USPSYCH: Diagnosing And Treating Bipolar Disorder

NEW ORLEANS, November 21 -- As many as 30% of patients with bipolar disorder go untreated for 10 years or more, largely because the condition is so tricky to diagnose, said investigators here.

The chief difficulty with diagnosis is that while the first depressive symptoms typically appear in a patient's 20s, the first manic symptoms might not arise until a patient is nearly 30, said Jeffrey H. Nard, M.D., of the Eastern Virginia Medical School in Norfolk.

In addition, patients with manic symptoms tend not to report them or to see a physician because manic symptoms are pleasurable, Dr. Nard said at a symposium held in conjunction with the U.S. Psychiatric & Mental Health Congress here. The symposium was supported by Pfizer.

While mental health care professionals are aware of the usual hallmarks of a manic episode-abnormally elevated mood, inflated self-esteem, decreased need for sleep-some may not know how to recognize a manic patient sitting in front of them during an office visit, Dr. Nard said.

One key to recognizing mania is a patient's distractibility. "They will distract you, interrupt you," Dr. Nard said. "They won't let you get a word in,.

The correct diagnosis and treatment are important to reach as early as possible because the condition has such negative consequences, Dr. Nard said. Up to 50% of those with bipolar disorder attempt suicide, according to a recent analysis. And the World Health Organization ranked bipolar disorder as the fifth leading cause of years lost to disability worldwide.

Sufferers also experience difficulties at work and with family, and 35% are substance abusers, he added.

When treating acute mania in a bipolar disorder, the goal should be to stabilize the patient's mood within a matter of days, said Mark H. Townsend, M.D., of the Louisiana State University Health Sciences Center here. Dr. Townsend was the second symposium speaker.

After that, Dr. Townsend recommends what he calls the "workhorse" strategy, identifying one or possibly a combination of two well-tolerated medications that are effective in controlling the patient's manic and depressive symptoms in the long-term.

What succeeds as a workhorse for one patient may fail for another. There is no formula for success other than trial and error. However, beginning with a single drug and switching until you find one that is effective, and then perhaps adding a second later if necessary, is likely to be more successful than trying out combinations of two drugs initially, Dr. Townsend said.

Non-compliance with medication is a particular problem among bipolar patients, Dr. Nard said. However, contrary to what some might assume, missing the euphoria of manic episodes is not the chief reason for non-adherence. In fact, this was the least-cited reason among non-compliant patients during a survey published in Psychopharmacology Bulletin, Dr. Nard noted.

The survey found that missing the euphoria of mania was cited by only about 2% of patients. For comparison, about 30% of those surveyed said they failed to comply with medication because of side effects, which include diabetes, sexual dysfunction, and weight gain, Dr. Nard noted.

Weight gain is one of patients' chief concerns, Dr. Townsend said. "Many patients will simply refuse a drug that causes weight gain," he said.

In an analysis of 10 antipsychotic drugs for bipolar disorder published in the American Journal of Psychiatry, most drugs were associated with weight gain. Among the so-called conventional antipsychotics, Haldol (haloperidol) was associated with the least amount of weight gain from baseline (about 1 kg), while Mellaril (thioridazine) was associated with the most weight gain (more than 3 kg), Dr. Townsend said.

Among the second-generation antipsychotics, Risperdal (risperidone) was associated with the least amount of weight gain (about 2 kg) while Clozaril (cozapine) was associated with the most (about 4 kg), Dr. Townsend said.

Dr. Townsend also pointed out that the FDA has determined an increased risk of mortality based on a review of 17 placebo controlled studies of atypicals in older dementia patients with behavioral disorders. None of these agents is approved for use by the FDA in this condition.

Both Dr. Nard and Dr. Townsend are members of the speakers bureau for Pfizer, as well as a number of other pharmaceutical companies.