Not all mood swings are bipolar disorder

Robert A. Kowatch, MD, PhD, Professor of Psychiatry and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Erin Monroe, CNS, Clinical Nurse Specialist, Division of Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Sergio V. Delgado, MD, Associate Professor of Psychiatry and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Mood swings is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of “mood swings” may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale (K-MRS) developed by Axelson and colleagues as “rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.” On K-MRS mood lability items, children with mania typically score:

• Moderate—many mood changes throughout the day, can vary from elevated mood to anger to sadness within a few hours; changes in mood are clearly out of proportion to circumstances and cause impairment in functioning

• Severe—rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances

• Extreme—constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to circumstances.

Patients with BD typically exhibit what is best described as a “mood cycle”—a pronounced shift in mood and energy from 1 extreme to another. An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.

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Bipolar disorder and substance abuse

Bryan K. Tolliver, MD, PhD, Assistant professor, Clinical neuroscience division, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

The high prevalence of substance use disorders (SUDs) in persons with bipolar disorder (BD) is well documented. Up to 60% of bipolar patients develop an SUD at some point in their lives. Alcohol use disorders are particularly common among BD patients, with a lifetime prevalence of roughly 50%. Recent epidemiologic data indicate that 38% of persons with bipolar I disorder and 19% of those with bipolar II disorder meet criteria for alcohol dependence. Comorbid SUDs in patients with BD are associated with:

• poor treatment compliance
• longer and more frequent mood episodes
• more mixed episodes
• more hospitalizations
• more frequent suicide attempts.

The impact of co-occurring SUDs on suicidality is particularly high among those with bipolar I disorder. Frequently referred to as “dual diagnosis” conditions, co-occurring BD and SUDs may be more accurately envisioned as multi-morbid, rather than comorbid, illnesses.

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Antidepressants in bipolar disorder

Joseph F. Goldberg, MD Associate clinical professor, Department of psychiatry, Mount Sinai School of Medicine, New York, NY, Affective Disorders Research Program, Silver Hill Hospital, New Canaan, CT

Few topics are as controversial as the role of antidepressants for patients with bipolar disorder. Although depression usually is the predominant, most enduring mood state in bipolar disorder, clinicians often face uncertainty about using antidepressants because of concerns about safety and efficacy. Whether and when to use antidepressants for bipolar depression hinges on complex parameters that preclude any single, simple rule.

Rather than asking if antidepressants are useful or detrimental for depressed patients with bipolar disorder, a more practical question might be: Under what circumstances are antidepressants likely to be beneficial, deleterious, or ineffective for an individual patient? Because “real world” patients often have idiosyncrasies that defy practice guidelines’ generic treatment recommendations, clinicians who practice in the proverbial trenches need strategies to tailor treatments to each patient that are informed—but not dictated—by evidence-based research.

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Is seasonal affective disorder a bipolar variant?

Kathryn A. Roecklein, PhD, Assistant professor of psychology, The University of Pittsburgh, Pittsburgh, PA

Kelly J. Rohan, PhD, Associate professor of psychology, University of Vermont, Burlington, VT

Teodor T. Postolache, MD, Associate professor of psychiatry, Director, Mood and Anxiety Program, University of Maryland School of Medicine, Baltimore, MD

Seasonal affective disorder (SAD) is an umbrella term for mood disorders that follow a seasonal pattern of recurrence. Bipolar I disorder (BD I) or bipolar II disorder (BD II) with seasonal pattern (BD SP) is the DSM-IV-TR diagnosis for persons with depressive episodes in the fall or winter and mania (BD I) or hypomania (BD II) in spring or summer.

This article compares BD SP with major depressive disorder with seasonal pattern (MDD SP), in which depressive episodes usually occur in fall or winter and fully remit in spring or summer. Rather than being categorically distinct from each other, BD SP and MDD SP may represent extreme variants on a seasonal depression continuum from unipolar to bipolar.

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Borderline, bipolar, or both?

Jess G. Fiedorowicz, MD, Assistant professor, Department of psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA

Donald W. Black, MD, Professor, Department of psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA

Borderline personality disorder (BPD) and bipolar disorder are frequently confused with each other, in part because of their considerable symptomatic overlap. This redundancy occurs despite the different ways these disorders are conceptualized: BPD as a personality disorder and bipolar disorder as a brain disease among Axis I clinical disorders.

BPD and bipolar disorder—especially bipolar II—often co-occur and are frequently misidentified, as shown by clinical and epidemiologic studies. Misdiagnosis creates problems for clinicians and patients. When diagnosed with BPD, patients with bipolar disorder may be deprived of potentially effective pharmacologic treatments. Conversely, the stigma that BPD carries—particularly in the mental health community—may lead clinicians to:

• not even disclose the BPD diagnosis to patients

• lean in the direction of diagnosing BPD as bipolar disorder, potentially resulting in treatments that have little relevance or failure to refer for more appropriate psychosocial treatments.

To help you avoid confusion and the pitfalls of misdiagnosis, this article clarifies the distinctions between bipolar disorder and BPD. We discuss symptom overlap, highlight key differences between the constructs, outline diagnostic differences, and provide useful suggestions to discern the differential diagnosis.

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Listen to Dr. Fiedorowicz explains why a thorough and rigorous psychiatric history is essential to distinguish BPD from bipolar disorder

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Help your bipolar disorder patients remain employed

Charles L. Bowden, MD

Clinical professor of psychiatry and pharmacology, Nancy U. Karren Distinguished Chair of Psychiatry, The University of Texas Health Science Center at San Antonio

Bipolar disorder’s long-term course presents a therapeutic challenge when patients desire to remain employed, seek temporary or permanent disability status, or—most commonly—attempt to return to employment after a period of inability to work. As the experience of Mrs. S illustrates, previous capabilities that appear higher than the person’s present or recent work experience are a key issue to address in interpersonal therapy.

Evidence-based research is informative, but ultimately you must apply judgment and flexibility in setting and revising goals with the bipolar individual. Attention to the disorder’s core characteristics can help you equip patients for work that contributes to their pursuit of health.

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Controversies in bipolar disorder: Trust evidence or experience?

Gary E. Miller, MD
Clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Richard L. Noel, MD
Assistant clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Today’s buzzword in health care is evidence-based medicine. Most clinicians would agree that evidence from clinical research should guide decisions about treating bipolar disorder. In theory, randomized controlled trials should tell us how to manage bipolar patients and achieve therapeutic success. But good theory does not always translate to good practice; many patients with bipolar disorder have poor outcomes, even when clinicians adhere to research-derived evidence.

The problem is that one well-designed study’s conclusions may contradict those of another equally well-designed study because of differences in subject selection, comorbidities, dosages, outcome criteria, and other variables. As a result, bipolar experts often disagree about issues as basic as antidepressants’ role in often disagree about issues as basic as antidepressants’ role in managing bipolar disorder and whether recurrent major depression should be considered a form of bipolar disorder. This leaves the clinician with the task of interpreting not only conflicting research findings but also conflicting expert opinion.

This article conveys clinical impressions gained from treating approximately 10,000 patients with bipolar disorder over 16 years. We do not claim to have resolved the issues in dispute, but we hope our experience will help practicing clinicians. We examine the evidence and address controversies in bipolar disorder—such as subthreshold hypomania, manic switches, use order—such as subthreshold hypomania, manic switches, use of antidepressants, juvenile depression/bipolar disorder, and atypical depression—together with our opinions on each.

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