    Article  PubMed  CAS  Google Scholar 

  66. Denicoff KD, Smith-Jackson EE, Disney ER, et al.: Comparative prophylactic efficacy of lithium, carbamazepine, and the combination in bipolar disorder.J Clin Psychiatry 1997,58:470–478.

    PubMed  CAS  Google Scholar 

  67. Tohen M, Ketter TA, Zarate CA, et al.: Olanzapine versus divalproex sodium for the treatment of acute mania and maintenance of remission: 7-week study.Am J Psychiatry 2003,160:1263–1271.

    Article  PubMed  Google Scholar 

  68. Tohen M, Calabrese JR, Sachs GS, et al.: Randomized, placebo-controlled trial of olanzapine as maintenance therapy in patients with bipolar I disorder responding to acute treatment with olanzapine.Am J Psychiatry 2006,163:247–256.

    Article  PubMed  Google Scholar 

  69. Keck PE Jr, Calabrese JR, McQuade RD, et al.: A randomized, double-blind, placebo-controlled 26-week trial of aripiprazole in recently manic patients with bipolar I disorder.J Clin Psychiatry 2006,67:626–637.

    PubMed  CAS  Google Scholar 

  70. Suppes T, Webb A, Paul B, et al.: Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment-resistant illness and a history of mania.Am J Psychiatry 1999,156:1164–1169.

    PubMed  CAS  Google Scholar 

  71. Bonds C, Frye A, Coudreaut MF, et al.: Cost reduction with maintenance ECT in refractory bipolar disorder.J ECT 1998,14:36–41.

    PubMed  CAS  Google Scholar 

  72. Gyulai L, Bowden CL, McElroy SL, et al.: Maintenance efficacy of divalproex in the prevention of bipolar depression.Neuropsychopharmacology 2003,28:1377–1385.

    Article  CAS  Google Scholar 

  73. Ghaemi SN, Lenox MS, Baldessarini RJ: Effectiveness and safety of long-term antidepressant treatment in bipolar disorder.J Clin Psychiatry 2001,62:565–569.

    Article  PubMed  CAS  Google Scholar 

  74. Fava GA: Can long-term treatment with antidepressant drugs worsen the course of depression?J Clin Psychiatry 2003,64:123–133.

    Article  PubMed  CAS  Google Scholar 

  75. Leverich GS, Altshuler LL, Frye A, et al.: Risk of switch in mood polarity to hypomania or mania in patients with bipolar depression during acute and continuation trials of venlafaxine, sertraline, and bupropion as adjuncts to mood stabilizers.Am J Psychiatry 2006,163:232–239.

    Article  PubMed  Google Scholar 

  76. Teicher MH, Glod CA, Cole JO: Antidepressant drugs and the emergence of suicidal tendencies.Drug Saf 1993,8:186–212.

    Article  PubMed  CAS  Google Scholar 

  77. Bauer MS, Wisniewski SR, Marangell LB, et al.: Are antidepressants associated with new-onset suicidality in bipolar disorder? A prospective study of participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).J Clin Psychiatry 2006,67:48–55.

    Article  PubMed  CAS  Google Scholar 

  78. Swann AC: Adaptive psychopharmacology.Psychiatr Ann 2005,35:831–838.

    Google Scholar 

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  1. Department of Psychiatry, University of Texas Health Science Center, 1300 Moursund Street, Suite 270, Houston, TX, 77030, USA

    Alan C. Swann MD

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Swann, A.C. Bipolar disorder: Strategies for the lifelong illness. Current Psychosis & Therapeutics Reports 4, 143–150 (2006). https://doi.org/10.1007/BF02629388

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