Bipolar disorder: Managing the peaks and valleys

Abstract

Bipolar disorder is a psychiatric illness that is relatively common among patients presenting for treatment in primary care clinics. Physicians in primary care often face difficult decisions about how and when to intervene when a patient is experiencing depressive, manic, or hypomanic episodes consistent with bipolar disorder. This article reviews the literature on how to assess and diagnose bipolar disorder in primary care, and how to choose from the array of treatment options that exist. The psychotherapy and pharmacotherapy evidence base provides guidance on how to help patients effectively manage this ailment. Collaboration among health and mental health practitioners is key in helping manage the “peaks and valleys” of bipolar disorder. Special considerations need to be made to routinely assess for impulsivity, suicidality, and patient progress throughout the course of treatment.

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“…Early diagnoses are difficult to achieve, since some symptoms overlap with other disorders, such as mood swings (schizophrenia) or depressive episodes (depression) [15][16][17]. Bipolar disorders can either be classified as type I, being mostly characterized by the existence manic episodes (uncontrollable thoughts, restlessness or hyperactivity, obsessive compulsive behavior, exaggerated emotions, and extreme mood changes, including magnified irritability or happiness), or type II, being characterized by hypomanic episodes (a less severe form of mania, with similar symptoms as manic episodes, but in a less intense manner) associated with depressive features [14,15,18]. Geneenvironment interactions are believed to explain their etiology the best, having a strong genetic component (approximately 70% heritability), but also being commonly related to traumatizing events, especially those occurring in early life (adverse environmental exposures, such as childhood maltreatment) [14,17].…”

“…Pharmacological treatment often includes antipsychotic (quetiapine, lurasidone, and olanzapine), antidepressant (amitriptyline, paroxetine, and bupropion), or even some antiepileptic drugs (carbamazepine, lamotrigine, and valproic acid), although lithium continues to be one of the most effective therapies, due to its general mood-stabilizing properties, with specific antidepressant and antimanic effects due to its role in the reduction of dopamine and glutamate and increase of GABA neurotransmission [15,[19][20][21]. Nevertheless, treatment efficacy is known to be reduced, and the need for a patient-tailored approach leads to patient non-compliance due to the long time it can take until a proper treatment is found [15,16,18].…”

Elevated cognitive rumination and adverse life events are associated with lower cortical surface area and suicidal ideation in adolescents with major depressive disorder

“…Risk for STBs is also elevated after exposure to early-life stress (ELS) such as trauma, abuse, neglect, or bullying experiences in childhood or adolescence (Barzilay et al, 2021;Chen et al, 2021;Duprey et al, 2021;Gonçalves Peter et al, 2020;Lebowitz et al, 2019;Roh et al, 2015;Saint Onge et al, 2013;Sewall et al, 2020). Stress experiences in early life are thought to shape brain development in multiple ways, including through alterations in synaptic pruning of neuronal networks (Johnson et al, 2020). In line with this, ELS has been linked with structural brain alterations in young people, including reduced corticostriatal-limbic grey matter volumes (Edmiston et al, 2011), that underpin psychological functioning (i.e., cognitive flexibility) associated with STBs (Spann et al, 2012).…”

Elevated cognitive rumination and adverse life events are associated with lower cortical surface area and suicidal ideation in adolescents with major depressive disorder

“…Risk for STBs is also elevated after exposure to early-life stress such as trauma, abuse, neglect, or bullying experiences in childhood or adolescence (Barzilay et al, 2021;Chen et al, 2021;Duprey, Handley, Manly, Cicchetti, & Toth, 2021;Gonçalves Peter et al, 2020;Lebowitz, Blumberg, & Silverman, 2019;Roh et al, 2015;Saint Onge, Cepeda, Lee King, & Valdez, 2013;Sewall et al, 2020). Stress experiences during development are thought to shape brain development in multiple ways, including through alterations in synaptic pruning of neuronal networks (Johnson, Fields, & Bluett, 2020). In line with this, stressful experiences during childhood and adolescence have been linked with structural brain alterations in young people, including reduced corticostriatallimbic gray matter volumes (Edmiston et al, 2011), that underpin cognitive flexibility associated with STBs (Spann et al, 2012).…”