Diagnosing bipolar disorder: Defining thresholds and setting boundaries

Malhi, Gin S; Berk, Michael

doi:10.1177/0004867414536670

Cited by 17 publications

(17 citation statements)

References 30 publications

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“…For instance, antidepressants are thought to be more useful in bipolar II disorder but both the upper and lower boundaries of this subtype are difficult to define 6. Recent developments in the definition of mixed states in Diagnostic and Statistical Manual Fifth Edition employing the use of ‘mixed features specifiers’ has meant that distinguishing bipolar and unipolar depression has become more difficult 7 8.…”

Section: Resultsmentioning

confidence: 99%

Antidepressants in bipolar depression: yes, no, maybe?

Malhi

2015

Evid Based Mental Health

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Antidepressants are widely used in the treatment of bipolar depression despite relatively meagre evidence for their efficacy and significant concerns that their prescription can precipitate an acute affective switch into mania/hypomania and that long-term administration can lead to mood instability. Therefore, the use of antidepressants to treat bipolar depression is an important but contentious issue that two recent studies, which provide important new evidence, attempt to inform. One study suggests that long-term continuation of antidepressants in patients with rapid-cycling bipolar disorder leads to a threefold increase in mood episodes during the first year of follow-up-supporting the notion that antidepressants can cause more harm than good, and that they should be used sparingly. However, this is countered by findings from the other study, which suggests that continuation antidepressant monotherapy provides patients with bipolar II disorder reasonable prophylaxis, and that the risk of switching into mania/ hypomania is actually quite low. In addition to contrary findings both studies are modest in sample sizes and have significant design limitations and hence the debate remains unresolved. This brief perspective presents both views in the context of evidence and provides some key insights into the complexity of this challenging but common clinical issue.

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Section: Resultsmentioning

confidence: 99%

Antidepressants in bipolar depression: yes, no, maybe?

Malhi

2015

Evid Based Mental Health

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“…The difficulties in defining boundaries between hypomania and mania, and between mood episodes in general, have been described as representing a challenge to the staging model, but could potentially be overcome with precise definitions and criteria. Furthermore, the question whether persons with hypomania and depression of varying severity fit into stages 1b or 2 needs further clarification.…”

Section: Caveats and Limitationsmentioning

confidence: 99%

Staging in bipolar disorder: from theoretical framework to clinical utility

et al. 2017

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Illness staging is widely utilized in several medical disciplines to help predict course or prognosis, and optimize treatment. Staging models in psychiatry in general, and bipolar disorder in particular, depend on the premise that psychopathology moves along a predictable path: an atrisk or latency stage, a prodrome progressing to a first clinical threshold episode, and one or more recurrences with the potential to revert or progress to late or end-stage manifestations. The utility and validity of a staging model for bipolar disorder depend on its linking to clinical outcome, treatment response and neurobiological measures. These include progressive biochemical, neuroimaging and cognitive changes, and potentially stage-specific differences in response to pharmacological and psychosocial treatments. Mechanistically, staging models imply the presence of an active disease process that, if not remediated, can lead to neuroprogression, a more malignant disease course and functional deterioration. Biological elements thought to be operative in bipolar disorder include a genetic diathesis, physical and psychic trauma, epigenetic changes, altered neurogenesis and apoptosis, mitochondrial dysfunction, inflammation, and oxidative stress. Many available agents, such as lithium, have effects on these targets. Staging models also suggest the utility of stage-specific treatment approaches that may not only target symptom reduction, but also impede illness neuroprogression. These treatment approaches range from prevention for at-risk individuals, to early intervention strategies for prodromal and newly diagnosed individuals, complex combination therapy for rapidly recurrent illness, and palliative-type approaches for those at chronic, late stages of illness. There is hope that prompt initiation of potentially disease modifying therapies may preclude or attenuate the cognitive and structural changes seen in the later stages of bipolar disorder. The aims of this paper are to: a) explore the current level of evidence supporting the descriptive staging of the syndromal pattern of bipolar disorder; b) describe preliminary attempts at validation; c) make recommendations for the direction of further studies; and d) provide a distillation of the potential clinical implications of staging in bipolar disorder within a broader transdiagnostic framework.

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“…Lithium has been found to be particularly effective in patients with a ‘classic’ pattern of manic‐depressive illness . However, with the introduction of the diagnosis of bipolar disorder and the emergence over time of non‐specific cross‐sectional diagnostic categories in DSM and ICD, longitudinal patterns of illness have lost prominence . Thus, in practice clinicians should aim to map the course of a mood disorder over time in order to gauge likely lithium responsivity .…”

Section: Instrument: Lithiumeter 20mentioning

confidence: 99%