Bipolar affective disorder (BPAD): the facts not the fictions (part 2)

In a previous article about bipolar affective disorder (BPAD), I talked about the different types of this condition and who is generally affected by them. Here I move on to explain the facts, not the fictions, about BPAD's causes and treatment options.

How is BPAD caused?

The cause of BPAD is debated, but likely lies within the triad of the biological, psychological and social. There is evidence for a genetic cause, with a high rate of diagnosis in identical twins. There is a 10-15% chance of developing the disease if a family member has BPAD or depression. There is growing evidence for the role of childhood psychological trauma in the development of adult BPAD

There are a number of hormones and chemicals that may play a role. Variations in the concentration of serotonin (the happy hormone), have been linked to mania and depressive states. Excess dopamine has been linked to psychosis, and increased GABA has been found during manic episodes.

Changes in brain structure, such as greater activation and size in brain areas associated with emotion have been observed in some patients. Manic episodes triggered by medication have opened some avenues of investigation, mainly around the activation of 'stress hormones'.

Research into the cause or causes of BPAD is still in relative infancy, but is likely to find a complex integration of multiple factors, which a genetic predisposition balanced with an individual's experiences, is likely to make them more significant in the context of chemical abnormalities; this increases a person's risk of developing disease.

How is it treated?

BPAD is treated dependent on the severity of symptoms. Classical treatment of BPAD1 is long term, with mood-stabilising agents such as lithium. Anticonvulsants, such as sodium valproate, and antipsychotics such as olanzapine, may be used alone or in combination dependent on patient response. These medications are very effective, but have a range of side effects and must be monitored to prevent toxicity. Severe or psychotic episodes will require hospital admission.

Use of antidepressants is not shown to be helpful, and in some cases may precipitate a manic phase through modulation of chemicals. The use of talking therapies poses some benefit alongside medication.

Earlier diagnosis and treatment may improve patient experience. The complicated nature of BPAD means that diagnosis may occur late, with the patient's life significantly affected by disease. A 'high performer' with 'depression' may be undiagnosed until the disease progresses, with multiple examples found in medical and science fields. The use of universally-established clinical and behavioural markers, coupled with a high index of suspicion in resistant or complex depression, may lead to earlier and better care.

Prognosis

Most people will fully recover from a manic episode. The disease itself is life-long, and is best understood as managed, not cured. The disease is likely to recur if not treated. The judicious use of medication, expert monitoring and lifestyle adjustments will go a long way to improving quality of life. There is strong evidence for an increased rate of suicide due to mania, especially in the context of strong depressive episodes and early trauma. The legacy of BPAD is the effect on life quality, with significant problems in work, relationships and day-to-day life in severe forms. In spite of this, people with BPAD can live long and good lives.

Earlier diagnosis, better treatment and patient-led care will help with all of the above. Although celebrity fascination with BPAD has brought it to the fore, it is worth stating that an over diagnosis of BPAD is dangerous due to the risks of medication.

If you are concerned that you or a loved one may be exhibiting symptoms I encourage you to seek consultation with a medical professional. BPAD is a disease that needs talking about, but perhaps 'Closer' is not the best place to do it.

Any opinions above are the author's alone. Guidance is based the best available evidence at the time of writing. Online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice. There are no conflicts of interest.


Ben is a young NHS doctor in the Southwest. His interests include neurology, health communication, and medical ethics. He is also an avid advocate of compassionate care and quality improvement, running a project in the Southwest around medical humanities. Please follow and support: Dr Janaway on Facebook Dr Janaway on Twitter

Sources:

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4) Vrabie M et al (2015) 'Cognitive impairment in bipolar patients: important, understated, significant aspects' Ann Gen Psychiatry 14:41

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