New horizons in bipolar I

The first speaker, Professor Lakshmi Yatham, Department of Psychiatry, University of British Columbia, Vancouver, Canada reflected on the change in perception about bipolar disorder due to improved understanding about the severity of the condition over the past few decades.

“Thirty years ago, the belief was that bipolar disorder was episodic but nowadays,” Professor Yatham told delegates, “psychiatrists are in agreement that it is a lifetime chronic disease on a parallel to schizophrenia. In fact, a study in the Lancet in 2013 showed that years of life lost was comparable between bipolar disorder and schizophrenia.”

Suicide risk

In a shocking revelation, Prof Yatham stated that risk of suicide among patients with bipolar disorder can be 20-30 times greater than in the general population.¹ In fact bipolar disorder may account for one-quarter of all completed suicides. “Drivers for suicide risk/attempts in patients with bipolar disorder include prior suicide attempts, family history, female gender, younger age at illness onset, depressive polarity of first illness episode, and substance abuse, among other risk factors,”^1,2 said Prof Yatham.

Bipolar I patients at greater risk

Also of great significance is the fact that suicide attempts are more prevalent in bipolar I than in bipolar II; this makes sense given that the presence of mixed states (mania with depressive symptoms) in bipolar I is associated with a higher suicide risk.

Prof Yamar also talked about a prospective, real-world study of patients with bipolar I disorder using the The Mini International Neuropsychiatric Interview (MINI) questionnaire which revealed that about one-third of patients with mania meet the DSM-5 mixed features specifier category.³

Notice AIA: red flag to mixity

This neatly led to the next talk about gateway symptoms for mixed states by Professor Trisha Suppes, Stanford University School of Medicine and Director of the Bipolar and Depression Research Program at the VA Palo Alto Heatlh Care System in Palo Alto, California. When discussing manic episodes, Prof Suppes said: “The combination of anxiety and irritability and agitation (AIA) are a red flag to alert the psychiatrist to patients experiencing depressive symptoms.” In one large self-report study, 72% of patients who experienced mania with depressive symptoms suffered from AIA.⁴

Prof Suppes also brought attention to the benefits of the new DSM-5 criteria for bipolar disorder with mixed features compared to the DSM-IV described by comparison as too restrictive. The DSM-V redefined the ‘mixed episode’ criteria, using instead a ‘mixed feature’ specifier which applies to a full mood episode where syndromal or subsyndromal symptoms from the opposing poles are present and can apply to either manic or depressive episodes.

Developed to evaluate the new DSM-5 ‘with mixed features’ specifier for hypomanic and manic episodes, in a version that can be filled in by patients, Prof Suppes recommended the MINI questionnaire. “It consists of nine questions to assess the presence or absence of depressive symptoms according to DSM-5 (six symptoms) and can easily be incorporated into routine psychiatric evaluation of patients with manic episodes,” said Prof Suppes. You can download a copy of the MINI here.

Better diagnoses = better treatment

Clearly the most important outcome of improved patient assessment is more appropriate treatment. In the case of bipolar I this could lead to a reduction in suicide attempts and suicides. Whilst evidence-based treatment options for managing mania with depressive symptoms are limited, various antipsychotics have been investigated in clinical trials and evaluated as potential treatment options for patients who are exhibiting mania with depressive symptoms.

Professor Roger McIntyre, Department of Psychiatry and Pharmacology, University of Toronto, Canada who chaired the meeting, also talked about the benefits of psychoeducation in the prevention and treatment of mania with depressive symptoms. “The aim of treatment is prevention and a heavy dose of psychoeducation in addition to psychpharmacology,” said Prof McIntyre. “The notion is it’s a multi-pronged approach for what is a multi-dimensional phenotype.”

“We also need a greater understanding of pathophysiological processes to identify biological markers for bipolar disorder, and provide more accurate diagnosis and new personalised treatment approaches, said Prof McIntyre. “Specific targeted therapies, capable of affecting the underlying disease processes, may prove to be more effective, faster acting, and better tolerated than existing therapies, therefore providing better outcomes for the individuals affected by bipolar disorder,” he concluded.

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