Progress in bipolar I management

Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout life. Whilst we’re still in the very early stages of understanding exactly what goes wrong in the brain to make someone ill, without a doubt we’ve witnessed many advances in terms of basic science and clinical research into bipolar disorder and the patient has benefitted.

Management of bipolar I has evolved to include new and improved treatments including both pharmacological and psychological treatments; coupled with an understanding that all aspects of an individual’s life are important to well-being, this serves to optimise the lives of patients living with bipolar I.

In our on-line poll at IRPB 2015 there appeared to be a lack of positivity about progress but we can only speculate as to why; potentially negative responses can arise from current individual frustrations which tend to affect our memory of the fact that there have in fact been improvements over the years in the management of psychological conditions.

Dr Jose Goikolea, commentator for the poll said: “The past decade has resulted in interesting advances in the bipolar field. Important clinical studies have improved our knowledge of the illness: diagnostic boundaries, clinical course, comorbidities. Besides, neuropsychological and neurobiological studies tend to support progression of the disease along the years. In this line, staging models have been proposed, where treatments are tailored to the stage.

“The psychopharmacological arsenal has grown to include several atypical antipsychotics for the treatment of mania and also for maintenance, especially for patients with manic predominant polarity. Even some atypicals have shown efficacy in bipolar depression, although there is a big need for better treatments in this area. Different psychological interventions (psychoeducation, CBT, interpersonal and social rhythm therapy, functional remediation) have shown positive results in well-designed studies.

“Altogether, these discoveries have improved the management of the bipolar I patient. Of course there is still a long way to go,” said Dr Goikolea.

DSM-5

One particular recent advance in the management of bipolar I has been the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The fifth edition of the DSM-5 replaces the diagnosis of “mixed episode” with a mixed-features specifier that can be applied to episodes of major depression, hypomania or mania.

Dr Goikolea said: “The previous DSM-IV definition of mixed episode, where criteria for both manic and depressive episodes had to be fulfilled, was too restrictive. In clinical practice, many patients presenting with symptoms of both poles (mixed) could not be diagnosed as “mixed”, according to DSM-IV. This is not a minor issue: mixed states have important clinical and therapeutic implications such as worse outcome, increased suicidality and different treatments.

Most respondents agreed with this view, and consider this new approach as beneficial. Only one out of five did not support the new approach. However, it is not completely clear if they preferred the previous DSM-IV definition, or instead, would have chosen a third definition, (for example, keeping the "mixed" as an episode, but modifying the criteria to be more sensitive). In any case, there is a generalized consensus supporting this change present in the DSM-5.

Mixed episodes in bipolar I are common

So is it common to actually consult bipolar I patients whilst they are experiencing an episode of mania with depressive symptoms? Three-quarters of respondents believed that it is, which stands to reason given that from a dimensional point of view, such as Kraepelin’s model, mixed states where symptoms of both poles combine are even more frequent than pure episodes.

For the 25% who answered “no” to the question, Dr Goikolea suggested that they may have a narrower concept of ‘mixed mania’, which he argued is far less common in clinical practice.