If I’m on fire they dance around it and cook marshmallows. And if I’m ice they simply skate on me in little ballet costumes Anne Sexton was a poet born in the US who suffered from manic depression

Depression Low mood (for at least 2 weeks) with at least 4 of: disturbed sleep poor concentration loss of interest & pleasure/withdrawal reduced appetite & weight loss agitation or retardation loss of energy innapropriate guilt recurrent thoughts of death

Bipolar Affective Disorder Is the term used to distinguish those who have manic episodes from those who have only (unipolar) depressive episodes

The relationships with other psychiatric disorders

Symptoms of mania A change in mood often elated but also irritabilty A change in mood often elated but also irritabilty This is usually accompanied by A decreased need for sleep An increased level of energy and activity Talking more and quickly – difficult to interupt Distractibilty Disinhibition - doing and saying what we usually only think Overconfidence – can be grandiose to the level of delusions Impairment of function – at work or in the family or socially Usually because of irritability or disinhibition Hypomania is the same symptoms but to a less severe level and no major impairment in function.

Flight of ideas “People are cleaning up the house, working very hard, there’s Flash on the floor. The dog doesn’t like Flash. There’s a flash in my eye as I’m looking at the trees, there’s not much oxygen from the trees. There’s water on the floor, agua. Run the water, don’t block the sink.” Digression with loss of goals. Talk uses combinations of words, sounds and ideas with humour and flippancy

Psychotic symptoms in mania Delusions are usually grandiose but often paranoid Depressive delusions can also be present particularly in mixed states

A mood clock

Normal Mania Depression Mixed

% risk of major affective disorder

Age of Onset in bipolar illness Age No. of Patients

Recovery from a manic episode Kraepelin: “one could hope with great probability for complete restoration of health” ?Average untreated length of about 1 year? –Pollock 1931 Recent studies: 2-3 months

Recurrence of mania More common than in depressive disorder –single manic episodes occurred in 2 out of 393 patients in Angst et al 1973 –half will have a recurrence within 2 years

First episode manics 21 patients 15 female : 6 male (including 5 females post partum) Average age : 29 years (range 19-47) Incidence of 5.5 per 100,000 per annum

Prognosis of first episode mania at two years 10 relapsed (8 manic & 7 depressive episodes) 9 remained well 1 died (murder) 1 not traced

Precipitants of recurrence in bipolar disorder Seasonal changes Personal adversity Childbirth Drugs

Season Life events Childbirth stop lithium

Prophylactic efficacy of lithium in bipolar disorder 2 year placebo controlled study 205 patients on lithium following a manic episode entered trial on discharge. Half randomly switched to placebo Hospitalisation: placebo lithium 70/10431/101 67% 31% Non relapsed completers at 2 years 11 (10%)66 (66%) Prien et al 1973

Tondo et al 2001

Suicide in bipolar disorder Lifetime risk of 15-20% Most have been recently (or are) depressed Often late in the course of illness (15 years) particularly females Inadequate (or non compliant) treatment Isometsa 1994

Lithium and suicide Mortality by suicide for bipolars is at least x 2-3 higher than the general population (up to x15?) a rate of 3.2 per 100 patient years While on lithium ?similar level of suicides to general population 0.37 per 100 patient years Suicide attempts x10 lower in bipolars when on lithium compared to when not on lithium Schou 1998