Trends in Bipolar I

2013 was an important year for mental health. The introduction of the new DSM-5 has given our entire system of diagnosis its first refresh in over a decade. We’ve seen wide-ranging (and in some cases, controversial) changes to criteria for conditions ranging from schizophrenia to post- traumatic stress disorder, but one area where I feel that there has been definite change for the better is bipolar disorder.

DSM-5 is a valuable resource for us in the psychiatric profession, providing a solid framework for diagnosing the common patient-type, manic with depressive symptoms. In addition to granting features like anxiety their deserved status as a dimension of bipolar disorder, the new criteria place mania and depression on coexisting gradients, giving us the flexibility to diagnose and treat in a way that reflects the true complexity of our patients’ conditions.

I’ve already noticed this increased flexibility in many parts of my own practice, with diagnosis of hypomanic symptoms being a notable example. Since DSM III, these have been commonly associated with bipolar disorder but recent thinking has suggested associations with both unipolar and bipolar disorders. The new DSM-5 reflects the accommodation of this thinking, providing a metric for assessment that allows not only the detection of the presence of hypomanic features, but also the diagnostic criteria to specify their severity.

While this greater sophistication has obvious benefits in helping us to identify which treatment path to follow, almost as important is clarifying which to avoid. Emerging evidence supports the view that bipolar patients with mixed features respond less well to conventional antidepressants. An increased ability to detect the presence of depressive symptoms amongst mania means the clarity to distinguish these patients from those with more defined depression and offer atypical antipsychotics instead.

Likewise the stricter definition of mania, requiring the presence of excess activity or energy, helps us to differentiate between purely manic patients and those with the presence of depressive symptoms and to adjust treatment accordingly.

EPA 2014 is our opportunity to agree ways in which the new DSM can assist us moving forward and, together, start the gathering of evidence to inform these new approaches. I believe that a collaborative discussion is the best way to do this, which is why my colleagues and I will focus on mixed features in our symposium on Tuesday afternoon, an event we hope you’ll all take part in. I’ll also be running an open Q&A on Monday where I’ll be looking for even more feedback from front line practitioners worldwide.

I’m also looking forward to the many symposia around comorbidities of mental illness, especially cognitive dysfunction and poor fitness. Maintaining cognitive function should always be a priority but, with the recent revelation of increased mortality in mood disorders due to cardiovascular disease, discussions of practical ways to improve our patients’ physical health are urgently needed.

This year’s EPA promises to be a fantastic congress and I look forward to seeing you all there.