The latest article in our Clinical Practice series, “Bipolar Disorder — A Focus on Depression,” comes from Dr. Mark Frye from the Mayo Clinic.
Bipolar disorder, a medical illness with substantial morbidity and mortality, is characterized by episodic recurrent mania or hypomania and major depression. A U.S. study reported a lifetime prevalence rate of bipolar disorder of 4.5%.
Clinical Pearls
• What is the morbidity associated with bipolar disorder?
Bipolar disorder is associated with premature death and is among the leading causes of disability in the developed world in people 15 to 44 years of age. The rate of completed suicide is approximately 5% among patients who have never been hospitalized, but it is particularly high (25%) early in the course of the illness.
• What features are more typical of bipolar as compared with unipolar depression?
A family history of bipolar disorder, the onset of symptoms before 25 years of age, and more frequent episodes with a shorter duration (i.e., <6 months), increase the likelihood of a diagnosis of bipolar depression rather than unipolar depression. Some, but not all, studies have also suggested that hypersomnia and hyperphagia are more common in bipolar depression, whereas insomnia (specifically early-morning awakening) and reduced appetite are more typical of unipolar depression.
Table 3. Treatments for Bipolar Disorder.
Morning Report Questions
Q: What medications are approved by the Food and Drug Administration for the treatment of bipolar depression?
A: There are only two FDA-approved treatments for bipolar depression — quetiapine and a combination of olanzapine and fluoxetine. Quetiapine and olanzapine are among several medications broadly defined as mood stabilizers, based on their efficacy in treating acute mania or depression and in maintaining a clinical response without precipitating a switch to the alternate phase of the illness.
Q: What medications have been associated with an increased risk of switching from depression to hypomania or mania?
A: A randomized trial comparing paroxetine with quetiapine suggested that paroxetine was less effective in improving depression scores and was more likely to cause a switch to mania or hypomania. The tricyclic antidepressant desipramine and venlafaxine have been associated with higher rates of switching from depression to hypomania or mania than other agents.
