eMedicine Specialties > Psychiatry > Adult

Bipolar Affective Disorder: Follow-up

Author: Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Coauthor(s): Lynne Alison McInnes, MD, Associate Adjunct Professor of Psychiatry and Genetics and Genomic Sciences, Department of Psychiatry and Human Genetics, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Sep 10, 2009

Follow-up

Further Inpatient Care

Electroconvulsive therapy (ECT) is useful in a number of instances. ECT has proven to be highly effective in the treatment of acute mania. Often, the severity of the symptoms, the lack of response to medications, or the contradiction of certain medications necessitates the use of ECT. In a study of 400 patients with acute mania who received ECT, 313 showed significant clinical improvement.

Further Outpatient Care

All patients with bipolar disorder need outpatient monitoring for both medications and psychotherapy. In addition, they need education. The schedule must be regular, with great flexibility if they need extra sessions.

Fortunately, most patients recover from the first manic episode, but their course beyond that is variable.28

Inpatient & Outpatient Medications

The same medications are applicable in both settings.

Transfer

If the patient is in a short-term inpatient care unit and has not made significant progress, transfer to a long-term inpatient care unit might be in order.

If the patient is in a depressed or manic phase and is not responding to medications, transfer the patient to a facility where ECT can be administered.

Deterrence/Prevention

Prevention is the key to the long-term treatment of bipolar disorders, as follows:

  • First, medications such as lithium serve as mood stabilizers.
  • Second, psychoeducation is instituted for the patient and the patient's family. Both the patient and the patient's family must understand and recognize the importance of medication compliance and the early signs of mania and depression. This is critical.

Complications

The complications are suicide, homicide, and addictions. These are discussed in Special Concerns.

Prognosis

  • Patients with bipolar I fare worse than patients with a major depression. Within the first 2 years after the initial episode, 40-50% of patients experience another manic attack.
  • Only 50-60% of patients with bipolar I who are on lithium gain control of their symptoms. In 7% of these patients, symptoms do not recur, 45% of patients experience more episodes, and 40% go on to have a persistent disorder.
  • Often, the cycling between depression and mania accelerates with age.
  • Factors suggesting a worse prognosis include the following:
    • Poor job history
    • Alcohol abuse
    • Psychotic features
    • Depressive features between periods of mania and depression
    • Evidence of depression
    • Male sex
  • Indicators of a better prognosis include the following:
    • Manic phases (short in duration)
    • Late age of onset
    • Few thoughts of suicide
    • Few psychotic symptoms
    • Few medical problems

Patient Education

Treatment of patients with bipolar disorder involves initial and ongoing patient education. The educational efforts must be directed not only toward the patient but also toward their family and support system. Furthermore, evidence continues to mount that these educational efforts not only increase patient compliance and their knowledge of the disease, but also their quality of life.29

  • An explanation of the biology of the disease must be provided. This decreases feelings of guilt and promotes medication compliance.
  • Include information about how to monitor the illness in terms of an appreciation of the early warning signs, reemergence, and symptoms. Recognition of changes can serve as a powerful preventive step.
  • A strong therapeutic alliance remains an essential part of treatment and education.
  • Education must also encompass the dangers of stressors. Helping the individual identify and work with stressors provides a critical aspect of patient and family awareness.
  • Inform the patient about relapses within the total context of the disorder.
  • Individual stories help patients and families. The National Institute of Mental Health (NIMH) has a story of a person with manic-depressive illness that can help the patient see the struggle and challenge from another perspective.30 Others have written about their family struggles and challenges.31

Important resources for patients and families to gain information on dealing with manic-depressive illness include the following:

For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education articles Depression and Bipolar Disorder.

Miscellaneous

Medicolegal Pitfalls

  • Involuntary hospitalization for depression: In the clearest case of the bipolar/depressed phase, the patient is suicidal and homicidal in a few situations (this can result in homicide followed by suicide). In these scenarios, commitment is in order and indicated. In other situations, the depression has led to an inability to work, eat, and function; hospitalization is also indicated in these cases.
  • Involuntary hospitalization for mania: In the situation of a patient in bipolar/manic phase, often, less clear and dramatic evidence of homicide or suicide is present, but a pattern of very poor judgment and impairment emerges. Because of the behavior during the manic phase, the person often does major damage to their finances, career, and position in the community. This type of self-destructive mania calls for containment with good documentation and family support.

Special Concerns

Several special concerns, including suicide, homicide, and addiction, accompany patients with bipolar disorder.

  • Suicidal patients remain at risk for suicide. Patients emerging from a depression are thought to be at an increased risk for suicide. The risk of self-destructive behavior and death is lifelong. Hong's 2003 study demonstrates a genetic link between bipolar disorder and suicidal behavior, especially in white individuals.32
  • Homicidal patients, often in the manic phase, can be very demanding and grandiose. In this context, they are angered if others do not immediately comply with their wishes. This can make them turn dramatically violent. Also, they can become homicidal by acting on delusions.
  • Individuals with bipolar disorder are at risk for an addiction. This creates the problem of a dual diagnosis and, therefore, complicates treatment.
 


More on Bipolar Affective Disorder

Overview: Bipolar Affective Disorder
Differential Diagnoses & Workup: Bipolar Affective Disorder
Treatment & Medication: Bipolar Affective Disorder
Follow-up: Bipolar Affective Disorder
References
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Further Reading

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Keywords

bipolar depression, bipolar disorder, bipolar symptoms, bipolar treatment, manic depression, affective disorder, mood disorder, bipolar affective disorder, bipolar disorder, bipolar I, bipolar II, subthreshold bipolar disorders, bi polar disorder, bipolar treatment, bipolar symptoms, manic-depressive disorder, manic-depressive illness, MDI, manic depression, BPI, BPII, schizophrenia, psychosis, mood disorders, cyclothymia, suicide, mania

electroconvulsive therapy, ECT, electroshock, hypomania, psychomotor agitation, grandiosity, inflated self-esteem, racing thoughts, flight of ideas, distractibility, hypersomnia, insomnia, depression, Mental Status Examination, MSE, aggression

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Contributor Information and Disclosures

Author

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Lynne Alison McInnes, MD, Associate Adjunct Professor of Psychiatry and Genetics and Genomic Sciences, Department of Psychiatry and Human Genetics, Mount Sinai School of Medicine
Lynne Alison McInnes, MD is a member of the following medical societies: Alpha Omega Alpha, American Psychiatric Association, and American Society of Human Genetics
Disclosure: Nothing to disclose.

Medical Editor

Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center
Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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