Bipolar Disorders

Author:  Eduard Vieta et al; Bipolar Disorders Programme, Hospital Clínic, University of Barcelona; Spain 2011-04-11 BMC Psychiatry

Bipolar disorder (BD) is not just a single disorder, but a category of lifelong mood disorders characterised by the presence of one or more recurrent manic, hypomanic and depressive episodes. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present. While these episodes are usually separated by periods of normal mood, in some patients depression and mania may rapidly alternate [1].

Estimates for lifetime prevalence (frequency) of any type of BD range from 0.5% to 5%. However, caution must be used when comparing studies, as the diagnostic assessment methods and criteria used to formulate diagnoses vary from study to study [2]. A recent review of epidemiological studies, which aimed to determine the prevalence of BD in Europe, revealed a remarkable degree of consistency across diverse study designs and between countries. The lifetime prevalence rate of mania (BD type I) appears to be very similar across studies, with estimates ranging from 0.1-0.2% to 1.8%. There is reasonably consistent evidence that BD-I and BD-II disorders, diagnosed according to criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [1], have an estimated 1-year prevalence of approximately 1%, with no major differences by age group and gender [3].

Over 90% of patients with BD experience recurrences during their lifetime [4], often within 2 years of the initial episode, and the consequences of recurrent illness are substantial for patients. Most randomised controlled trials investigating the efficacy of guideline-based treatment with current drug therapies, or with new emerging therapies, have assessed recurrence in patients who had initially recovered from a mood episode. A further need is to identify the association between patient characteristics and clinical characteristics as predictors of recurrence. This information may allow clinicians to better understand the course of the disease, and to focus on clinical management of those factors with a significant impact on disease outcomes [5].

The emerging picture of the course of BD is quite heterogeneous and includes slow or incomplete recovery from acute episodes, continued risk of recurrences, and sustained morbidity over time, even with continuous long-term use of current treatments. Recovery from an acute episode of mania, even if treatment is established very early in the course of the disorder, may require 3-6 months and thus may no longer meet the standard diagnostic criteria for an acute episode (syndromal remission). Achieving symptomatic remission, defined as the presence of minimal symptoms, may take longer and an 2 additional months may be needed to attain the start of recovery, defined as a sustained remission. Time to remission is even longer following repeated recurrences of BD [6].

Moreover, BD can adversely affect the individual, reducing health-related quality of life and functioning, including employment and productivity at work [7]. It is becoming increasingly recognised that BD is associated with a higher level of functional impairment than previously thought, particularly with regard to social adjustment and vocational functioning [6,7].

In addition to patient burden, caregiver burden is currently one of the key factors in managing patients with BD. The term "caregiver burden" refers to the emotional, social, and financial stresses that caring for a relative or friend with mental illness imposes on the caregiver, and is defined as "the presence of problems, difficulties or adverse events which affect the life of psychiatric patient's caregivers" [8]. On the basis of the method established by Pollak and Perlik [9] the primary caregiver is defined as the family member, friend or significant other who satisfied the greatest number (and at least three) of five criteria, namely: a spouse, parent or spouse equivalent; has the most frequent contact with the patient; helps to support the patient financially; has been the most frequent collateral participant in the patient's treatment; and is the person contacted by treatment staff in case of emergency.

While caregivers can accept some of the burden for the care of patients with BD, management of the disease also places a substantial burden on healthcare providers. BD typically places greater demand on hospital psychiatric services than non-BD depression [10].

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington; 2000.
   
2. Kupfer DJ, (Ed):
   Epidemiology and clinical course of bipolar disorder. 2004.
   
3. Pini S, de Queiroz V, Pagnin D, Pezawas L, Angst J, Cassano GB, Wittchen HU: Prevalence and burden of bipolar disorders in European countries.
   Eur Neuropsychopharmacol 2005, 15(4):425-434. PubMed Abstract | Publisher Full Text
   
4. Solomon DA, Keitner GI, Miller IW, Shea MT, Keller MB: Course of illness and maintenance treatments for patients with bipolar disorder.
   J Clin Psychiatry 1995, 56(1):5-13. PubMed Abstract
   
5. Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, Ketter TA, Miklowitz DJ, Otto MW, Gyulai L, Reilly-Harrington NA, Nierenberg AA, Sachs GS, Thase ME: Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).
   Am J Psychiatry 2006, 163(2):217-224. PubMed Abstract | Publisher Full Text
   
6. Huxley N, Baldessarini RJ: Disability and its treatment in bipolar disorder patients.
   Bipolar Disord 2007, 9(1-2):183-196. PubMed Abstract | Publisher Full Text
   
7. Martinez-Aran A, Vieta E, Torrent C, Sanchez-Moreno J, Goikolea JM, Salamero M, Malhi GS, Gonzalez-Pinto A, Daban C, Alvarez-Grandi S, Fountoulakis K, Kaprinis G, Tabares-Seisdedos R, Ayuso-Mateos JL: Functional outcome in bipolar disorder: the role of clinical and cognitive factors.
   Bipolar Disord 2007, 9(1-2):103-113. PubMed Abstract | Publisher Full Text
   
8. Chakrabarti S, Gill S: Coping and its correlates among caregivers of patients with bipolar disorder: a preliminary study.
   Bipolar Disord 2002, 4(1):50-60. PubMed Abstract | Publisher Full Text
   
9. Pollak CP, Perlick D: Sleep problems and institutionalization of the elderly.
   J Geriatr Psychiatry Neurol 1991, 4(4):204-210. PubMed Abstract | Publisher Full Text
   
10. Stensland MD, Jacobson JG, Nyhuis A: Service utilization and associated direct costs for bipolar disorder in 2004: an analysis in managed care.
    J Affect Disord 2007, 101(1-3):187-193. PubMed Abstract | Publisher Full Text