- Always consider bipolar disorder in someone who has depression (75% of women with bipolar disorder experience a depressive episode as their first episode, Kawa et al., 2005).
- Bipolar disorder is common, according to one recent major study (Merikangas, K et al 2007) affecting Bipolar I – 1%, Bipolar II – 1% , Bipolar Spectrum – 2.4% of the population
- Antidepressants can make bipolar disorder more unstable.
- Involve family in assessment and treatment, often the woman is unable to recognise manic or hypomanic symptoms and family are better able to describe these.
- The postpartum risk of relapse from bipolar disorder is between 50-80%.
- Have a high index of suspicion if a family member suffers from bipolar disorder.
- This illness can be managed very successfully but often close monitoring is required along with appropriate medication.
- For medications used, see section on mood stabilisers.
See information for women on Bipolar Disorder and Bipolar Disorder in pregnancy.
Bipolar I Disorder
- To make this diagnosis requires the presence or a history of at least one manic episode or one mixed episode.
- The person may or may not have experienced depressive episodes (depressive episodes are often the most debilitating but it is not necessary to have been depressed to meet diagnostic criteria for Bipolar I disorder).
Core Features of Mania (In adults)
Elevated, expansive or irritable mood. The abnormal mood state is clearly abnormal for that individual although may not be apparent during a 10 minute office consultation. Irritability may be experienced as quite unpleasant. Expansive mood refers to a sense of emotions/emotional reactions being 'bigger', more inclusive and all encompassing or more significant than is normal for that person.
Energy Levels and Activities: These are increased and result in either agitation or increase in activities which may be productive, especially initially. This may also result in inappropriate behaviour or behaviour with embarrassing or painful consequences, particularly if she feels like spending money or if her libido is high and she acts on this. A manic person appears busy and overactive (again this may not be very obvious in a 10 minute consultation).
Sleep: There is a reduced need for sleep e.g., a person who usually needs 8-9 hours per night may feel 3 hours of sleep is sufficient.
Thought Content: There is an inapproprite increase in self-esteem which may reach the point of grandiosity.
Racing Thoughts: Usually the person feels as if their thoughts are racing and they will often describe this. It may also be evident from what they are saying that their thoughts are shifting rapidly from one topic to another.
Speech: The person is usually more talkative than is usual for them. Their speech may appear fast, difficult to interupt or contain.
Distractability: Poor attention which is easily diverted onto unimportant or irrelevant things. The person may start one task then move to another before completing the first, then move to another and so-on.
The symptoms result in significant impairment of functioning in at least one major sphere of life.
Symptoms last for at least one week or longer, or result in hospitalisation
Symptoms are not better explained by the direct physiological effects of another illness or substance/medication use.
Most experts in Bipolar Disorder would agree that mania induced by antidepressant medication indicates bipolar disorder (ie is not an exclusion criteria).
Mixed Episodes (In adults)
- The postpartum appears to be a time of particular vulnerability to mixed episodes.
- These can be difficult to diagnose and confusing.
- Symptoms can range from very severe to more mild.
- Mixed episodes can be predominantly depression, predominantly manic or very 'mixed'.
Core Features of a Mixed Episode
(i) Symptoms are predominantly that of a major depressive episode but some features of mania are present, e.g. agitation, restlessness, a sense of being driven or racing thoughts,
(ii) Symptoms are predominantly those of mania but some depressive features are present, e.g.anxiety, negative thoughts, suicidal thoughts,
(iii) Symptoms may alternate at different times of the day between those of depression and those of mania.
- Mixed mood states are particularly concerning because of the high risk of suicide and self-harm associated with them
- A cross sectional assessment of mental state can be very misleading
- The symptoms result in significant impairment of functioning in at least one major sphere of life.
- Symptoms last for at least one week or longer, or result in hospitalisation.
- Symptoms are not better explained by the direct physiological effects of another illness or substance/medication use.
Bipolar II Disorder
Careful history taking is often required to ellicit symptoms of previous (or even of current), hypomanic episodes.
Core Features of Bipolar II Disorder (In adults)
- Presence (or history) of one or more Major Depressive Episodes.
- Presence (or history) of at least one Hypomanic Episode.
- There has never been a Manic Episode or a Mixed Episode.
- The mood symptoms are not better accounted for by a Schizoaffective Disorder or other Psychotic Disorder.
- The symptoms cause clinically significant distress, or impairment in at least one major aspect of functioning.
Core Features of Hypomania (In adults)
Core Symptoms: The symptoms are essentially the same as those of mania but with less intensity.
Other Features: Essentially the same as for mania however the minimum duration of symptoms is reduced from one week to four days.
Other Bipolar Disorders
Many clinicians think of Bipolar I Disorder when they think of Bipolar Disorder but we have come to recognise that there are a spectrum of disorders of which Bipolar I is the most severe.
These include Bipolar NOS and cyclothymia.
Bipolar Disorder Not Otherwise Specified (NOS) is a diagnostic term used to refer to a range of variants of bipolar disorder which do not meet diagnostic criteria for Bipolar I or Bipolar II disorder but can be just as debilitating.
In a major recent Christchurch study, Bipolar NOS was as frequent as Bipolar II disorder.
Core Features of Bipolar NOS
The most common forms seen in the postpartum are:
- rapid alternation (over days) between manic symptoms and depressive symptoms,
- hypomanic states which last less than four days but more than one day interspersed in a major depressive episode (these are commonly missdiagnosed as unipolar depression or postnatal depression)
- an elevated, productive and energetic state lasting for 1-3 weeks postpartum followed by the onset of a major depressive episode
Cyclothymia refers to mood fluctuations occuring over at least two years during which there are numerous peroids of both hypomanic symptoms and depressive symptoms but these symptoms are insufficient in number or severity to meet diagnostic criteria for a Major Depressive Episode or Bipolar Disorder.
Treatment for cyclothymia is usually with a mood stabiliser as a first line medication however antidepressants may also be indicated. If antidepressants are used in the absence of a mood stabiliser the person needs to be warned of hypomania/mania as a side effect, followed up closely and advised to make contact sooner if any signs of elevation occur.
Bipolar Disorders tend to be recurrent and often chronic and for many, sustained periods of being completely symptom free are uncommon.
To say someone has responded to treatment suggests a significant improvement in symptoms. If this improvement is sustained ( usually for more than 2 months) they are said to be in full remission.
Rapid Cycling: Refers to the occurrence of four or more periods of abnormal mood (Manic, Mixed, Hypomanic or Major Depressive Episode) in one year.
Kawa, I., Carter, JD. Joyce,PR., Doughty, CJ., Frampton,CM. Wells,JE., Walsh,AE., Old,RJ. Gender differences in bipolar disorder: age at onset, course, comorbidity and symptom presentation. Bipolar Disorders. 7(2): 119-25. 2005,Apr.
Merikangas, Kathleen R; Akiskal, Hagop S; Angst, Jules; Greenberg, Paul E; Hirschfeld, Robert M. A; Petukhova, Maria; Kessler, Ronald C. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry. Vol 64(5) May 2007, 543-552.