Current challenges and Indian perspectives in the diagnosis and management of bipolar disorders
DOI:
https://doi.org/10.18203/2320-6012.ijrms20244165Keywords:
Bipolar disorder, Mood stabilisers, Non-psychiatric, Psychiatric, PsychotherapyAbstract
Bipolar disorders (BDs) are episodic illnesses characterised by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. BDs present many diagnostic and therapeutic challenges because of their varying clinical course, symptoms, severity and the presence of comorbidities. They severely burden healthcare systems, particularly in low-income and middle-income countries. In India, managing bipolar disorder is challenging, due to inadequate resources, poor knowledge about the disorder or its treatment, and limited access to healthcare facilities. These disorders impact a large portion of the Indian population, thus highlighting an urgent need to effectively facilitate better diagnosis and management of mental disorders across the country. A careful assessment of previous manic or hypomanic episodes and early identification of comorbidities helps predict disease course and treatment options. Treatment of BDs usually combines medications and psychotherapy. In Indian clinical settings, the first-line treatment for BDs includes pharmacotherapy with mood stabilisers, such as divalproex, lithium, anticonvulsants, and antipsychotics. Psychotherapy, along with lifestyle approaches are useful adjuncts. To reinforce the overall management of BDs, focused group discussions were conducted among 87 psychiatrists across nine cities in India, to gather insights about the burden, diagnostic challenges, and treatment approaches. This review discusses expert insights on optimal diagnostic and treatment approaches for BDs, focusing on psychiatric and non-psychiatric comorbidities, prevalent among Indian patients with type I and II bipolar disorders. It also covers lithium adverse effects, divalproex-place in therapy, and the use of anti-depressant a risk factor for rapid cycling.
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Lublóy Á, Keresztúri JL, Németh A, Mihalicza P. Exploring factors of diagnostic delay for patients with bipolar disorder: a population-based cohort study. BMC Psychiatry. 2020;20(1):75
Marzani G, Price Neff A. Bipolar disorders: evaluation and treatment. Am Fam Physician. 2021;103(4):227-39.
Baldessarini RJ, Vázquez GH, Tondo L. Bipolar depression: a major unsolved challenge. Int J Bipolar Disord. 2020;8(1):1.
India State-Level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990-2017. Lancet Psychiatry. 2020;7(2):148-61.
Jain A, Mitra P. Bipolar affective disorder. [Updated 2023 Feb 20]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.
Institute of Health Metrics and Evaluation. GBD compare data visualisation. Available at: https://vizhub.healthdata.org/gbd-compare/. Accessed on 27 July 2024.
Indian Council of Medical Research. Release of GBD India Mental Disorders Paper, 2019. Available at: https://main.icmr.nic.in/sites/default/files/press_realease_files/PR_GBD_India_Mental_Disorders_Paper_0.pdf. Accessed on 10 August 2024.
Rowland TA, Marwaha S. Epidemiology and risk factors for BD. Ther Adv Psychopharmacol. 2018;8(9):251-69.
Datta D, Pandey SK, Datta S, Verma Y. Comorbid physical and mental health illness of prescription opioid abusers attending de-addiction centers of Sikkim: A Northeastern State of India. J Pharmacol Pharmacother. 2018;9(3):160-4.
Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: challenges and future directions. Lancet. 2013;381(9878):1663-71.
Bipolar Definition and DSM-5 Diagnostic Criteria. Available at: https://www.psycom.net/bipolar-definition-dsm-5/. Accessed on 14 December 2024.
Practice guideline for the treatment of patients with bipolar disorder. Second Edition. 2002. Available at: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf. Accessed on 15 August 2024.
Singh T, Rajput M. Misdiagnosis of bipolar disorder. Psychiatry (Edgmont). 2006;3(10):57-63.
Aguirre L. Navigating the diagnostic challenges of bipolar disorder in youth. JAAPA. 2021;34(8):21-7.
Beyer JL, Ketter TA, McIntyre RS, Suppes T. Managing bipolar depression: an evidence-based approach. Current Psychiatry 2013;12(10):S1-8.
Salloum IM, Brown ES. Management of comorbid BD and substance use disorders. Am J Drug Alcohol Abuse. 2017;43(4):366-76.
Hunt GE, Malhi GS, Cleary M, Lai HMX, Sitharthan T. Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: systematic review and meta-analysis. J Affect Disord. 2016;206:331-49.
Practice guideline for the treatment of patients with substance use disorders. Second Edition. 2006. Available at: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf. Accessed on 11 May 2024.
Nakagawa A, Grunebaum MF, Sullivan GM, Currier D, Ellis SP, Burke AK, et al. Comorbid anxiety in bipolar disorder: does it have an independent effect on suicidality? Bipolar Disord. 2008;10(4):530-8.
Forty L, Ulanova A, Jones L, Jones I, Gordon-Smith K, Fraser C, et al. Comorbid medical illness in bipolar disorder. Br J Psychiatry. 2014;205(6):465-72.
Alda M, Manchia M. Personalized management of bipolar disorder. Neurosci Lett. 2018;669:3-9.
Bobo WB. The diagnosis and management of bipolar I and II disorders: clinical practice update. Mayo Clin Proc. 2017;92(10):1532-51.
McCormick U, Murray B, McNew B. Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. J Am Assoc Nurse Pract. 2015;27(9):530-42.
Severus E, Bauer M. Diagnosing bipolar disorders: ICD-11 and beyond. Int J Bipolar Disord. 2020;8(1):4.
Angst J, Ajdacic-Gross V, Rössler W. BDs in ICD-11: current status and strengths. Int J Bipolar Disord. 2020;8(1):3.
Yatham LN, Kennedy SH, Schaffer A, Parikh SV, Beaulieu S, O'Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for BDs (ISBD) collaborative update of CANMAT guidelines for the management of patients with BD: update 2009. Bipolar Disord. 2009;11(3):225-55.
Bipolar treatment: Are bipolar I and bipolar II treated differently? 2018 Available at: https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/expert-answers/bipolar-treatment/faq-20058042. Accessed on 11 May 2023.
Shah N, Grover S, Rao GP. Clinical practice guidelines for the management of BD. Indian J Psychiatry. 2017;59(1):S51-66.
Bipolar I Disorder. Johns Hopkins Psychiatry Guide, 2017. Available at: https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787045/all/Bipolar_I_Disorder. Accessed on 16 August 2021.
Gibbs M, Winsper C, Marwaha S, Gilbert E, Broome M, Singh SP. Cannabis use and mania symptoms: a systematic review and meta-analysis. J Affect Disord. 2015;171:39-47.
Oedegaard KJ, Alda M, Anand A, Andreassen OA, Balaraman Y, Berrettini WH, et al. The Pharmacogenomics of BD study (PGBD): identification of genes for Lithium response in a prospective sample. BMC Psychiatry. 2016;16:129.
Hou L, Heilbronner U, Degenhardt F, Adli M, Akiyama K, Akula N, et al. Genetic variants associated with response to Lithium treatment in bipolar disorder: a genome-wide association study. Lancet. 2016;387(10023):1085-93.
Stovall J, Keck P, Solomon D. Bipolar disorder in adults: epidemiology and diagnosis. UpToDate. https://medilib.ir/uptodate/show/678. Accessed on 16 August 2024.
Herb K, Stuart A. Kirk. Diagnostic and Statistical Manual of Mental Disorders. In: Social Work. 4th ed. Washington, DC: American Psychiatric Association. 1995;286-7.
Smith LA, Cornelius V, Warnock A, Tacchi MJ, Taylor D. Pharmacological interventions for acute bipolar mania: a systematic review of randomized placebo-controlled trials. Bipolar Disord. 2007;9(60):551-60.
Scherk H, Pajonk FG, Leucht S. Second-generation antipsychotic agents in the treatment of acute mania: a systematic review and meta-analysis of randomized controlled trials. Arch Gen Psychiat. 2007;64(4):442-55.
American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159(4):1-50.
Amsterdam JD, Shults J. Efficacy and mood conversion rate of short-term fluoxetine monotherapy of bipolar II major depressive episode. J Clin Psychopharmacol. 2010;30(3): 306-11.
Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, et al. The International College of Neuro-Psychopharmacology (CINP) treatment guidelines for BD in adults (CINP-BD-2017), part 2: review, grading of the evidence, and a precise algorithm. Int J Neuropsychopharmacol. 2017;20(2):121-79.
Kupka RW, Luckenbaugh DA, Post RM, Leverich GS, Nolen WA. Rapid and nonrapid cycling bipolar disorder: a meta-analysis of clinical studies. J Clin Psychiatry. 2003;64(12):1483-94.
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;264(19):2511-8.
Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Ruan WJ, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2005;66(10):1205-15.
Weiss RD, Griffin ML, Kolodziej ME, Greenfield SF, Najavits LM, Daley DC, et al. A randomized trial of integrated group therapy versus group drug counseling for patients with BD and substance dependence. Am J Psychiatry. 2007;164(1):100-7.
Geller B, Cooper TB, Sun K, Zimerman B, Frazier J, Williams M, et al. Double-blind and placebo-controlled study of Lithium for adolescent BDs with secondary substance dependency. J Am Acad Child Adolesc Psychiatry. 1998;37(2):171-8.
Davis LL, Bartolucci A, Petty F. Divalproex in the treatment of bipolar depression: a placebo-controlled study. J Affect Disord. 2005;85(3):259-66.
Muzina DJ, Gao K, Kemp DE, Khalife S, Ganocy SJ, Chan PK, et al. Acute efficacy of Divalproex sodium versus placebo in mood stabilizer-I bipolar I or II depression: a double-blind, randomized, placebo-controlled trial. J Clin Psychiatry. 2011;72(6):813-9.
Gyulai L, Bowden CL, McElroy SL, Calabrese JR, Petty F, Swann AC, et al. Maintenance efficacy of Divalproex in the prevention of bipolar depression. Neuropsychopharmacology. 2003;28(7):1374-82.
Nery FG. Comorbid BD and substance abuse: evidence-based options. Curr Psychiatr. 2011;10(4):57-67.
Salloum IM, Cornelius JR, Daley DC, Kirisci L, Himmelhoch JM, Thase ME. Efficacy of valproate maintenance in patients with BD and alcoholism: a double-blind placebo-controlled study. Arch Gen Psychiatry. 2005;62(1):37-45.
Salloum IM, Douaihy A, Cornelius JR, Kirisci L, Kelly TM, Hayes J. Divalproex utility in BD with co-occurring cocaine dependence: a pilot study. Addict Behav. 2007;32(2):410-15.
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