bipolar 1 case study

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Bipolar I Disorder

• A chronic, treatable mood disorder with a relapsing and remitting course marked by manic episodes, with most patients also experiencing major depressive episodes
• Manic episodes are periods of elevated mood, elevated self attitude (e.g. self esteem or self confidence), and increased vital sense (physical and mental energy).
• Depressive episodes are characterized by the triad of low mood, self-attitude and vital sense.
• Previously known as manic-depressive illness

EPIDEMIOLOGY

• Lifetime prevalence is 1%.
• Women with bipolar I disorder are at very high risk for postpartum mania and psychosis.
• Women are also more likely to have rapid cycling, which is defined as having four or more manic or depressive episodes per year.
• Onset of symptoms is typically in the late teens or early twenties, but earlier or later onset can occur.
• Patients are often initially diagnosed with major depressive disorder and only receive the diagnosis of bipolar I disorder after a later manic episode.
• Lifetime history of alcohol use disorder, comorbid anxiety disorder are risks for poorer treatment response. [1] [2] [3]
• Suicide risk is even greater if a patient with bipolar I disorder also has a substance use disorder .
• Bipolar disorder has a strong genetic component; individuals with a first-degree relative with bipolar disorder have a ten-fold risk of developing the disorder compared with the general population.

Clinical Presentation

Course of Illness

• If episode causes marked impairment in social/occupational functioning, requires hospitalization, or has associated psychotic symptoms (e.g., hallucinations or delusions), it is mania as compared to hypomania.
• Manic symptoms should not be caused by medications, substances, or medical conditions; although if manic symptoms arise during treatment for depression (e.g., anti-depressants or ECT), they can be considered evidence of manic episode.
• Some patients have rapid cycling - with four or more manic or depressive episodes in a year.
• Depressive episodes often occur immediately before or after a manic episode.
• Some patients have hypomanic symptoms that progress to a manic episode.
• Many patients return to normal mood between episodes, although others have residual mood symptoms between episodes, and 10% remain chronically ill.
• Risk factors for impaired functioning include substance abuse, earlier age at onset of disease, and family history of mood disorder.
• Stress is associated with onset of manic episodes and depressive episodes, though less so with episodes later in the course.
• Sleep deprivation, drug/alcohol use, and antidepressants can also trigger manic episodes.

Manic episodes:

• These are marked by elevated/irritable mood and increased activity, as well as other symptoms that can include inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, increased distractibility, and increased, reckless involvement in pleasurable activities like spending sprees, sexual activity, and substance abuse.
• Patients may not have insight regarding their elevated mood, but they may notice that they are having trouble controlling their drinking or drug use, or that they are having relationship problems.
• The hedonistic triad of spending sprees, sexual activity, and substance abuse can have catastrophic financial and personal consequences.
• The most common delusions are delusions of grandiosity (often with a religious theme) or paranoid delusions.
• Hallucinations are less common than delusions; when patients do have hallucinations, auditory hallucinations are more common than visual hallucinations.
• Although the beginning of a manic episode can be experienced by the patient as pleasant and is marked by elated mood, a severe manic state can be very unpleasant for the patient and can involve bizarre delusions, frenzied activity, and disorganized cognition.
• Severe mania is dangerous due to agitation and an increased risk of violence toward both self and others.

Major depressive episodes :

• Associated changes include variation in sleep patterns, changes in appetite, reduced libido, diurnal variation in symptoms, recurrent thoughts of death, and suicidality.
• Patients with bipolar I disorder are at greatest risk for suicide during depressive episodes and mixed episodes.

Mixed episodes:

• In addition to manic episodes and major depressive episodes , some patients have mixed states that combine the symptoms of a manic episode and a major depressive episode. These episodes are typified by low/irritable mood with increased activity, as well as other symptoms that can include pressured speech, insomnia, grandiosity, thoughts of death or suicide, and other combinations of manic or depressive episodes.
• Patients are at increased risk of suicide during mixed episodes given the dangerous combination of low mood and increased energy/restlessness.

Tests and Procedures

• Bipolar I disorder is a clinical syndromal diagnosis based on history and mental status exam, without a diagnostic laboratory test.
• Tests to assess etiologic factors include CBC, BMP, LFTs, TSH, B12, folate, vitamin D, RPR, blood alcohol level, urinalysis, and urine toxicology.
• Many patients with bipolar I disorder will present with a depressive episode; it is important to ask about past manic/hypomanic symptoms (mood swings, episodes of increased energy and decreased need for sleep).
• It is also important to ask patients’ family members or friends about past manic/hypomanic symptoms, since patients often lack insight regarding manic/hypomanic symptoms or may not remember them clearly (especially if the patient is currently depressed).
• Patients in a manic or mixed state will often be agitated and unable to give a coherent history; additional information should be obtained from family members or friends.
• It is important to ask about suicidal ideation and substance abuse .
• Eliciting a family history of bipolar disorder is also helpful given the strong genetic basis of bipolar disorder.
• Screening questionnaires, e.g., the Mood Disorder Questionnaire (MDQ), can be filled out by the patient; it is helpful to have a family member fill one out as well, since patients often do not self-report manic symptoms.

Differential Diagnosis

• Major depressive disorder
• Bipolar II disorder
• Cyclothymic disorder
• Schizoaffective disorder
• Schizophrenia
• Attention-deficit/hyperactivity disorder (ADHD)
• Personality disorder
• Alcohol , amphetamine, cocaine, hallucinogens , PCP, or LSD intoxication
• Alcohol or sedative withdrawal
• Medications that have been reported to cause mania include corticosteroids, stimulants, levodopa, isoniazid, levetiracetam, decongestants, immunosuppressants, certain chemotherapeutic agents, cimetidine, captopril, cyclobenzaprine, cyproheptadine, disulfiram, felbamate, L-glutamine, L-tryptophan, metrizamide, metoclopramide, procainamide, procarbazine, propafenone, sympathomimetics, thyroxine, tolmetin, triazolam, yohimbine, and zidovudine.
• Medication withdrawal: clonidine, diltiazem, atenolol, isocarboxazid, propanolol
• Cushing disease; multiple sclerosis; thalamic stroke; traumatic brain injury; Huntington disease ; Creutzfeld-Jakob disease; complex partial aeizures; systemic lupus erythematosus; CNS neoplasm; paraneoplastic syndrome; endocrine disorders, especially thyrotoxicosis, Wilson’s disease
• Infections (Lyme disease, HIV , neurosyphilis, influenza, Q fever, post-St. Louis type A encephalitis, cryptococcal meningitis)
• The foundations of treatment include medications and psychotherapy.
• Treatment of bipolar I disorder occurs in three stages: (1) acute treatment of a manic or depressive episode, (2) the improvement phase, and (3) the maintenance phase.

Acute Treatment

• Treatment of an acute manic or depressive episode focuses on diagnosis, safety, initiation of pharmacological treatment, support, and education.
• Patients are at high risk of suicide, particularly during depressive or mixed states.
• Patients may need psychiatric hospitalization, possibly on an involuntary basis, to ensure safety if the patient is suicidal, homicidal, severely agitated, or not adequately eating/drinking.
• If the patient does not require hospitalization, clinicians should consider limiting access to vehicles, credit cards, etc., given the propensity for reckless behavior in manic or mixed states.
• The mainstay of pharmacological treatment is mood stabilizers .
• Behavioral interventions: ensure that the patient is in a calm environment without excessive stimulation.
• Antidepressants are not first-line treatment for depressive episodes in bipolar disorder given their association with switching into hypomanic/manic/mixed episodes as well as increased cycling (in which mood episodes occur more frequently).
• ECT can be used in patients whose symptoms worsen in spite of medication, and ECT is also an option for patients who are not well-suited to medication (e.g., women in the first trimester of pregnancy, elderly patients, or patients with a high risk of suicide ).
• The focus of psychotherapy in the acute phase of treatment is support and education.
• It can take 4 weeks or more for a severely manic patient to achieve remission and be ready for outpatient care, which requires both medication adherence and attending regular clinic visits.
• The acute phase usually lasts 6-12 weeks.

Improvement Phase of Treatment

• During this phase of treatment, which lasts 6 months on average, the patient’s mood symptoms have improved, but the patient is still vulnerable to mood instability.
• Treatment during the improvement phase consists of frequent assessments, medication adjustments based on response and side effects, and psychotherapy.
• Psychotherapy during the improvement phase focuses on identifying and addressing stressors that can trigger mood symptoms and dealing with damage to relationships, work, or finances that occurred during a mood episode.
• If the patient does not relapse during the improvement phase of treatment, he/she is said to have recovered from the episode and enters the maintenance phase of treatment .

Maintenance Treatment

• The goal of maintenance treatment is to prevent future manic or depressive episodes.
• Because of the relapsing and remitting nature of bipolar I disorder, maintenance treatment is indicated after the first manic episode.
• The focus of maintenance treatment is long-term medication management, psychotherapy, and lifestyle changes.
• The mainstay of pharmacological treatment is mood stabilizers; many patients may benefit from being on more than one medication.
• Psychotherapy focuses on medication adherence, education, lifestyle changes, and addressing potentially devastating consequences of the illness.
• It is very important to have good continuity of care, so that the patient’s physician(s) will be familiar with his/her illness and particular constellation of symptoms and/or prodromal symptoms.
• It is also important to ask family members about their observations.
• It is important to treat substance misuse, comorbid anxiety, breakthrough symptoms, and side effects of medications.
• Patients and their family members may also benefit from attending support groups.

Special Populations

• Given that all mood stabilizers are potentially teratogenic, many patients discontinue them during pregnancy, but patients with severe illness may need to continue treatment during pregnancy.

Pharmacotherapy

Acute Treatment of a Manic Episode

• The mainstay of pharmacological treatment of manic episodes is mood stabilizers, with antipsychotics or benzodiazepines as needed for agitation.
• Lithium and divalproex are first-line mood stabilizers ; other options include carbamazepine, oxcarbazepine, and atypical antipsychotics (e.g., aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone).
• The above medications can be used as monotherapy for patients with less severe illness.
• Some patients may do well on lithium or divalproex plus an atypical antipsychotic; others may need triple therapy consisting of lithium, divalproex, and an atypical antipsychotic.
• Atypical antipsychotic are also recommended for patients who present with psychotic features (e.g., delusions, hallucinations ).
• Medication choice is based on mood symptoms, medication side effects, and past responses to medication, but some degree of trial and error is expected.
• Lithium is well-suited for classic manic episodes.
• Divalproex may be more effective for mixed episodes or rapid cycling.
• Carbamazepine also appears helpful for rapid cycling.
• One needs to carefully monitor mood symptoms and medication side effects, and titrate doses appropriately.
• For lithium , divalproex, and carbamazepine, blood levels are also important in guiding therapy.
• ECT is an option if a patient is not improving on medication or if he/she is not well-suited to medication (e.g., a patient in the first trimester of pregnancy trying to avoid teratogenic effects, a patient with a high risk of suicide, or an elderly patient).
• Severe agitation can be treated with atypical antipsychotics administered parenterally or intramuscularly while waiting for mood stabilizers to take effect.
• Benzodiazepines are not as effective for acute manic agitation.

Acute Treatment of a Bipolar Depressive Episode

• First-line treatments for bipolar depressive episodes include lithium or lamotrigine monotherapy.
• For more severe cases, can add second mood stabilizer (e.g., lamotrigine combined with lithium or divalproex).
• Atypical antipsychotics can be added for patients with psychotic features (e.g., delusions , hallucinations ).
• Antidepressant monotherapy is contraindicated in bipolar depressive episodes since antidepressants can cause rapid cycling or switches into mania /hypomania.
• Must monitor for increased cycling or switch into mania/hypomania/mixed state.
• Consider ECT if there is a high risk of suicide or the patient is not well-suited to medication (i.e., the patient is pregnant, elderly, or previously experienced rapid cycling or a switch into mania/hypomania/mixed state on antidepressants).

Improvement Phase

• Continue medications from acute episode.
• Assess mood symptoms and side effects frequently to guide dosage.

Maintenance Phase

• Many patients do well on lithium or divalproex as monotherapy maintenance treatment and can taper off adjunctive medications that were added during treatment of the acute episode; others will need combination maintenance treatment.
• The decision to taper adjunctive medications used during an acute episode is based on the individual patient’s response to medication and weighing side effects of continuing adjunctive medications vs. risk of relapse.
• Lithium or lamotrigine for prevention of depressive episodes
• Divalproex and carbamazepine for rapid cycling
• Maintenance antidepressant only if the patient repeatedly relapses after stopping
• Need to carefully monitor mood symptoms and medication side effects, and titrate medication dose appropriately, including verifying therapeutic blood levels for certain medications (e.g., lithium, divalproex, carbamazepine)
• Patients who received ECT during the acute phase of treatment may also benefit from maintenance ECT.

Psychotherapy

Acute Treatment of Manic Episode or Depressive Episode

• Education for the patient and family should emphasize that the patient’s mood symptoms are due to a treatable illness, that the patient must continue taking his/her medication and coming to appointments, and that suicide is not acceptable.
• During the improvement phase, psychotherapy focuses on identifying and addressing stressors that can trigger mood symptoms, and dealing with damage to relationships, work, or finances that occurred during mood episodes.

Maintenance Phase of Treatment

• Psychotherapy during the maintenance phase can become more intensive.
• Medication adherence is an important focus of psychotherapy because patients often want to stop taking maintenance medication when they are feeling better, but medication nonadherence puts them at risk for recurrence.
• Education about the illness is important for both the patient and the family.
• The most important lifestyle change is good sleep hygiene, since sleep deprivation can impact mood and can often trigger mania -- patients need to get enough sleep on a regular basis.
• Avoiding alcohol and illicit substances is important.
• A healthy diet, regular exercise, and other stress reduction techniques are also helpful.
• Another focus of psychotherapy is continuing to address potentially devastating consequences of the illness, which can include suicide , violence, drug and alcohol use, divorce, job loss, and financial ruin.

WHEN TO REFER

• Patients with bipolar I disorder will need acute management of manic or depressive episodes, a potentially complex pharmacological regimen, psychotherapy, and management of common comorbidities including substance misuse and other psychiatric conditions.
• Referral to a psychiatrist is recommended if a bipolar I diagnosis is suspected, or a patient has a depressive episode and either past manic/hypomanic symptoms or a family history of bipolar disorder.
• Because patients with bipolar I disorder can have relatively poor health outcomes, and medications for bipolar I disorder can have serious side effects, it is important for primary care physicians and psychiatrists to work closely to coordinate care.
• Primary care physicians can be an invaluable resource for recognizing when a patient is experiencing breakthrough mood symptoms.
• Cannabis use may worsen or contribute to manic episodes in patients with bipolar disorder, and may worsen overall patient outcomes. [6]
• Sportiche S, Geoffroy PA, Brichant-Petitjean C, et al. Clinical factors associated with lithium response in bipolar disorders. Aust N Z J Psychiatry . 2017;51(5):524-530.   [PMID:27557821]
• Ahn SW, Baek JH, Yang SY, et al. Long-term response to mood stabilizer treatment and its clinical correlates in patients with bipolar disorders: a retrospective observational study. Int J Bipolar Disord . 2017;5(1):24.   [PMID:28480482]
• Hunt GE, Malhi GS, Cleary M, et al. Comorbidity of bipolar and substance use disorders in national surveys of general populations, 1990-2015: Systematic review and meta-analysis. J Affect Disord . 2016;206:321-330.   [PMID:27426694]
• Oedegaard KJ, Alda M, Anand A, et al. The Pharmacogenomics of Bipolar Disorder study (PGBD): identification of genes for lithium response in a prospective sample. BMC Psychiatry . 2016;16:129.   [PMID:27150464]
• Hou L, Heilbronner U, Degenhardt F, et al. Genetic variants associated with response to lithium treatment in bipolar disorder: a genome-wide association study. Lancet . 2016;387(10023):1085-93.   [PMID:26806518]
• Gibbs M, Winsper C, Marwaha S, et al. Cannabis use and mania symptoms: a systematic review and meta-analysis. J Affect Disord . 2015;171:39-47.   [PMID:25285897]
• Cohen BJ. Theory and Practice of Psychiatry. Oxford University Press. 2003.
• Connolly KR et al: The Clinical Management of Bipolar Disorder: A Review of Evidence-Based Guidelines. Prim Care Companion CNS Disord 13:PCC.10r01097, 2011.
• Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA . 2005;293(8):956-63.   [PMID:15728166]
• Goodwin FK & Jamison KR. Manic-Depressive Illness. Oxford University Press. 2007.
• Mondimore FM. Bipolar Disorder: A Guide for Patients and Families. Johns Hopkins University Press. 2006.
• Perlis RH: The Role of Pharmacological Treatment Guidelines for Bipolar Disorder. J Clin Psychiatry 66 (suppl 3): 37, 2005.
• Tohen M, Zarate CA, Hennen J, et al. The McLean-Harvard First-Episode Mania Study: prediction of recovery and first recurrence. Am J Psychiatry . 2003;160(12):2099-107.   [PMID:14638578]

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5 Psychiatric Treatment of Bipolar Disorder: The Case of Janice

• Published: February 2013
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Chapter 5 covers the psychiatric treatment of bipolar disorder, including a case history, key principles, assessment strategy, differential diagnosis, case formulation, treatment planning, nonspecific factors in treatment, potential treatment obstacles, ethical considerations, common mistakes to avoid in treatment, and relapse prevention.

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• Published: 06 November 2018

The challenges of living with bipolar disorder: a qualitative study of the implications for health care and research

• Eva F. Maassen   ORCID: orcid.org/0000-0003-0211-0994 1 , 2 ,
• Barbara J. Regeer 1 ,
• Eline J. Regeer 2 ,
• Joske F. G. Bunders 1 &
• Ralph W. Kupka 2 , 3  

International Journal of Bipolar Disorders volume  6 , Article number:  23 ( 2018 ) Cite this article

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In mental health care, clinical practice is often based on the best available research evidence. However, research findings are difficult to apply to clinical practice, resulting in an implementation gap. To bridge the gap between research and clinical practice, patients’ perspectives should be used in health care and research. This study aimed to understand the challenges people with bipolar disorder (BD) experience and examine what these challenges imply for health care and research needs.

Two qualitative studies were used, one to formulate research needs and another to formulate healthcare needs. In both studies focus group discussions were conducted with patients to explore their challenges in living with BD and associated needs, focusing on the themes diagnosis, treatment and recovery.

Patients’ needs are clustered in ‘disorder-specific’ and ‘generic’ needs. Specific needs concern preventing late or incorrect diagnosis, support in search for individualized treatment and supporting clinical, functional, social and personal recovery. Generic needs concern health professionals, communication and the healthcare system.

Patients with BD address disorder-specific and generic healthcare and research needs. This indicates that disorder-specific treatment guidelines address only in part the needs of patients in everyday clinical practice.

Bipolar disorder (BD) is a major mood disorder characterized by recurrent episodes of depression and (hypo)mania (Goodwin and Jamison 2007 ). According to the Diagnostic and Statistical Manual 5 (DSM-5), the two main subtypes are BD-I (manic episodes, often combined with depression) and BD-II (hypomanic episodes, combined with depression) (APA 2014 ). The estimated lifetime prevalence of BD is 1.3% in the Dutch adult population (de Graaf et al. 2012 ), and BD is associated with high direct (health expenditure) and indirect (e.g. unemployment) costs (Fajutrao et al. 2009 ; Michalak et al. 2012 ), making it an important public health issue. In addition to the economic impact on society, BD has a tremendous impact on patients and their caregivers (Granek et al. 2016 ; Rusner et al. 2009 ). Even between mood episodes, BD is often associated with functional impairment (Van Der Voort et al. 2015 ; Strejilevich et al. 2013 ), such as occupational or psychosocial impairment (Huxley and Baldessarini 2007 ; MacQueen et al. 2001 ; Yasuyama et al. 2017 ). Apart from symptomatic recovery, treatment can help to overcome these impairments and so improve the person’s quality of life (IsHak et al. 2012 ).

Evidence Based Medicine (EBM), introduced in the early 1990s, is a prominent paradigm in modern (mental) health care. It strives to deliver health care based on the best available research evidence, integrated with individual clinical expertise (Sackett et al. 1996 ). EBM was introduced as a new paradigm to ‘de - emphasize intuition’ and ‘ unsystematic clinical experience’ (Guyatt et al. 1992 ) (p. 2420). Despite its popularity in principle (Barratt 2008 ), EBM has also been criticized. One such criticism is the ignorance of patients’ preferences and healthcare needs (Bensing 2000 ). A second criticism relates to the difficulty of adopting evidence-based treatment options in clinical practice (Bensing 2000 ), due to the fact that research outcomes measured in ‘the gold standard’ randomized-controlled trials (RCTs) seldom correspond to the outcomes clinical practice seeks and are not responsive to patients’ needs (Newnham and Page 2010 ). Moreover, EBM provides an overview on population level instead of individual level (Darlenski et al. 2010 ). Thus, adopting research evidence in clinical practice entails difficulties, resulting in an implementation gap.

To bridge the gap between research and clinical practice, it is argued that patients’ perspectives should be used in both health care and research. Patients have experiential knowledge about their illness, living with it in their personal context and their care needs (Tait 2005 ). This is valuable for both clinical practice and research as their knowledge complements that of health professionals and researchers (Tait 2005 ; Broerse et al. 2010 ; Caron-Flinterman et al. 2005 ). This source of knowledge can be used in the process of translating evidence into clinical practice (Schrevel 2015 ). Moreover, patient participation can enhance the clinical relevance of and support for research and the outcomes in practice (Abma and Broerse 2010 ). Hence, it is argued that these perspectives should be explicated and integrated into clinical guidelines, clinical practice, and research (Misak 2010 ; Rycroft-Malone et al. 2004 ).

Given the advantages of including patients’ perspectives, patients are increasingly involved in healthcare services (Bagchus et al. 2014 ; Larsson et al. 2007 ), healthcare quality (e.g. guideline development) (Pittens et al. 2013 ) and health-related research (e.g. agenda setting, research design) (Broerse et al. 2010 ; Boote et al. 2010 ; Elberse et al. 2012 ; Teunissen et al. 2011 ). However, patients’ perspectives on health care and on research are often studied separately. We argue that to be able to provide care focused on the patients and their needs, care and research must closely interact.

We hypothesize that the challenges BD patients experience and the associated care and research needs are interwoven, and that combining them would provide a more comprehensive understanding. We hypothesize that this more comprehensive understanding would help to close the gap between clinical practice and research. For this reason, this study aims to understand the challenges people with BD experience and examine what these challenges imply for healthcare and research needs.

To understand the challenges and needs of people with BD, we undertook two qualitative studies. The first aimed to formulate a research agenda for BD from a patient’s perspective, by gaining insights into their challenges and research needs. A second study yielded an understanding of the care needs from a patient’s perspective. In this article, the results of these two studies are combined in order to investigate the relationship between research needs and care needs. Challenges are defined as ‘difficulties patients face, due to having BD’. Care needs are defined as that what patients ‘desire to receive from healthcare services to improve overall health’ (Asadi-Lari et al. 2004 ) (p. 2). Research needs are defined as that what patients ‘desire to receive from research to improve overall health’.

Study on research needs

In this study, mixed-methods were used to formulate research needs from a patient’s perspective. First six focus group discussions (FGDs) with 35 patients were conducted to formulate challenges in living with BD and hopes for the future, and to formulate research needs arising from these difficulties and aspirations. These research needs were validated in a larger sample (n = 219) by means of a questionnaire. We have reported this study in detail elsewhere (Maassen et al. 2018 ).

Study on care needs

This study was part of a nationwide Dutch project to generate a practical guideline for BD: a translation of the existing clinical guideline to clinical practice, resulting in a standard of care that patients with BD could expect. The practical guideline (Netwerk Kwaliteitsontwikkeling GGZ 2017 ) was written by a taskforce comprising health professionals, patients. In addition to the involvement of three BD patients in the taskforce, a systematic qualitative study was conducted to gain insight into the needs of a broader group of patients.

Participants and data collection

To formulate the care needs of people with BD, seven FGDs were conducted, with a total of 56 participants, including patients (n = 49) and caregivers (n = 9); some participants were both patient and caregiver. The inclusion criteria for patients were having been diagnosed with BD, aged 18 years or older and euthymic at time of the FGDs. Inclusion criteria for caregivers were caring for someone with BD and aged 18 years or older. To recruit participants, a maximum variation sampling strategy was used to collect a broad range of care needs (Kuper et al. 2008 ). First, all outpatient clinics specialized in BD affiliated with the Dutch Foundation for Bipolar Disorder (Dutch: Kenniscentrum Bipolaire Stoornissen) were contacted by means of an announcement at regular meetings and by email if they were interested to participate. From these outpatient clinics, patients were recruited by means of flyers and posters. Second, patients were recruited at a quarterly meeting of the Dutch patient and caregiver association for bipolar disorder. The FGDs were conducted between March and May 2016.

The FGDs were designed to address challenges experienced in BD health care and areas of improvement for health care for people with BD. The FGDs were structured by means of a guide and each session was facilitated by two moderators. The leading moderator was either BJR or EFM, having both extensive experience with FGD’s from previous studies. The first FGD explored a broad range of needs. The subsequent six FGDs aimed to gain a deeper understanding of these care needs, and were structured according to the outline of the practical guideline (Netwerk Kwaliteitsontwikkeling GGZ 2017 ). Three chapters were of particular interest: diagnosis, treatment and recovery. These themes were discussed in the FGDs, two in each session, all themes three times in total. Moreover, questions on specific aspects of care formulated by the members of the workgroup were posed. The sessions took 90–120 min. The FGDs were audiotaped and transcribed verbatim. A summary of the FGDs was sent to the participants for a member check.

Data analysis

To analyze the data on challenges and needs, a framework for thematic analysis to identify, analyze and report patterns (themes) in qualitative data sets by Braun and Clarke ( 2006 ) was used. First, we familiarized ourselves with the data by carefully reading the transcripts. Second, open coding was used to derive initial codes from the data. These codes were provided to quotes that reflected a certain challenge or care need. Third, we searched for patterns within the codes reflecting challenges and within those reflecting needs. For both challenges and needs, similar or overlapping codes were clustered into themes. Subsequently, all needs were categorized as ‘specific’ or ‘generic’. The former are specific to BD and the latter are relevant for a broad range of psychiatric illnesses. Finally, a causal analysis provided a clear understanding of how challenges related to each other and how they related to the described needs.

To analyze the data on needs regarding recovery, four domains were distinguished, namely clinical, functional, social and personal recovery (Lloyd et al. 2008 ; van der Stel 2015 ). Clinical recovery refers to symptomatic remission; functional recovery concerns recovery of functioning that is impaired due to the disorder, particularly in the domain of executive functions; social recovery concerns the improvement of the patient’s position in society; personal recovery concerns the ability of the patient to give meaning to what had happened and to get a grip on their own life. The analyses were discussed between BR and EM. The qualitative software program MAX QDA 11.1.2 was used (MaxQDA).

Ethical considerations

According to the Medical Ethical Committee of VU University Medical Center, the Medical Research Involving Human Subjects Act does not apply to the current study. All participants gave written or verbal informed consent regarding the aim of the study and for audiotaping and its use for analysis and scientific publications. Participation was voluntary and participants could withdraw from the study at any time. Anonymity was ensured.

This section is in three parts. The first presents the participants’ characteristics. The second presents the challenges BD patients face, derived from both studies, and the disorder-specific care and research needs associated with these challenges. The third part describes the generic care needs that patients formulated.

Characteristics of the participants

In the study on care needs, 56 patients and caregivers participated. The mean age of the participants was 52 years (24–75), of whom 67.8% were women. The groups varied from four to sixteen participants, and all groups included men and women. Of all participants 87.5% was diagnosed with BD, of whom 48.9% was diagnosed with BD I. 3.5% was both caregivers and diagnosed with BD. Of 4 patients the age was missing, and from 6 patients the bipolar subtype.

Despite the fact that participants acknowledge the inevitable diagnostic difficulties of a complex disorder like BD, in both studies they describe a range of challenges in different phases of the diagnostic process (Fig.  1 ). Patients explained that the general practitioner (GP) and society in general did not recognize early-warning signs and mood swings were not well interpreted, resulting in late or incorrect diagnosis. Patients formulated a need for more research on what early-warning signs could be and on how to improve GPs’ knowledge about BD. Formulated care needs were associated with GPs using this knowledge to recognize early-warning signs in individual patients. One participant explained that certain symptoms must be noticed and placed in the right context:

Challenges with diagnosis (squares) including relating research needs (white circles) and care needs (grey circles). (1): mentioned in study on research needs; (2): mentioned in study on care needs. Dotted lines: division of challenges into sub challenges. Arrows: causal relation between challenges

I call it, ‘testing overflow of ideas’. [….] When it happens for the first time you yourself do not recognize it. Someone else close to you or the health professional, who is often not involved yet, must signal it. (FG6)

Moreover, these challenges are associated with the need to pay attention to family history and to use a multidisciplinary approach to diagnosis to benefit from multiple perspectives. The untimely recognition of early symptoms also results in another challenge: inadequate referral to the right specialized health professional. After referral, people often face a waiting list, again causing delay in the diagnostic process. These challenges result in the need for research on optimal referral systems and the care need for timely referral. One participant described her process after the GP decided to refer her:

But, yes, at that moment the communication wasn’t good at all. Because the general practitioner said: ‘she urgently has to be seen by someone’. Subsequently, three weeks went by, until I finally arrived at depression [department]. And at that department they said: ‘well, you are in the wrong place, you need to go to bipolar [department ]’. (FG1)

The challenge of being misdiagnosed is associated with the need to be able to ask for a second opinion and to have a timely and thorough diagnosis. On the one hand, it is important for patients that health professionals quickly understand what is going on, on the other hand that health professionals take the time to thoroughly investigate the symptoms by making several appointments.

From both studies, two main challenges related to the treatment of BD were derived (Fig.  2 ). The first is finding appropriate and satisfactory treatment. Participants explained that it is difficult to find the right medication and dosage that is effective and has acceptable side-effects. One participant illustrates:

Challenges with treatment (squares) including relating research needs (white circles) and care needs (grey circles). (1): mentioned in study on research needs; (2): mentioned in study on care needs. Dotted lines: division of challenges into sub challenges. Arrows: causal relation between challenges

I think, at one point, we have to choose, either overweight or depressed. (FG1)

Some participants said that they struggle with having to use medication indefinitely, including the associated medical checks. The difficult search for the right pharmacological treatment results in the need for research on long-term side-effects, on the mechanism of action of medicine and on the development of better targeted medication with fewer adverse side-effects. In care, patients would appreciate all the known information on the side-effects and intended effects. One participant explained the importance of being properly informed about medication:

I don’t read anything [about medication], because then I wouldn’t dare taking it. But I do think, when you explain it well, the advantages, the disadvantages, the treatment, the idea behind it, that would help a lot in compliance. (FG1)

A second aspect is the challenge of finding non-pharmacological therapies that fit patients’ needs. They said they and the health professionals often do not know which non-pharmacological therapies are available and effective:

But we found the carefarm ourselves Footnote 1 [….]. You have to search for yourself completely. Yes, I actually hoped that that would be presented to you, like: ‘this would be something for you’. (FG3)

Participants mentioned a variety of non-pharmacological therapies they found useful, namely cognitive behavior therapy (CBT), EMDR, running therapy, social-rhythm training, light therapy, mindfulness, psychotherapy, psychoeducation, and training in living with mood swings. They formulated the care need to receive an overview of all available treatment options in order to find a treatment best suited to their needs. They would appreciate research on the effectiveness of non-pharmacological treatments.

A third aspect within this challenge is finding the right balance between non-pharmacological and pharmacological treatment. Participants differed in their opinion about the need for medication. Whereas some participants stated that they need medication to function, others pointed out that they found non-pharmacological treatments effective, resulting in less or no medication use. They explained that the preferred balance can also change over time, depending on their mood. However, they experience a dominant focus on pharmacological treatment by the health professionals. To address this challenge, patients need support in searching for an appropriate balance.

Next to the challenge of finding appropriate and satisfactory treatment, a second treatment-related challenge is hospitalization. Participants often had a traumatic experience, due to seclusion, the authoritarian attitudes of clinical staff, and not involving their family. Patients therefore found it important to try preventing being hospitalized, for example by means of home treatment, which some participants experienced positively. Despite the challenges relating to hospitalization, participants did acknowledge that in some cases it cannot be avoided, in which case they urged for close family involvement, open communication and being treated by their own psychiatrist. Still, in the study on research needs, hospitalization did not emerge as an important research theme.

In both studies, participants described challenges in all four domains of recovery: clinical, functional, social and personal (Fig.  3 ). In relation to clinical recovery, participants struggled with the symptoms of mood episodes, the psychosis and the fear of a future episode. In contrast, some participants mentioned that they sometimes miss the hypomanic state they had experienced previously due to effective medical treatment. In the domain of functional recovery, participants contended with having to function below their educational level due to residual symptoms, such as cognitive problems, due to the importance of preventing stress in order to reduce the risk of a new episode, and because of low energy levels. This leads to the care need that health professionals should pay attention to the level of functioning of their patients.

Challenges with recovery (squares) including relating research needs (white circles) and care needs (grey circles). (1): mentioned in study on research needs; (2): mentioned in study on care needs. Dotted lines: division of challenges into sub challenges. Arrows: causal relation between challenges

In the domain of social recovery, participants described challenges with maintaining friendships, due to stigma, being unpredictable and with deciding when to disclose the disorder. The latter resulted in the care need for tips on disclosure. Moreover, patients experienced challenges with reintegration to work, due to colleagues’ lack of understanding, problems with functioning during an episode, the complicating policy of the (Dutch) Employee Insurance Agency Footnote 2 in relation to the fluctuating course of BD and the negative impact of stress. These challenges are associated with the care need that health professionals should pay attention to work and the need for research on how to improve the Social Security Agency’s policy.

For their personal recovery, participants struggled with acceptance of the disorder, due to shame, stigma, having to live by structured rules and disciplines, and the chronic nature of BD. This results in care needs for grief counselling and attention to acceptance and the need for research on the impact of being diagnosed with BD. Limited understanding within society also causes problems with acceptance, corresponding with the care need for education for caregivers and for research on how to increase social acceptance. Another challenge in personal recovery was discovering what recovery means and what constitute meaningful daily activities. Patients appreciated the support of health professionals in this area. One participant described the difficult search for the meaning of recovery:

I have been looking to recover towards the situation [before diagnosis] for a long time; that I could do what I always did and what I liked. But then I was confronted with the fact that I shouldn’t expect that to happen, or only with a lot of effort. (…) Then you start thinking, now what? A compromise. I don’t want to call that recovery, but it is a recovered, partly accepted, situation. But it is not recovery as I expected it to be. (FG5)

In general, participants considered frequent contact with a nurse or psychiatrist supportive, to help them monitor their mood and help them find (efficient) self-management strategies. Most participants appreciated the involvement of caregivers in the treatment and contact with peers.

Generic care needs

We have described BD-specific needs, but patients mentioned also mentioned several generic care needs. The latter are clustered into three categories. The first concerns the health professionals . Participants stressed the importance of a good health professional, who carefully listens, takes time, and makes them feel understood, resulting in a sense of connection. Furthermore, a good health professional treats beyond the guideline, and focuses on the needs of the individual patient. When there is no sense of connection, it should be possible to change to another health professional. The second category concerns communication between the patient and the health professional . Health professionals should communicate in an open, honest and clear way both in the early diagnostic phase and during treatment. Open communication facilitates individualized care, in which the patient is involved in decision making. In addition, participants wanted to be treated as a person, not as a patient, and according to a strength-based approach. The third category concerns needs at the level of the healthcare system . Participants struggled with the availability of the health professionals and preferred access to good care 24/7 and being able to contact their health professional quickly when necessary. Currently, according to the participants, the care system is not geared to the mood swings of BD, because patients often faced waiting lists before they could see a health professional.

Is adequate treatment also having a number from a mental health institution you can always call when you are in need, that you can go there? And not that you can go in three weeks, but on a really short notice. So at least a phone call. (FG3)

Participants were often frustrated by the limited collaboration between health professionals, within their own team, between departments of the organization, and between different organizations, including complementary health professionals. They would appreciate being able to merge their conventional and complementary treatment, with greater collaboration among the different health professionals. Furthermore, they would like continuity of health professionals as this improves both the diagnostic phase and treatment, and because that health professional gets to know the patient.

We hypothesized that research and care needs of patients are closely intertwined and that understanding these, by explicating patients’ perspectives, could contribute to closing the gap between research and care. Therefore, this study aimed to understand the challenges patients with BD face and examine what these imply for both healthcare and research. In the study on needs for research and in the study on care needs, patients formulated challenges relating to receiving the correct diagnosis, finding the right treatment, including the proper balance between non-pharmacological and pharmacological treatment, and to their individual search for clinical, functional, social and personal recovery. The formulated needs in both studies clearly reflected these challenges, leading to closely corresponding needs. Another important finding of our study is that patients not only formulate disorder-specific needs, but also many generic needs.

The needs found in our study are in line with the current literature on the needs of patients with BD, namely for more non-pharmacological treatment (Malmström et al. 2016 ; Nestsiarovich et al. 2017 ), timely recognition of early-warning signs and self-management strategies to prevent a new episode (Goossens et al. 2014 ), better information on treatment and treatment alternatives (Malmström et al. 2016 ; Neogi et al. 2016 ) and coping with grief (Goossens et al. 2014 ). Moreover, the need for frequent contact with health professionals, being listened to, receiving enough time, shared decision-making on pharmacological treatment, involving caregivers (Malmström et al. 2016 ; Fisher et al. 2017 ; Skelly et al. 2013 ), and the urge for better access to health care and continuity of health professionals (Nestsiarovich et al. 2017 ; Skelly et al. 2013 ) are confirmed by the literature. Our study added to this set of literature by providing insights in patients’ needs in the diagnostic process and illustrating the interrelation between research needs and care needs from a patient’s perspective.

The generic healthcare needs patients addressed in this study are clustered into three categories: the health professional , communication between the patient and the health professional and the health system. These categories all fit in a model of patient-centered care (PCC) by Maassen et al. ( 2016 ) In their review, patients’ perspectives on good care are compared with academic perspectives of PCC and a model of PCC is created comprising four dimensions: patient, health professional, patient – professional interaction and healthcare organization. All the generic needs formulated in this study fit into these four dimensions. The need to be treated as a person with strengths fits the dimension ‘patient’, and the need for a good health professional who carefully listens, takes time and makes them feel understood, resulting in a good connection with the professional, fits the dimension ‘health professional’ of this model. Furthermore, patients in this study stressed the importance of open communication in order to provide individualized care, which fits the dimension of ‘patient–professional interaction’. The urge for better access to health care, geared to patients’ mood swings and the need for better collaboration between health professionals and continuity of health professionals fits the dimension of ‘health care organization’ of the model. This study confirms the findings from the review and contributes to the literature stressing the importance of a patient-centered care approach (Mills et al. 2014 ; Scholl et al. 2014 ).

In the prevailing healthcare paradigm, EBM, the best available evidence should guide treatment of patients (Sackett et al. 1996 ; Darlenski et al. 2010 ). This evidence is translated into clinical and practical guidelines, which thus facilitate EBM and could be used as a decision-making tool in clinical practice (Skelly et al. 2013 ). For many psychiatric disorders, treatment is based on such disorder - specific clinical and practical guidelines. However, this disease-focused healthcare system has contributed to its fragmented nature Stange ( 2009 ) argues that this fragmented care system has expanded without the corresponding ability to integrate and personalize accordingly. We argue that acknowledging that disorder - specific clinical and practical guidelines address only parts of the care needs is of major importance, since otherwise important aspects of the patients’ needs will be ignored. Because there is an increasing acknowledgement that health care should be responsive to the needs of patients and should change from being disease-focused towards being patient-focused (Mead and Bower 2000 ; Sidani and Fox 2014 ), currently in the Netherlands generic practical guidelines are written on specific care themes (e.g. co-morbidity, side-effects, daily activity and participation). These generic practical guidelines address some of the generic needs formulated by the patients in our study. We argue that in addition to disorder-specific guidelines, these generic practical guidelines should increasingly be integrated into clinical practice, while health professionals should continuously be sensitive to other emerging needs. We believe that an integration of a disorder-centered and a patient-centered focus is essential to address all needs a patient.

Strengths, limitations and future research

This study has several strengths. First, it contributes to the literature on the challenges and needs of patients with BD. Second, the study is conducted from a patient’s perspective. Moreover, addressing this aim by conducting two separate studies enabled us to triangulate the data.

This study also has several limitations. First, this study reflects the challenges, care needs and research needs of Dutch patient with BD and caregivers. Despite the fact that a maximum variation sampling strategy was used to derive a broad range of challenges and needs throughout the Netherlands, the Dutch setting of the study may limit the transferability to other countries. To understand the overlap and differences between countries, similar research should be conducted in other contexts. Second, given the design of the study, we could not differentiate between patients and caregivers since they participated together in the FGDs. More patients than caregivers participated in the study. For a more in-depth understanding of the challenges and needs faced by caregivers, in future research separate FGDs should be conducted. Third, due to the fixed outline of the practical guideline used to conduct the FGDs, only the healthcare needs for diagnosis, treatment and recovery of BD are studied. Despite the fact that these themes might cover a broad range of health care, it could have resulted in overlooking certain needs in related areas of well-being. Therefore, future research should focus on needs outside of these themes in order to provide a complete set of healthcare needs.

Patients and their caregivers face many challenges in living with BD. Our study contributes to the literature on care and research needs from a patient perspective. Needs specific for BD are preventing late or incorrect diagnosis, support in search for individualized treatment, and supporting clinical, functional, social and personal recovery. Generic healthcare needs concern health professionals, communication and the healthcare system. This explication of both disorder-specific and generic needs indicates that clinical practice guidelines should address and integrate both in order to be responsive to the needs of patients and their caregivers.

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Maassen, E.F., Regeer, B.J., Regeer, E.J. et al. The challenges of living with bipolar disorder: a qualitative study of the implications for health care and research. Int J Bipolar Disord 6 , 23 (2018). https://doi.org/10.1186/s40345-018-0131-y

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Real Life Bipolar Disorder: A Case Study of Susan

Bipolar disorder is a complex and often misunderstood mental health condition that affects millions of individuals worldwide. For those living with bipolar disorder, the highs and lows of life can be dizzying, as they navigate through periods of intense mania and debilitating depression. To truly grasp the impact of this disorder, it’s crucial to explore real-life experiences and the stories of those who have dealt firsthand with its challenges.

In this article, we delve into the fascinating case study of Susan, a woman whose life has been profoundly shaped by her bipolar disorder diagnosis. By examining Susan’s journey, we aim to shed light on the realities of living with this condition and the strategies employed to manage and treat it effectively.

But before we plunge deeper into Susan’s story, let’s first gain a comprehensive understanding of bipolar disorder itself. We’ll explore the formal definition, the prevalence of the condition, and its impact on both individuals and society as a whole. This groundwork will set the stage for a more insightful exploration of Susan’s experience and provide valuable context for the subsequent sections of this article.

Bipolar disorder is more than just mood swings; it is a condition that can significantly disrupt an individual’s life, relationships, and overall well-being. By studying a real-life case like Susan’s, we can gain a personal insight into the multifaceted challenges faced by those with bipolar disorder and the importance of effective treatment and support systems. In doing so, we hope to foster empathy, inspire early diagnosis, and contribute to the advancement of knowledge about bipolar disorder’s complexities.

The Case of Susan: A Real Life Experience with Bipolar Disorder

Susan’s story provides a compelling illustration of the impact that bipolar disorder can have on an individual’s life. Understanding her background, symptoms, and the effects of the disorder on her daily life can provide valuable insights into the challenges faced by those with bipolar disorder.

Background Information on Susan

Susan, a thirty-eight-year-old woman, was diagnosed with bipolar disorder at the age of twenty-five. Her early experiences with the disorder were characterized by periods of extreme highs and lows, often resulting in strained relationships and an inability to maintain steady employment. Susan’s episodes of mania frequently led to impulsive decision-making, excessive spending sprees, and risky behaviors. On the other hand, her depressive episodes left her feeling hopeless, fatigued, and unmotivated.

Symptoms and Diagnosis of Bipolar Disorder in Susan

To receive an accurate diagnosis, Susan underwent a thorough examination by mental health professionals. The criteria for diagnosing bipolar disorder include significant and persistent mood swings, alternating between periods of mania and depression. Susan exhibited classic symptoms of bipolar disorder, such as elevated mood, increased energy, racing thoughts, decreased need for sleep, and reckless behavior during her manic episodes. These episodes were interspersed with periods of deep sadness, loss of interest in activities, and changes in appetite and sleep patterns during depressive phases.

Effects of Bipolar Disorder on Susan’s Daily Life

Living with bipolar disorder presents unique challenges for Susan. The unpredictable shifts in her mood and energy levels significantly impact her ability to function in both personal and professional spheres. During manic phases, Susan experiences heightened productivity, creativity, and confidence, often leading her to take on excessive responsibilities and projects. However, these periods are eventually followed by crashes into depressive episodes, leaving her unable to complete tasks, maintain relationships, or even perform routine self-care. The constant fluctuations in her emotional state make it difficult for Susan to establish a sense of stability and predictability in her life.

Susan’s struggle with bipolar disorder is not uncommon. Many individuals with this condition face similar obstacles in their daily lives, attempting to manage the debilitating highs and lows while striving for a sense of normalcy. By understanding the real-life implications of bipolar disorder, we can more effectively tailor our support systems and treatment options to address the needs of individuals like Susan. In the next section, we will explore the various approaches to treating and managing bipolar disorder, providing potential strategies for improving the quality of life for those living with this condition.

Treatment and Management of Bipolar Disorder in Susan

Managing bipolar disorder requires a multifaceted approach that combines psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications. Susan’s journey towards finding effective treatment and management strategies highlights the importance of a comprehensive and tailored approach.

Psychopharmacological Interventions

Pharmacological interventions play a crucial role in stabilizing mood and managing symptoms associated with bipolar disorder. Susan’s treatment plan involved medications such as mood stabilizers, antipsychotics, and antidepressants. These medications aim to regulate the neurotransmitters in the brain associated with mood regulation. Susan and her healthcare provider closely monitored her medication regimen and made adjustments as needed to achieve symptom control.

Psychotherapy and Counseling

Psychotherapy and counseling provide individuals with bipolar disorder a safe space to explore their thoughts, emotions, and behaviors. Susan engaged in cognitive-behavioral therapy (CBT), which helped her identify and challenge negative thought patterns and develop healthy coping mechanisms. Additionally, psychoeducation in the form of group therapy or support groups allowed Susan to connect with others facing similar challenges, fostering a sense of community and reducing feelings of isolation.

Lifestyle Modifications and Self-Care Strategies

In addition to medical interventions and therapy, lifestyle modifications and self-care strategies play a vital role in managing bipolar disorder. Susan found that maintaining a stable routine, including regular sleep patterns, exercise, and a balanced diet, helped regulate her mood. Avoiding excessive stressors and implementing stress management techniques, such as mindfulness meditation or relaxation exercises, also supported her overall well-being. Engaging in activities she enjoyed, nurturing her social connections, and setting realistic goals further enhanced her quality of life.

Striving for stability and managing bipolar disorder is an ongoing process. What works for one individual may not be effective for another. It is crucial for individuals with bipolar disorder to work closely with their healthcare providers and engage in open communication about treatment options and progress. Fine-tuning the combination of psychopharmacological interventions, therapy, and self-care strategies is essential to optimize symptom control and maintain stability.

Understanding the complexity of treatment and management helps foster empathy for individuals like Susan, who face the daily challenges associated with bipolar disorder. It underscores the importance of early diagnosis, accessible mental health care, and ongoing support systems to enhance the lives of individuals living with this condition. In the following section, we will explore the various support systems available to individuals with bipolar disorder, including family support, peer support groups, and the professional resources that contribute to their well-being.

Support Systems for Individuals with Bipolar Disorder

Navigating the challenges of bipolar disorder requires a strong support system that encompasses various sources of assistance. From family support to peer support groups and professional resources, these networks play a significant role in helping individuals manage their condition effectively.

Family Support

Family support is vital for individuals with bipolar disorder. Understanding and empathetic family members can provide emotional support, monitor medication adherence, and help identify potential triggers or warning signs of relapse. In Susan’s case, her family played a crucial role in her recovery journey, providing a stable and nurturing environment. Education about bipolar disorder within the family helps foster empathy, reduces stigma, and promotes open communication.

Peer Support Groups

Peer support groups provide individuals with bipolar disorder an opportunity to connect with others who share similar experiences. Sharing personal stories, strategies for coping, and offering mutual support can be empowering and validating. In these groups, individuals like Susan can find solace in knowing that they are not alone in their struggles. Peer support groups may meet in-person or virtually, allowing for easier access to support regardless of physical proximity.

Professional Support and Resources

Professional support is crucial in the management of bipolar disorder. Mental health professionals, such as psychiatrists, psychologists, and therapists, provide expertise and guidance in developing comprehensive treatment plans. Regular therapy sessions allow individuals like Susan to explore emotional challenges and develop healthy coping mechanisms. Psychiatrists closely monitor medication effectiveness and make necessary adjustments. Additionally, case managers or social workers can assist with navigating the healthcare system, accessing resources, and connect individuals with other community services.

Beyond direct professional support, there are resources and organizations dedicated to bipolar disorder education, advocacy, and support. Online forums, websites, and helplines provide information, guidance, and a sense of community. These platforms allow individuals to access information at any time and connect with others who understand their unique experiences.

Support systems for bipolar disorder are crucial in empowering individuals and enabling them to lead fulfilling lives. They contribute to reducing stigma, providing emotional support, and ensuring access to resources and education. Through these support systems, individuals with bipolar disorder can gain self-confidence, develop effective coping strategies, and improve their overall well-being.

In the next section, we explore the significance of case studies in understanding bipolar disorder and how they contribute to advancing research and knowledge in the field. Specifically, we will examine how Susan’s case study serves as a valuable contribution to furthering our understanding of this complex disorder.

The Importance of Case Studies in Understanding Bipolar Disorder

Case studies play a vital role in advancing our understanding of bipolar disorder and its complexities. They offer valuable insights into individual experiences, treatment outcomes, and the overall impact of the condition on individuals and society. Susan’s case study, in particular, provides a unique perspective that contributes to broader research and knowledge in the field.

How Case Studies Contribute to Research

Case studies provide an in-depth examination of specific individuals and their experiences with bipolar disorder. They allow researchers and healthcare professionals to observe patterns, identify commonalities, and gain valuable insights into the factors that influence symptom presentation, treatment response, and prognosis. By analyzing various case studies, researchers can generate hypotheses and refine treatment approaches to optimize outcomes for individuals with bipolar disorder.

Case studies are particularly helpful in documenting rare or atypical presentations of bipolar disorder. They shed light on lesser-known subtypes, such as rapid-cycling bipolar disorder or mixed episodes, contributing to a more comprehensive understanding of the condition. Case studies also provide opportunities for clinicians and researchers to discuss unique challenges and discover innovative interventions to improve treatment outcomes.

Susan’s Case Study in the Context of ATI Bipolar Disorder

Susan’s case study is an example of how individual experiences can inform the development of Assessment Technologies Institute (ATI) for bipolar disorder. By examining her journey, researchers can analyze treatment approaches, evaluate the effectiveness of various interventions, and develop evidence-based guidelines for managing bipolar disorder.

Susan’s case study provides rich information about the impact of medication, psychotherapy, and lifestyle modifications on symptom control and overall well-being. It offers valuable insights into the benefits and limitations of specific interventions, highlighting the importance of personalized treatment plans tailored to individual needs. Additionally, Susan’s case study can contribute to ongoing discussions about the role of support systems and the integration of peer support groups in managing and enhancing the lives of individuals with bipolar disorder.

The detailed documentation of Susan’s experiences serves as a powerful tool for healthcare providers, researchers, and individuals living with bipolar disorder. It highlights the complexities and challenges associated with the condition while fostering empathy and understanding among various stakeholders.

Case studies, such as Susan’s, play a crucial role in enhancing our understanding of bipolar disorder. They provide insights into individual experiences, treatment approaches, and the impact of the condition on individuals and society. Through these case studies, we can cultivate empathy for individuals with bipolar disorder, advocate for early diagnosis and effective treatment, and contribute to advancements in research and knowledge.

By illuminating the realities of living with bipolar disorder, we acknowledge the need for accessible mental health care, support systems, and evidence-based interventions. Susan’s case study exemplifies the importance of a comprehensive approach to managing bipolar disorder, integrating psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications.

Moving forward, it is essential to continue studying cases like Susan’s and explore the diverse experiences within the bipolar disorder population. By doing so, we can foster empathy, encourage early intervention and personalized treatment, and contribute to advancements in understanding bipolar disorder, ultimately improving the lives of individuals affected by this complex condition.

Empathy and Understanding for Individuals with Bipolar Disorder

Developing empathy and understanding for individuals with bipolar disorder is crucial in fostering a supportive and inclusive society. By recognizing the unique challenges they face and the complexity of their experiences, we can better advocate for their needs and provide the necessary resources and support.

It is important to understand that bipolar disorder is not simply a matter of mood swings or being “moody.” It is a chronic and often debilitating mental health condition that affects individuals in profound ways. The extreme highs of mania and the lows of depression can disrupt relationships, employment, and overall quality of life. Developing empathy means acknowledging that these struggles are real and offering support and understanding to those navigating them.

Encouraging Early Diagnosis and Effective Treatment

Early diagnosis and effective treatment are key factors in managing bipolar disorder and reducing the impact of its symptoms. Encouraging individuals to seek help and reducing the stigma associated with mental illness are crucial steps toward achieving early diagnosis. Increased awareness campaigns and education can empower individuals to recognize the signs and symptoms of bipolar disorder in themselves or their loved ones, facilitating timely intervention.

Once diagnosed, providing access to quality mental health care and ensuring individuals receive appropriate treatment is essential. Bipolar disorder often requires a combination of pharmacological interventions, psychotherapy, and lifestyle modifications. By advocating for comprehensive treatment plans and promoting ongoing care, we can help individuals with bipolar disorder achieve symptom control and improve their overall well-being.

The Role of Case Studies in Advancing Knowledge about Bipolar Disorder

Case studies, like Susan’s, play a significant role in advancing knowledge about bipolar disorder. They provide unique insights into individual experiences, treatment outcomes, and the wider impact of the condition. Researchers and healthcare providers can learn from these individual cases, developing evidence-based guidelines and refining treatment approaches.

Additionally, case studies contribute to reducing stigma by providing personal narratives that humanize the disorder. They showcase the challenges faced by individuals with bipolar disorder and highlight the importance of support systems, empathy, and understanding. By sharing these stories, we can help dispel misconceptions and promote a more compassionate approach toward mental health as a whole.

In conclusion, developing empathy and understanding for individuals with bipolar disorder is essential. By recognizing the complexity of their experiences, advocating for early diagnosis and effective treatment, and valuing the insights provided by case studies, we can create a society that supports and uplifts those with bipolar disorder. It is through empathy and education that we can reduce stigma, promote accessible mental health care, and improve the lives of those affected by this condition.In conclusion, gaining a comprehensive understanding of bipolar disorder is crucial in order to support individuals affected by this complex mental health condition. Through the real-life case study of Susan, we have explored the numerous facets of bipolar disorder, including its background, symptoms, and effects on daily life. Susan’s journey serves as a powerful reminder of the challenges individuals face in managing the highs and lows of bipolar disorder and emphasizes the importance of effective treatment and support systems.

We have examined the various approaches to treating and managing bipolar disorder, including psychopharmacological interventions, psychotherapy, and lifestyle modifications. Understanding the role of these treatments and the need for personalized care can significantly improve the quality of life for individuals like Susan.

Support systems also play a crucial role in helping those with bipolar disorder navigate the complexities of the condition. From family support to peer support groups and access to professional resources, fostering a strong network of assistance can provide the necessary emotional support, education, and guidance needed for individuals to effectively manage their symptoms.

Furthermore, case studies, such as Susan’s, contribute to advancing our knowledge about bipolar disorder. By delving into individual experiences, researchers gain valuable insights into treatment outcomes, prognosis, and the impact of the condition on individuals and society as a whole. These case studies foster empathy, reduce stigma, and contribute to the development of evidence-based guidelines and interventions that can improve the lives of individuals with bipolar disorder.

In fostering empathy and promoting early diagnosis, effective treatment, and ongoing support, we create a society that actively embraces and supports individuals with bipolar disorder. By encouraging understanding, reducing stigma, and prioritizing mental health care, we can ensure that those affected by bipolar disorder receive the support and resources necessary to lead fulfilling and meaningful lives. Through empathy, education, and continued research, we can work towards a future where individuals with bipolar disorder are understood, valued, and empowered to thrive.

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A Case in the Bipolar Spectrum

Sibel koÇbiyik.

1 Clinic of Psychiatry, Atatürk Training and Research Hospital, Ankara, Turkey

Sedat BATMAZ

2 Clinic of Psychiatry, Mersin State Hospital, Mersin, Turkey

Levent TURHAN

3 Clinic of Psychiatry, Kartal Training and Research Hospital, İstanbul, Turkey

It has been reported that the correct diagnosis and treatment are delayed when subsyndromal bipolar mood disorder symptoms are overlooked. Patients in this spectrum are reported to have a diminished level of functioning, and these patients fail to accept their diagnosis; therefore, there is a low level of treatment adherence. This case report focuses on the diagnosis and treatment of a patient in the bipolar spectrum.

INTRODUCTION

Mania is defined as a distinct mood episode in which the patient’s level of functioning is diminished compared with the premorbid level, and where a high or irritable mood is accompanied by three or four classical mania symptoms and findings ( 1 ). Acute mania may further be grouped into classical/pure, psychotic features, and mixed state subtypes. Although major depression and bipolar disorder are defined as distinct clinical entities, in recent years it has been proposed that bipolar disorder may be viewed as part of the spectrum ( 2 ). On the other hand, these different clinical presentations cause difficulty in correctly diagnosing and treating bipolar disorder. One possible explanation could be that in clinical follow-up bipolar disorder, patients who do not meet the full diagnostic criteria for hypomania or depression are frequently encountered. In this report, a case whose symptoms first appeared during adolescence, with social phobia symptoms, and who met diagnostic criteria for atypical or major depressive episodes, but failed to meet the full diagnostic criteria for hypomania will be presented in line with the bipolar spectrum definition. The case consented that her history and mental status examination findings may be used solely for scientific purposes and under the terms that her personal information will be confidential.

A 25-year old university graduate female patient presented to our outpatient clinic with symptoms of not completely remitting despite a 5-year-long psychiatric treatment. She complained of not being able to express herself and being incapable of social interaction with others, and she cried during the psychiatric interview.

The patient had been administered different medication regimens for the last 3 years and lamotrigine 100 mg/day and moclobemide 600 mg/day for the last 1.5 years. Despite being adherent to her drugs, her symptoms of depression, lack of volition, thoughts of worthlessness, and anorexia persisted. She felt irritable and tense for no apparent reason from time to time, could not concentrate, felt an urge to move around restlessly, did not want to go to her house, and despite her family’s objections, left the house to walk around at midnight. She said that during these periods she had higher levels of self-confidence; got more sociable with strangers; was more talkative; felt more irritable, tense, and behaved aggressively; and burst into laughter, which was quite unusual for her.

The patient reported that her symptoms first appeared during sixth grade after she began wearing glasses and was afraid of disgracing herself, felt unhappy, could not feel well even when something good happened, but her appetite and sleep were normal. Her symptoms increased when she left for college, and she only had a limited relationship with others. She felt more distressed in crowded places such as the classroom, dining hall, or library. She felt that she was worthless, had no motivation, and lacked energy, did not feel like leaving the bed all day long. Furthermore, she ate too much and felt the urge to move around restlessly. During this period she presented to a psychiatrist and was diagnosed with depression and prescribed fluoxetine 20 mg/day and trifluoperazine 1 mg/day. She did not completely adhere to her drugs. After 1 year, because her symptoms persisted, she presented to the psychiatry outpatient clinic of a university clinic; she was diagnosed with bipolar disorder type II and prescribed valproic acid 1000 mg/d and sertraline 50 mg/day. She was receiving these drugs for 1 year; however, she suffered from a dampening of her feelings and stopped her drugs because she thought that she did not need them anymore. At this time, another psychiatrist claimed that she was not suffering from bipolar disorder, and that diagnosing this disorder was not easy, and if she was diagnosed with that the disorder, it would not be a good decision to change her treatment. Therefore, she was confused, and decided not to take any more drugs. After a short period, she was taken to the psychiatrist by her family members because she could not stop crying. The psychiatrist offered her lithium after he was told that she had been previously diagnosed with bipolar disorder. Further, because of the nausea that she experienced, she stopped lithium. Yet, after 5 months, she presented to another psychiatrist with symptoms of frequent crying, thoughts of worthlessness, depression, and anhedonia. She was prescribed lamotrigine and moclobemide, but she did not completely adhere to her treatment regimen and her symptoms did not remit.

The psychiatric evaluation of the patient revealed the following findings: She appeared to be of her biological age, was casually dressed and her hair was disheveled, was overly restrained and shy, and could not easily express herself. She was alert and oriented, but did not have any issues with attention, memory, or perception. Her affect was depressed and she had thoughts of worthlessness. No psychotic features were observed, and she had partial insight into her symptoms. No suicidal ideation was observed. All her routine laboratory investigation, including thyroid functions, was within normal limits. Computerized brain tomography did not reveal any significant findings. On her psychometric evaluations, she received the following scores: Hamilton Depression Rating Scale: 23/51, Young Mania Rating Scale: 2/60, Liebowitz Social Phobia-Anxiety Rating: 76/96, Avoidance Rating: 62/96. Her Minnesota Multiphasic Personality Inventory results were interpreted as “social withdrawal, low activity level, shy, and incompetent during interaction with others.”

During her psychiatric evaluation she interestingly stated the following: “There were times when I laughed, laughed without any reason, but I suppose that was not very healthy. It felt like some cream on spinach. The cream was fine, but it felt awkward because it was on spinach.”

She was diagnosed with “bipolar mood disorder, unspecified type” according to DSM 5 criteria because of her symptom onset during adolescence, atypical features of her depressive episodes, chronicity of symptoms, psychomotor agitation, and her hypomania like symptoms, which do not completely meet the diagnostic criteria. Furthermore, she was diagnosed with social anxiety disorder because of her anxiety symptoms she experiences in social situations or around people she does not know well and her avoidance of such situations ( 3 ). Her mood swings, low self-worth, frequent change of psychiatrists, distrust in relationships, and low adherence to treatment suggested a diagnosis of personality disorder; however, she did not meet the criteria for a specific personality disorder. She was further evaluated for dysthymia; however, because her comorbidity with social phobia and antidepressant induced hypomanic episodes could not be totally ruled out, a diagnosis within the bipolar spectrum was deemed clinically appropriate.

The patient was provided detailed information regarding her condition and advised to take her lamotrigine and moclobemide regularly. During follow-up, because she had previously responded, valproic acid was titrated up to 1000 mg/day, and her lamotrigine dosage was halved. Furthermore, she received regular individual psychotherapy sessions, and her depressive symptoms partially resolved. She began private tutoring high school students, which reflected a significant increase in her level of functioning; she stated that her communication issues with others decreased.

The terms “soft bipolar” or “bipolar spectrum” were first proposed by Akiskal and Mallya ( 4 ) to describe psychopathological states that could not be easily diagnosed. It has been reported that soft bipolar cases may be prevalent up to 5.1%–23.7% ( 5 ). Cyclothymia and unspecified type of bipolar disorder are suggested to be present on the extreme end of this spectrum.

Diagnosing hypomania may be difficult for the practicing clinician because the distinction between mania and hypomania is not clearly defined in DSM or other classification systems. Hypomania is defined as a less severe form of mania without any specific criteria. This may result in the clinicians to overlook a diagnosis of bipolar disorder type 2 or misdiagnosing bipolar disorder type I as type 2. Some researchers have proposed that the 4-day-criterion of DSM to diagnose hypomania is not empirically validated, that this time criterion may be unnecessarily long, and that the time threshold should be 2 days instead of 4 days, with a modal time of 1–3 days ( 6 , 7 ). Furthermore, it is suggested that an increase in the level of activity in social and occupational contexts and psychomotor symptoms may be more relevant in the diagnosis of hypomania rather than the mood elevation criteria ( 8 ). Angst has grouped hypomania into two clusters referred to as hard and soft criteria in his Zurich study ( 7 ). According to the hard criteria, euphoria, irritability, or overactivity in addition to at least the three criteria listed in DSM is present to meet a hypomania diagnosis. The time criterion requests that a 1-day period is sufficient. According to the soft criteria, euphoria, irritability, or overactivity and at least two DSM criteria are necessary for a hypomania diagnosis. No episode length is defined in the soft criteria. The Zurich study has shown that 90% of all major mood disorder diagnoses correspond to major depressive disorder, and that minor bipolar mood disorders and mild depression are overlooked. It has been proposed that the hard and soft Zurich criteria are more sensitive to diagnose hypomania and that it may detect minor bipolar mood disorders and mild depression (49.5% and 25.7%, respectively). The soft Zurich criteria suggest that almost half of all major depressive disorder diagnoses may actually be reclassified as bipolar disorder type 2 ( 9 ). On the other hand, a bipolar mood disorder diagnosis depends on the patient’s ability to recall hypomanic episodes and the report of significant others, irrespective of diagnostic criteria. In this particular case, the “cream on spinach” metaphor may reflect the elevated mood as a creamy taste, whereas its inappropriateness with the patient’s present context or other people’s reactions to it may be reflected by its being on spinach. Patients frequently fail to describe their hypomanic episodes as a part of their disorders, but they experience such episodes as joyful. Therefore, a correct diagnosis requires the collaboration of the patient’s significant others, and a thorough retrospective anamnesis of the patient’s mood episodes. In the present case, the role of a comprehensive history taking and the importance of a reliable therapeutic relationship are emphasized.

Bipolar spectrum disorders are recurrent and result in significant disruptions in interpersonal relationships and social contexts. Twenty percent of these patients who do not receive an adequate treatment act on their suicidal thoughts ( 10 ). Therefore, a comprehensive assessment of these patients’ symptoms is essential to prevent any negative consequences, including suicide. The incomplete history of the patient’s hypomania has caused confusion among the treating psychiatrists. The discrepancy between the diagnosing the disorder and conveying this to the patient appears to have impaired the doctor–patient relationship, which in turn may have led the patient to frequently change psychiatrists. This case aimed to highlight the difficulties of the patients’ acceptance of their bipolar spectrum diagnosis when they are not clearly informed, particularly if the case lies on the soft end of the bipolar spectrum.

Acknowledgements

We would like to thank Professor E. Timuçin Oral, MD for his guidance and feedback during the review of this case report.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

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What Causes Bipolar Disorder?

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Bipolar Disorder Explained: Everything You Need to Know

What is bipolar disorder, living with bipolar disorder.

• Next in Bipolar Disorder Guide Bipolar Disorder Symptoms and Traits

Bipolar disorder refers to a group of mental health conditions characterized by sudden, dramatic changes in mood, energy, and behavior. Formerly known as manic depression, this condition causes mood episodes lasting days or weeks at a time and hinder day-to-day functioning, school or work performance, and relationships.

This article describes the symptoms , causes, and treatments for bipolar disorder and discusses how to cope if you’re diagnosed with this mental health condition.

FG Trade / Getty Images

Estimated to affect 4.4% of U.S. adults at some point in their lives, bipolar disorder causes distinct periods of extreme emotional states or episodes that can last for days or weeks. Episodes are characterized by manic or depressive behavior.

Manic Episodes

A manic episode is a phase of a week or more during which you have an elevated mood and energy most of the time for most days. In this phase, you may feel abnormally happy, agitated, restless, and don’t need much sleep.

In rare and severe cases, people experience hallucinations and delusions during manic episodes. In addition, some people experience hypomanic episodes—less severe manic episodes lasting four or more days.    

Everything You Should Know About Bipolar Disorder

Major depressive episodes.

A major depressive episode is a period of two or more weeks of depressive symptoms, such as sadness, hopelessness, lethargy (lack of energy), and apathy. These episodes can become severe, leading to suicidal thoughts. As with manic episodes, severe depressive episodes can lead to hallucinations or delusions.

What Are the Types of Bipolar Disorder?

Healthcare providers break down bipolar disorder into four primary types : bipolar 1, bipolar 2, cyclothymic disorder, and unspecified bipolar disorder.

Bipolar 1 Disorder

With bipolar 1 disorder, manic episodes last a week or become so severe that you require hospitalization. In most cases, bipolar 1 also causes depressive episodes. Some people have “mixed” episodes that feature both manic and depressive symptoms at the same time. Neutral periods—neither manic nor depressive—are also common with this type.

Bipolar 2 Disorder

Bipolar 2 disorder occurs when you experience one depressive episode and at least one hypomanic episode (milder manic episodes that last four or more days). In between these are symptom-free periods. Those with bipolar 2 disorder often have other mental health conditions, such as anxiety or depression.

Cyclothymic Disorder (Cyclothymia)

Cyclothymic disorder is a milder type of bipolar disorder that causes regular mood swings. Ranging between those of mild depression and hypomania, the symptoms aren’t severe enough to be considered clinically depressive or hypomanic episodes.

Unspecified Bipolar Disorder

Unspecified bipolar disorder is when you have extreme mood fluctuations, but the symptoms aren’t as bad as those of bipolar 1 or 2. Still, with this type, the symptoms are significant enough to affect daily functioning, relationships, and work or school.

Bipolar Disorder Symptoms

Dramatic and intense changes in your mood, emotions, behaviors, and activity level are the primary signs of bipolar disorder. These shifts tend to be noticeable to others and impact your relationships, performance at work or school, or daily functioning.

The symptoms you experience depend on whether you’re having a manic or depressive episode.

Manic Episode Symptoms

During manic episodes, emotion and activity levels are elevated. Manic episode symptoms include the following:

• Abnormal giddiness or happiness 
• Changing topics when speaking 
• Distractibility
• Feeling energetic despite insufficient sleep
• Increased irritability or agitation
• Racing, uncontrollable thoughts
• Recklessness or risky, impulsive behaviors
• Restlessness, increased activity
• Talking faster or more often

Major Depressive Episode Symptoms

In contrast to manic episodes, during a depressive episode, you feel “low” in terms of energy, mood, and emotion. Symptoms of this type include combinations of the following:

• Despair, thoughts about death or suicide
• Difficulty falling or staying asleep or sleeping excessively
• Difficulty with routine tasks
• Feeling sad, hopeless, or anxious
• Forgetfulness, slowed speech, not knowing what to say
• Loss of energy or motivation 
• Loss of interest in activities
• Restlessness

When to Call 911

If you have bipolar disorder, go to an emergency room (ER) if you experience:

• Suicidal thoughts 
• Thoughts about hurting yourself or others
• Hallucinations or delusions
• Lithium toxicity symptoms: nausea, vomiting, dizziness, changes in vision, and slurred speech

Researchers don’t know what exactly causes bipolar disorder. The consensus is that genetic factors, brain chemistry and structure, and environmental factors all play a role in this condition.  

Genetic Factors

Though more work is needed, researchers have linked genetics with an increased risk of developing bipolar disorder. This condition is heritable, making family history a risk factor; people with a parent or sibling with the condition are more likely to have it.

Brain Chemistry and Structure

Using imaging techniques, researchers have found differences between the brains of those with and without bipolar disorder. Some research shows that people with bipolar disorder have smaller subcortical structures (associated with mood and cognition) and a thinner cortex (the outer layer of the brain).

In addition, researchers have linked imbalances in certain neurotransmitters (brain chemicals), particularly dopamine and serotonin, to bipolar disorder.

Environmental Factors

Stressful or traumatic life events and certain behaviors can also raise your risk of developing bipolar disorder. Examples of traumatic events found to trigger attacks include childbirth, losing a job or a loved one, divorce, misusing or overusing drugs or alcohol, or traumatic head injuries.

How Is Bipolar Disorder Diagnosed?

To diagnose bipolar disorder, a healthcare provider will ask about your medical history, current medications, symptoms, and your family’s mental health history. You’ll also undergo a physical exam and, in some cases, blood tests to rule out other potential causes of bipolar disorder symptoms, such as hypothyroidism, stroke, and substance use disorder. 

A healthcare provider or a mental health specialist, like a psychiatrist or psychologist , will perform a mental health evaluation. They will diagnose bipolar disorder and identify the type based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).     

Diagnosing Bipolar 1 Disorder

According to the DSM-5, to be diagnosed with bipolar 1 disorder, you must have had at least one manic episode. This may be followed or preceded by a hypomanic or major depressive episode. While hypomanic or major depressive episodes can occur in bipolar 1, they are not required for a diagnosis.

In bipolar 1 disorder, manic episodes last at least one week or are severe enough to require hospitalization. A healthcare provider will look for at least three (or four if you experience irritability) of the following to diagnose you with bipolar 1 disorder:

• An inflated self-esteem or sense of grandiosity
• Difficulty concentrating; being easily distracted
• Increased activities, agitation, toe-tapping, pacing, or other unnecessary movements
• Increased engagement in unusually risky or self-destructive activities    
• Racing thoughts; thoughts in flight
• Reduced need for sleep

Diagnosing Bipolar 2 Disorder

A diagnosis of bipolar 2 disorder is made based on four criteria:  

• A current or past episode of hypomania and at least one major depressive episode 
• Never having a manic episode 
• No other psychological or neurological issues can explain the symptoms
• The mood changes cause impairments in social, personal, and professional life and daily functioning

"Hypomania" is defined as at least four days of manic symptoms that aren’t as severe or numerous as with a full manic episode. Major depressive episodes are defined as having daily or nearly daily symptoms for at least two weeks. According to the DSM-5, these are diagnosed when you display five of the following criteria:

• Agitation, toe-tapping, or pacing
• A lack of interest or enjoyment in life
• Decreased ability to concentrate
• Depression, sadness
• Fatigue, insufficient energy
• Inappropriate guilt or lack of self-worth
• Thinking about suicide without making a concrete plan (suicidal ideation)
• Weight loss without dieting, weight gain, decrease or increase in appetite

Diagnostic Criteria for Cyclothymic Disorder

In the DSM-5, among the criteria for cyclothymic disorder are the following:

• You have neutral, asymptomatic periods for no more than three months at a time.
• Symptoms arise independent of substance use disorder. 
• Symptoms hinder your ability to function and impact your work, school, home, or social life.
• Symptoms are inconsistent with bipolar 1 or 2 or another mental health condition.
• You experience two or more years of hypomania and depressive episodes if an adult and at least one year of symptoms if a child.

Bipolar Disorder Treatment

Treating bipolar disorder typically involves adopting multiple strategies, including medications, counseling, and lifestyle changes.

Medications

Antidepressants, mood stabilizers, and atypical antipsychotics are medication types that healthcare providers consider. A healthcare provider may prescribe selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, for depression associated with bipolar disorder. However, these can cause what is known as cycling—rapid mood shifts—so healthcare providers prescribe them with caution.

Mood-stabilizing drugs, such as Lithobid (lithium) and Depacon (valproate), are indicated alongside SSRIs and help ease or shorten the length of mood episodes. A provider may also prescribe medications to address insomnia (sleep problems) and anxiety, which often accompany bipolar disorder.

Medication Side Effects

The side effects of medications depend on the type you’re taking. For bipolar disorder, the most common of these are unintended weight gain, sedation, restlessness, and changes in metabolism. 

Psychotherapy and Counseling

Psychotherapy and counseling involve talk therapy with a psychiatrist, therapist, or trained counselor. This work aims to identify and change problematic behaviors, thoughts, or emotions that set off episodes. Another alternative is cognitive behavioral therapy (CBT), which focuses on changing thought patterns.

Lifestyle Changes

Alongside medical treatments or therapy, lifestyle changes can help you manage bipolar disorder, including:

• Relax : Activities like yoga or meditation may help ease anxiety and help with symptoms.
• Stay active : Regular exercise improves sleep and helps with stress, among other benefits.
• Dietary changes : Poor diet is associated with an increased risk for bipolar disorder and a reduced risk of co-occurring conditions. 
• Avoid substances : Drinking alcohol, smoking tobacco, or using recreational drugs can all increase the risk of bipolar symptoms.
• Education : Understand the symptoms of bipolar disorder and keep track of events or things that trigger symptoms; know your medications and their side effects.

Living with bipolar disorder means finding a support system , developing coping mechanisms, and managing the shifts in your mood and behaviors. Strategies that can help include:

• Adding structure to your daily activities
• Enlisting loved ones and/or family members in your care
• Ensuring you’re getting regular exercise and enough sleep
• Making sure to take part in enjoyable activities, staying connected to friends, family, and the local community
• Seeking out social support from online or in-person support groups, social media, or message boards
• Seeking treatment, developing a treatment plan with your healthcare provider
• Tracking and logging your symptoms, medications, and triggers

Bipolar disorder causes dramatic and lasting mood and behavior shifts. People with the condition go through high-energy manic episodes and often also experience depressive episodes. Because of its effects on behavior, bipolar disorder can significantly impact your professional, academic, and/or personal life. If you suspect you or someone you care for has this condition, talk to a healthcare provider for an accurate diagnosis and treatment.

American Psychiatric Association.  What are bipolar disorders?

MedlinePlus. Bipolar disorder .

National Institute of Mental Health. Bipolar disorder: definition . 

National Institute of Mental Health. Bipolar disorder: overview .

National Alliance on Mental Illness (NAMI). Bipolar disorder .

MedlinePlus. Lithium toxicity . 

Rowland TA, Marwaha S. Epidemiology and risk factors for bipolar disorder . Ther Adv Psychopharmacol . 2018 26;8(9):251-269. doi:10.1177/2045125318769235.

Abé C, Liberg B, Klahn AL, Petrovic P, Landén M. Mania-related effects on structural brain changes in bipolar disorder – a narrative review of the evidence.  Mol Psychiatry . 2023;28(7):2674-2682. doi:10.1038/s41380-023-02073-4

Lee JG, Woo YS, Park SW, Seog DH, Seo MK, Bahk WM. Neuromolecular etiology of bipolar disorder: possible therapeutic targets of mood stabilizers .  Clin Psychopharmacol Neurosci . 2022;20(2):228-239. doi:10.9758/cpn.2022.20.2.228

Substance Abuse and Mental Health Services Administration. DSM-5 changes: implications for child serious emotional disturbance . Substance Abuse and Mental Health Services Administration; 2016. Table 12, DSM-IV to DSM-5 Bipolar I Disorder Comparison.

Perugi G, Hantouche E, Vannucchi G.  Diagnosis and treatment of cyclothymia: the "primacy" of temperament .  Curr Neuropharmacol . 2017;15(3):372-379. doi:10.2174/1570159X14666160616120157

Marzani G, Neff AP. Bipolar disorders: evaluation and treatment .  Am Fam Physician.  2021;103(4):227-239

Bauer IE, Gálvez JF, Hamilton JE, et al. Lifestyle interventions targeting dietary habits and exercise in bipolar disorder: A systematic review .  J Psychiatr Res . 2016;74:1-7. doi:10.1016/j.jpsychires.2015.12.006

By Mark Gurarie Gurarie is a freelance writer and editor. He is a writing composition adjunct lecturer at George Washington University.  

Patient Case: 75-Year-Old Female With Bipolar 1 Disorder

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC, presents the case of a 75-year-old female with bipolar 1 disorder and discusses challenges in bipolar disorder treatment.

EP: 1 . Patient Case: 75-Year-Old Female With Bipolar 1 Disorder

Ep: 2 . pharmacological treatment considerations for bipolar disorder, ep: 3 . role of patient education for bipolar 1 disorder treatment, ep: 4 . unmet needs in bipolar disorder management.

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC: Our case presentation today focuses on a 75-year-old female patient who has had a long history of bipolar 1 disorder for about 40 years recently referred for consultation by a fellow psychiatrist at the nursing home due to persistent depressive symptoms. For the last 40 years, she's been effectively maintained on lithium with the dose only recently increased to help with her reported depression. She suffered from a significant tremor as well as some polyuria polydipsia, which then again aggravated her propensity for UTIs [urinary tract infections]. Historically, her lithium levels were stable in the low normal range around 0.6 mEq/L but recently increased about a month ago with the dose increase and an attempt to treat her depressive episodes. Her current lithium level is about 1 mEq/L. Her lithium dosage was decreased to achieve the prior stable level of 0.6 before she came to us. Lithium was then augmented with a little Lamictal or lamotrigine, which was then slowly titrated to 300 mg per day, but unfortunately, she failed to improve. Most recently, she underwent a trial of lurasidone 20 mg every evening with supper, but after about 7 days, she could not tolerate the nausea so then it was discontinued. She has historic diagnosis of diabetes Type 2 for about 30 years. She's being currently treated with Metformin 1000 mg a day and Invokana 300 mg a day. Hypertension for about the last 10 years effectively managed with olmesartan 40 mg a day. High cholesterol for about 40 years, effectively managed with rosuvastatin 40 mg a day and then also a history of frequent and recurrent urinary tract infections, about 5 years ongoing and effectively treated with nitrofurantoin 100 mg or other antibiotics when indicated.

Sadly, this presentation is quite common. As people age, our bodies process medications, and medications that have worked for long periods of time sometimes lose their efficacy as we age. Mostly due to those pharmacodynamic changes where our bodies age, our kidneys and our liver don't just quite function the way they did when we were younger and process things out. There's always a concern when you're using multiple medications on someone in this age range, just for interactions. Most notably in a review of the medications, Invokana itself actually can increase the incidence of polyuria and polydipsia and does have a potential side effect of an increase in urinary tract infections. As a provider, I do have some concerns about that particular medication being on board. Regarding her presentation, the onset of depressive symptoms, especially for a patient who might be within an assisted living facility, this is kind of common. Patients who live in assisted living facilities tend to get distanced from their families and don't have quite as much daily interaction and so an increase in depressive symptoms is quite common. Unfortunately, she's been maintained very well on lithium for quite a long time. It looks like even with the dose adjustment she was doing OK, but the addition of the lamotrigine really didn't help her depression so now we have concerns of what can we add on or what can we take away to help improve her overall outlook? Again, one of those concerns is that she's already got several medications onboard and the risk for polypharmacy among the elderly is always very high, including the potentiated risks of the medications interacting with each other.

Transcript Edited for Clarity

Blue Light Blockers: A Behavior Therapy for Mania

Individualizing Treatment Options in BDI

Positive Phase III Study Results Reported for Bipolar I Disorder Treatment in Adults

A Heavy Burden: Bipolar Disorder and Obesity

NDA for Long-Acting Injectable for Schizophrenia and Bipolar I Accepted

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May 15, 2024

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Treatment-resistant depression linked to body mass index: Study

by Vanderbilt University Medical Center

Genetic factors are a small but significant contributor to severe depression that does not respond to standard therapy, according to researchers at Vanderbilt University Medical Center and Massachusetts General Hospital.

The heritability of treatment-resistant depression (TRD) was found to have significant genetic overlap with schizophrenia, attention deficit disorder , cognitive, alcohol and smoking traits, and body mass index (BMI), suggesting a shared biology and, potentially, new treatment avenues.

The report, published May 15 in The American Journal of Psychiatry , provides insights into the genetics and biology underlying TRD, supports the utility of estimating disease probabilities from clinical data for genomic investigations, and "lays the groundwork for future efforts to apply genomic data for biomarker and drug development."

"Despite the large proportion of patients with TRD, the biology has remained poorly understood. Our work here provides genetic support for new biological directions to explore in addressing this gap," said Douglas Ruderfer, Ph.D., associate professor of Medicine (Genetic Medicine), Psychiatry, and Biomedical Informatics.

"This work finally gives us some new leads, rather than reinventing the same antidepressants over and over again, for a condition that is extremely common," said Roy Perlis, MD, professor of Psychiatry at Harvard Medical School and director of the MGH Center for Experimental Drugs and Diagnostics.

Nearly 2 out of every 10 people in the United States experience severe depression , and roughly a third of them do not respond to antidepressant treatments and therapies. TRD is associated with a significantly increased risk for suicide.

Despite evidence that treatment resistance may be a heritable trait, the "genetic architecture" of this condition remains unclear, largely because of the lack of a consistent and rigorous definition of treatment resistance, and the challenge of recruiting enough research subjects to study.

To overcome these barriers, the researchers selected a surrogate for the condition—whether an individual diagnosed with major depressive disorder had received electroconvulsive therapy (ECT).

ECT applies a low voltage applied to the head to induce a generalized seizure without muscle convulsions. Approximately half of patients with TRD respond to ECT, which is thought to improve symptoms by stimulating "rewiring" of brain circuits after they are disrupted by the electrical current.

To ensure the study was sufficiently "powered," or had enough patients from which valid results could be obtained, the researchers developed a machine-learning model to predict, from clinical information recorded in the electronic health record (EHR), which patients were most likely to receive ECT.

The researchers applied this model to EHRs and biobanks from Mass General Brigham and VUMC and validated the results by comparing the predicted cases to actual ECT cases identified through the Geisinger Health System in Pennsylvania, and the Million Veteran Program of the U.S. Department of Veterans Affairs.

More than 154,000 patients from the four health systems with medical records and genotypes, or sequences of their DNA samples, were included in a genome-wide association study , which can identify genetic associations with health conditions (in this case, a marker for TRD).

The study identified genes clustered in two locations, or loci, on different chromosomes that correlated significantly the likelihood of ECT predicted by the model. The first locus overlapped with a previously reported chromosomal location associated with body mass index (BMI).

The ECT-BMI relationship was inverse—patients with lower body weight tended to be at higher risk for treatment resistance.

This finding is supported by studies that found patients with anorexia nervosa, an eating disorder characterized by extremely low body weight, are more likely than those with a higher BMI to be resistant to treatment of coinciding depression.

The other locus associated with ECT points to a gene that is highly expressed in brain regions that regulate body weight and appetite. Recently this gene also has been implicated in bipolar disorder, a major psychiatric illness.

Large studies are currently underway to collect tens of thousands of ECT cases for a case-control study.

Confirmation of the link between the ECT marker for TRD and the complex metabolic pathways underlying food intake, maintenance of body weight, and energy balance could open the door to new, more effective treatments for treatment of major depressive disorder, the researchers said.

Co-authors from VUMC were JooEun Kang, MD, Ph.D., Michael Ripperger, Drew Wilimitis, Theodore Morley, Lide Han, Ph.D., Stephan Heckers, MD, MSc, and Colin G. Walsh, MD, MA; at MGH they included Thomas McCoy, MD, and Victor Castro.

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Newsroom / Maryville College grad’s drug research preps him for med school

Ahead of med school, Maryville College’s Christian Carlton ’24 researches environmental impact of carbamazepine

May 15, 2024

He ultimately will be concerned with how pharmaceuticals affect his patients, but Christian Carlton ’24 is enrolling in medical school with an impressive understanding of one drug’s larger impact on the environment and the life that the environment supports.

Carlton, a Rockwood, Tennessee, native who graduated on May 4 with a bachelor’s degree in science, majored in Biology and completed a Senior Study entitled “Effects of Carbamazepine on the Behavior and Coloration of Siamese Fighting Fish ( Betta Splendens ).” He chose the topic in spring 2023 after consultation with his advisor, Biology Professor Dr. Drew Crain .

One of the distinctive features of a Maryville education, the Senior Study requirement calls for students to complete an independent research and writing project that is guided by a faculty supervisor. According to the College’s catalog, the Senior Study program “facilitates the scholarship of discovery within the major field and integrates those methods with the educational goals fostered through the Maryville Curriculum.” Such in-depth research is an impressive endeavor by any Scot, made even more so in Carlton’s case, given that he was also an infielder with the MC baseball team , which recently won both the Collegiate Conference of the South regular season and tournament championships .

“[In medicine], you have to eventually use some of these pharmaceuticals,” Carlton said of his research choice. “And it’s interesting to learn how, through human excretion, some of them enter and stay in water systems and affect other living things that are not just humans. They may help a human but eventually hurt some other form of animal out there. Other studies could lead to better water management practices that could filter out these drugs and chemicals.”

Crain said multiple studies have been done on the presence and levels of pharmaceuticals in streams, rivers and lakes, but the effects of those drugs in specific species are relatively unknown.

Carbamazepine (CBZ), an anticonvulsant used to treat bipolar disorder and epilepsy, was chosen for the study because it is “one of the most abundantly found chemicals in waterways in every corner of the globe,” Carlton wrote in his abstract. And many animals, large and small, that live in water runoffs positive for CBZ are absorbing the drug into their bodies. Pharmaceuticals like CBZ are not filtered out by water treatment plants because of their small molecular size.

Carlton chose Betta fish (also known as Siamese fighting fish) for his study because they live in the wild in many affected areas and act similarly whether in their natural habitat or in controlled settings like laboratories. The fish, characterized by their vibrant colors and natural aggression, are commonly sold as pets for domestic fish tanks.

Conducting a paired study

Under the supervision of Crain, Carlton designed a paired study that would test CBZ’s effect on the vibrancy and behavior of the fish. He acquired 10 fish (five females and five males) and 10 tanks. During a 20-day period, he had all 10 fish spend equal time in both control tanks without CBZ and experimental exposure tanks with 1.10µg/L of the drug.

“All received both control and treatment,” Crain explained. “A paired study is a way to increase the statistical power, whenever you have a limited sample size, and control for that individual and the natural variation. At the beginning of the study, we had five fish that were not exposed to anything, and we measured their responses. Halfway through, we exposed them and measured responses. The other half started off exposed, and then didn’t get exposed for the rest of the study.”

Betta fish are known to be aggressive, with males typically exhibiting more aggressive behavior than females. Carlton measured aggressiveness by holding a mirror up to the tank. If the fish, suspecting a competitor was near, flared their gills or arched their bodies, Carlton assessed points for each behavior. He timed the experiment with the mirror, recording behavior every 20 seconds. Baseline measurements without the CBZ were measured against results in the experimental tanks.

“The data showed that the aggression of the fish was not significantly affected by carbamazepine, but females had higher levels of aggression than the males, which was not an expected outcome,” he said.

Carlton assessed vibrancy of the fish by taking photos of them throughout the study and comparing them to the photo of each fish taken at the start.

“Their color decreased in vibrancy, in most cases. Some changes were pretty dramatic,” he said. “I rated it from -5 to +5, with 0 being no change. I definitely got a lot of -2’s and a few -3’s.

“But in my study, I wrote that the color change could have been induced by the stresses in their environment,” Carlton continued. “The tanks didn’t have any rocks or plant life to make it homey, so they could have been very stressed out.”

However, Crain pointed out, the vibrancy in their bodies and fins returned once they were not exposed to CBZ.

Broader implications

While Carlton’s study did not present theories for the impact to humans, the research did open his mind to the broader implications.

“If there are small amounts of pharmaceuticals in water that have not been removed through the treatment process, then whatever water that the animals are living in, we’re also getting some of that, too,” he said. “So, we’re taking small doses of everyone’s medicine at times.”

Coursework in upper-level Biology classes like animal physiology, genetics and ecology and evolution helped inform this revelation, as well as prepare him to conduct the research.

“The general knowledge of the anatomy and physiology of many species of animals allowed me to have a clear understanding of what was taking place in the fish themselves over the course of the study,” he explained.

Studying watershed systems in another course, he became familiar with water treatment plants and how other countries are dealing with pharmaceuticals in water. Some use plants and other natural filtration processes while others use chemicals.

“I know the European water treatment plants are much more stringent as far as removing pharmaceuticals from the water,” Crain said, adding that United States is beginning to address this issue. “PFAS [Per- and polyfluoroalkyl substances] is a substance in Teflon coating that has just been regulated this spring.  It’s getting into the waterways, and it’s harmful — a carcinogen — so the EPA has regulated the amount allowable in drinking water, and water treatment plants are starting to say ‘We’re going to have to remove a lot of things in the future that we’re not removing right now.’ In years past, the operation has been ‘Let’s remove the bacteria. Let’s make sure there are no viruses in it. Let’s get rid of all the sediment.’ In the future, more removal will be occurring.”

Carlton is also aware of the need for more research to determine how carbamazepine breaks down.

“The studies I read found that about 3% of the total mass of carbamazepine that is excreted is the same chemical formula or makeup as the original carbamazepine that is ingested. So a lot of the body metabolizes it into smaller different parts or pieces of the carbamazepine and secrets it out,” he explained. “It might seem like it’s breaking down so it’s not harmful anymore, but we really don’t know what it’s breaking down into and if that could be harmful.”

 Next steps

In June, Carlton will report for anatomy bootcamp at the Lincoln Memorial University-DeBusk College of Osteopathic Medicine in Harrogate, Tennessee. The first day of medical school there will begin in late July.

“My mom is a family medicine doctor, so I’ve always been interested in family medicine because you get to treat nearly everything,” Carlton said. “But if there’s something that I eventually want to specialize in, then I’ll go down that route.”

He knows writing prescriptions will be in his future, and while recommending drugs that treat disease and improve the health of his patients will be his top priority, Carlton said he will remain interested in what is happening “downstream.”

He said he is thankful for the experience that required him to read more scientific studies, design an experiment and collect data. He said he expects to do more of that as a medical student and then as a doctor.

Acknowledging the limitations of his study in sample size and time, Carlton said he hopes future students will choose to build on his research and findings. Crain believes they will.

“I am extremely proud of the research that Christian conducted,” the professor said. “I expect future Senior Study students to continue to examine the effects of carbamazepine on fish behavior, and Christian’s foundational study is a great launching point for these future research projects.”

Christian Carlton '24 takes a water sample as part of his Senior Study research on the effects of carbamazepine.

In addition to his work as a Biology major, Christian Carlton '24 was also a member of the MC Scots baseball team, which won both the regular season and tournament championships as his senior year came to an end.