What is bipolar disease? How to treat it?

According to the American psychiatric association, bipolar disorder is a brain disorder that causes changes in a person's mood, energy, and ability to function. People with bipolar disorder experience intense emotional states that typically occur during distinct periods of days to weeks, called mood episodes. It impacts 1–2% of the population worldwide and causes high rates of functional impairment,2 poor quality of life, and has substantial economic effects. These mood episodes are categorized as manic/hypomanic (abnormally happy or irritable mood) or depressive (sad mood). People with bipolar disorder generally have periods of neutral mood as well. When treated, people with bipolar disorder can lead full and productive lives. The exact cause of bipolar disease is not clear but some causative factors include

• Genetic
• Stress and overwhelming problems
• Life changing events.
• Chemical factors like alcohol and drugs

There are basically four types of bipolar disease

• Bipolar disease type I
• Bipolar disease type II
• Cyclothymic disorder
• Unspecified bipolar disorder

In type I, there is extreme erratic behaviour, with manic “up” periods that last at least a week, so severe that medical care is needed with usually extreme “down” periods that last at least 2 weeks. In type II disorder, there are erratic highs and lows are seen, but it isn’t as extreme as bipolar I.

Cyclothymic disorder involves periods of manic and depressive behaviour that last at least 2 years in adults or 1 year in children and teens. The symptoms aren’t as intense as type I or II. Unspecified bipolar disorder is now used to describe conditions in which a person has only a few of the mood and energy symptoms that define a manic or hypomanic episode, or the symptoms may not last long enough to be considered as clear-cut episodes.

In bipolar disorder, the dramatic episodes of high and low moods do not follow a set pattern and can happen over a period of weeks, months, and sometimes even years. Severity varies from person to person and can also change over time, becoming more or less severe. Symptoms of mania excessive happiness, hopefulness, and excitement, sudden changes from being joyful to being irritable, angry, and hostile and restlessness and becoming impulsive. Drug and alcohol abuse happens at this time. During depressive periods sadness, loss of energy, feelings of hopelessness or worthlessness and trouble concentrating and in some patient’s thoughts of suicide or attempting suicide.

Very good methods of treatment are available which will stabilize the patient’s mood and reduce the severity of symptoms and help the person function effectively in daily life. Treatment involves a combination of therapies, including:

• Medication
• Counselling
• Physical intervention
• Lifestyle remedies

Drugs are the mainstay of treatment and include

• Mood stabilisers such as lithium
• Antidepressants
• Second-generation antipsychotics (SGAs)
• Anticonvulsants, to relieve mania
• Medication to help with sleep and anxiety

Psychotherapy can help relieve symptoms and equip a person to manage bipolar disorder. This will include cognitive behaviour therapy. In a few patients’ electroconvulsive therapy may be given. Lifestyle changes like a good sleep, regular healthy diet and exercise are also important. If other treatments have not helped, a doctor may prescribe electroconvulsive therapy (ECT).

Treatment resistant Bipolar depression (TRBD)

Bipolar depression accounts for most symptomatic periods in bipolar disorder and is associated with elevated suicide risk and high morbidity and mortality rates. Despite a current lack of consensus about its definition, treatment-resistant bipolar depression has been reported in about one-quarter of BD patients. No interventions have shown clear and established effectiveness for its treatment. Most studies have considered TRBD as a failure in two or more interventions.The symptoms of treatment-resistant bipolar disorder are similar to the symptoms of bipolar disorder, except the most commonly effective treatments don’t seem to help improve or reduce the severity of symptoms. The symptoms may stay the same during treatment or improve slightly but not enough to be clinically significant or improve for brief periods with breakthrough manic or depressive episodes

Many drugs are used for treatment resistant bipolar depression. These include lurasidone, aripiprazole, ketamine, D-cycloserine, minocycline, aspirin, pioglitazone, N acetylcyestine, ACE inhibitors and celecoxib. The fact that so many drugs have been tried shows that none is effective in most patients.

Repetitive Transcranial magnetic stimulation (rTMS) has been tried in some patients because of its noninvasiveness. But randomised controlled studies did not show much greater effect than placebos.

Vagal Nerve Stimulation involves stimulation of the left vagus nerve in the neck. It is an FDA approved surgery for depression. Recently there have been numerous studies on this in severe refractory bipolar depression. With very good results.

Deep brain Stimulation Deep brain stimulation (DBS) is a neurosurgical technique in which high-frequency stimulation electrodes are placed subcortically or in deep cortical regions to target neural circuits, whose dysfunction is associated with neuropsychiatric manifestations. DBS is approved for treating dystonia, treatment-resistant Parkinson's disease, and severe epilepsy and has been investigated as for its role in the management of psychiatric disorders such as MDD, obsessive-compulsive disorder, and anorexia nervosa. Although few studies have assessed DBS as a treatment for patients with TRBD, the available results suggest efficacy. No severe adverse effects have been reported within the follow-up period, which encourages further investigation.