Bipolar disorder

Psychiatry

Philip Mitchell
 FAMOUS PEOPLE WHO HAVE
SUFFERED FROM BIPOLAR DISORDER

 Musicians: e.g. Schumann

 Poets: e.g. Cowper, Lowell
 Authors: e.g. Virginia Woolf
 Actresses: Vivian Leigh, Carrie Fisher
 Comedian: Spike Milligan
 HISTORY OF TERMS FOR BIPOLAR
DISORDER

 1854: Falret – “la folie circulaire”

 1854: Baillarger – “la folie a double
forme”
 1899: Kraepelin – “manic-depressive
insanity”
 1957: Leonhard – “bipolar disorder”
How does bipolar disorder present?
Manic-depressive Insanity
and Paranoia (1921)
Emil Kraepelin
Manic-depressive Insanity
and Paranoia (1921)
Emil Kraepelin
“Nothing is more addictive than the high of a
manic euphoria. Once you have tasted that
soaring, exhilarating, invincible,
phantasmagorical feeling of ‘IT’S GREAT TO
BE ME! I CAN DO ANYTHING!’, once you’ve
experienced the rush of your mind in overdrive,
the creativity pouring through it, the connectivity
of burgeoning lateral thinking, the ridiculous
ease of witty repartee, the unutterable
knowledge of your own immensity, your own
infinity, then life without another mania is a
dreary prospect indeed”.
Margo Orum, 1996
“Fairytales in Reality”
“The manic euphoria has been, and will always
be, the high point of your life. Even despite the
fact that so often (as happens in my case) it
accelerates into full-blown psychosis - where
ecstasy can slice off into terror in an instant,
and the horrors of paranoia swarm blindly into
the mazes of your mind, and you are lost,
wandering among unidentified fears, trapped
alive in the echoes of nauseating madness.”

Margo Orum, 1996

“Fairytales in Reality”
 Mitchell et al,
MJA, 2010

Note: Minimum duration of mania is at least 7 days; hypomania at least 2-4 days
 Robert Lowell

“Mania is sickness for one’s friends, depression

for one’s self.”
 Overview of bipolar depression
 Most common first presentation of bipolar disorder is
a depressive episode (Mitchell et al, 2008)
 Depression accounts for most of the days unwell for
both bipolar I (13:1) and II (38:1) disorders (Judd et al,
2002; 2003)
 Depression accounts for much of the disability (Judd
et al, 2005)
 Most suicides and suicide attempts occur during
depressive or mixed episodes (10 – 15% of those with
bipolar disorder die by suicide)
Mitchell et al, Bipolar Disorders, 2008
Australian artist Diedre Oliver –
portrayal of bipolar mixed states

“Together, the two images depict mirror

perspectives, namely, the euphoria of
mania encircled by depression (top)
and the melancholy of depression
surrounded by a penumbra of mania
(bottom)”

Berk M, et al. Am J Psychiatry 163(7):1160, 2006.

The course and outcome of bipolar
disorder
THE NATURE OF BIPOLAR DISORDER

 Bipolar disorder is a disorder of mood

- most individuals have episodes of both
mania and depression
- 10% have manic episodes only

 Character - episodes of illness (varying in

number of severity) with full recovery
between episodes
THE COURSE OF BIPOLAR DISORDER

“We feel the machine slipping from our

hand as if someone else were steering
….”
 OUTCOME OF BIPOLAR DISORDER

 Highly recurrent
- approximately 70-75% of patients relapse at
least once over a 4-5 year period (Tohen et al,
1990; Gitlin et al, 1995)
- about 90% of those with one manic episode
have recurrences
 COURSE OF BIPOLAR DISORDER

 Average 0.4 to 0.7 episodes/year

 Average duration 3 to 6 months

Time to recovery from mood episodes

* *

Solomon et al, Arch Gen Psych; 2010

 THE IMPACT OF BIPOLAR
DISORDER

“The whole business has been very bruising,

and it is fierce facing the pain I have caused,
and humiliating (to) think that it has all
happened before and that control and self-
knowledge come so slowly, if at all.”

Robert Lowell
How common is bipolar disorder?
Mental health: The evidence
 *

Mental health: The evidence

Mental health: The evidence
Mental health: The evidence
* *

*
*

* *
 Bipolar Disorder in a Australian National
Survey of Mental Health and Wellbeing
 12-month prevalence 0.9%; lifetime prevalence 1.3%
 More likely to be unmarried than those with major depressive
disorder (MDD) and the rest of the sample
 More likely to be on a pension than rest of sample (no
different to MDD)
 More likely to have comorbid anxiety disorders and drug
abuse than rest of sample
 Bipolar Disorder in a National Population
Survey
 More days disabled than rest of sample; no difference to MDD
 Severe interference with multiple functional domains than
rest of sample; more interference with home activities than
MDD
 Higher rates of 12-month suicide plans and attempts than
MDD
What is the cause of bipolar disorder?
 Genetics and bipolar disorder
 Genetic factors account for
at least 80 - 90% of the
cause of bipolar disorder
(McGuffin et al, 2003)
 Individuals with a first-
degree relative (parent,
child or sibling) with bipolar
disorder are 10-14 times
more likely to develop
bipolar disorder than
someone without such a
family history (Mortensen
et al, 2003)
Treatment of bipolar disorder
John Cade, 1948
Australian psychiatrist who
discovered the anti-manic effect of
lithium
Psychological interventions for bipolar
disorder
Psychological therapies

 Excellent review by Miklowitz (Am J Psychiat

2008)
 18 RCTs of group psycho-education,
systematic care, family therapy, interpersonal
therapy and CBT
 Clear evidence of enhanced symptomatic and
functional outcomes over periods of up to 2
years
Ball, Mitchell et al. J Clin Psychiat 2006
 PERSONAL PAPER

Questions remain: will there be further episodes; how

frequently; and will they be as debilitating? No-one can
offer guarantees or even reliable answers yet.
Meanwhile what about my capacity to work, earn a
living, to occupy myself, and fulfil my responsibilities?
The qualities for a doctor are vastly different from
those of a poet. A hospital consultant is nothing if not
reliable. My unreliability is already manifest.
Rehabilitation would be, if possible, a dire uphill
struggle.
Lancet, Dec. 1, 1984