Living with anxiety, agitation and irritability

The session kicked off with a video of a simulated consultation between Doctor Roger McIntyre, Canada and a bipolar I patient suffering from a wide mix of symptoms such as restlessness, rapid thoughts, difficulty focussing, irritability, anxiety, agitation, reduced sleep, suicidal thoughts and very low energy. Through a process of questions around her anxiety levels and agitation, Dr McIntyre diagnosed mania with depressive symptoms and therefore ensured that the patient received the correct treatment to enable her to feel better, reducing her desperation, panic and hopelessness. The video served to remind us of the importance of a thorough diagnostic process and investigation of the full spectrum of symptoms which a patient may experience, which they might not even comprehend themselves.

How does mania with depressive symptoms impact patients and their families?

The video was followed by an insightful and moving talk by a patient suffering from bipolar I disorder. As a sufferer of mania with depressive features, she really hammered home the impact that bipolar I disorder, and specifically mania with depressive features, has on the patient and also on family members, friends and colleagues. Her mother and brother have played an important role, not only in supporting her but also in recognising the early signs of mania, but it really does reinforce how tough bipolar disorder can be on families and loved ones.

The impact of mania with depressive symptoms

Prof. Young concluded the session with a focus on mania with depressive features. He started by reinforcing that bipolar disorder is a complex combination of manic, depressive and overlapping symptoms such as anxiety, agitation and irritability. He noted that in the UK especially, treatment of mania is prioritised as it is seen as the most cost-effective way of treating patients. However, this may not be the case. For example, 64% of patients reported feelings of depression during a manic episode in the IMPACT study of 700 patients.¹ This mix of mania with depressive features is associated with a higher risk of suicidality, a more severe course of illness, more and longer hospitalisations, more life dissatisfaction and work impairment than patients with mania alone, leading to higher costs to the health system overall. In addition, 72% of patients experiencing mania with depressive features also have anxiety, irritability and agitation symptoms.¹ He also noted how positive DSM-5 has been for bipolar disorder in changing the categorisation from clear manic, mixed or depressive states to a continuum, which more accurately represents the reality of this multidimensional disease.

The new MINI module

As part of the transition from DSM-IV to DSM-5, Prof. Young has been involved in developing a new MINI module questionnaire, designed to be filled in by patients, to help identify ‘mixed features’ in patients with mania with depressive features. The simple questionnaire asks patients to consider how often they experience symptoms such as low energy or fatigue, feeling sad or depressed or worthless.

In his study evaluating the use of the MINI module in practice, according to physician assessments, 34% of patients met the DSM-5 specifier for ‘mixed features’², similar to the proportion found in an aripiprazole pooled analysis. The key findings from his study of the MINI module included: • Agitation, anxiety and irritability is significantly more prevalent in patients with ≥3 depressive symptoms • The severity of agitation, anxiety and irritability is significantly higher in patients with ≥3 depressive symptoms • Suicide attempts were higher in patients with ≥3 depressive symptoms • More physicians were dissatisfied with treatment response in patients with ≥3 depressive symptoms • Significantly more patients with ≥3 depressive symptoms answered ‘yes’ to each of the MINI module questions

Treatment of mania with depressive symptoms 

Prof. Young concluded the symposium with a brief round-up of the asenapine* data for mania with depressive symptoms, which demonstrates that the antimanic effect of asenapine increases with depressive symptom severity. In a similar vein, the effect on depressive symptoms also improves as depressive symptoms become more severe.

While there are still hurdles to overcome, the combination of increased patient engagement, effective diagnostic tools and an increased awareness of the importance of prompt diagnosis and treatment of mania with depressive symptoms will help to prioritise a comprehensive clinical approach.

*Asenapine is indicated for moderate to severe manic episodes associated with bipolar I disorder in adults.