Bipolar Disorder

A significant mental health problem

Bipolar affective disorder (also known as manic-depressive disorder) is a severe mental illness, characterised by episodes of extreme change in the mood (depressive, manic, mixed) and associated symptoms. The episodes happen without any exact pattern, but they are usually triggered by stressful situations (physical illness, bereavement, job loss). Episodes of depression and mania can follow each other, or they can be separated by periods of normal mental state which can last from a few months to several years. The number of episodes, the ratio of depressive to manic episodes and the length of asymptomatic intervals vary from patient to patient. However, 6 out of 10 episodes (on average) are depressive during the lifetime of a patient with bipolar affective disorder.

The bipolar affective disorder affects about one percent of the population. Despite being a rather rare condition, it causes very high burden and disability for patients, their families and society. They suffer all complications of depression, and the manic episodes have their own risks and difficulties. Patients with bipolar disorder have a life expectancy of 10 – 20 years shorter than the general population, with an annual mortality of 2.5 times the general population. Patients with bipolar disorder are prone to death due to suicide and accidents which are directly related to their symptoms. They are also at a higher risk of dying from physical health problems (e.g. heart disease). Furthermore, patients with bipolar disorder may have difficulty maintaining jobs and relationships, in particular, if their episodes are severe and too frequent with short periods of normal mood in between.

Causes of Bipolar Affective Disorder

Like other mental illnesses, bipolar disorder is a multi-factorial condition caused by a combination of genetic and environmental factors. 

Unlike conditions like cystic fibrosis, there is not a single gene which causes bipolar disorder. Instead, there are several genes that collectively increase the risk (i.e. the more of genes a person has, the higher risk of bipolar disorder). Hereditability of bipolar disorder is estimated to be approximately 59%. It is of note that bipolar disorder and schizophrenia overlap in terms of genetic factors; i.e. there are genes that can increase the risk of either disorder. This overlap is a likely reason that there is a higher risk of schizophrenia (than the general population) among family members of patients with bipolar disorder and vice versa. 

Many environmental risk factors for bipolar disorder affect the patients even before they are born. Studies have shown that maternal influenza and maternal stress in the 1st trimester of pregnancy increases the future risk of bipolar disorder in their children. There is also evidence that premature birth (or its causes) is associated with a higher risk of bipolar disorder. 

Similar to depression and other mental disorders, adversities in early years of life can increase risk of bipolar disorder; e.g. childhood maltreatment (the more prolonged and more frequent the abuse, the higher risk), loss of a parent in childhood, and lack of adequate parental care. 

Illicit drug use in adolescence and early adulthood is shown to increase the risk of bipolar disorder and to bring forward its onset.

Patient Focused Quality Care

Dr Behzad Basit can help patients suffering with Bipolar Disorder. We offer face to face appointments in London and virtual consultations.

Symptoms of Hypomanic/Manic Episode

  • Elated mood. Mood tends to be labile and changing rapidly. 
  • Excessive energy and tendency to engage in several activities at the same time (and leaving them half-finished). 
  • Reduced need for sleep; not feeling tired despite very limited sleep.
  • Over-familiar (asking personal questions, sharing private matters) or inappropriate behaviour.
  • Being over-confident and impulsive, reckless financial decisions, and taking over tasks/projects above one’s abilities. 
  • Increased libido, which can lead to promiscuity, unwanted/unplanned pregnancies and sexually transmitted diseases. • Poor attention and distractibility.
  • Fast speech, which is difficult to interrupt, racing thoughts to the point that patients find it difficult to express every idea (i.e. pressured speech). 
  • Patients change the topic of conversation rapidly (i.e. flight of ideas). In severe forms, it is not possible to follow the conversation as there is no link between sentences said (i.e. loosening of association). 
  • Reckless and high-risk behaviours; e.g. drink-driving, drug use, gambling. 
  • Irritability which can lead to violent behaviour.

In a hypomanic episode, patients have fewer symptoms and with less severity than what is seen in manic patients. In addition to the above, patients with mania can have psychotic symptoms:

  • Auditory hallucination: it is usually in the form of the second person (i.e. the voice(s) talking directly to the patient). The hallucinations are usually in line with the patient’s mood; e.g. hearing the voice of God referring to them as the “Chosen One”.
  • Delusions: Delusions are fixed and false beliefs which are not in line with the cultural and background of the patient and they cannot be corrected by reasoning or evidence. Delusions commonly seen in manic episode are:

a. Grandiose delusion: Patients believe they are unique or special; and they have extraordinary talents/capabilities, excessive wealth or noble/royal bloodline, 

b. Paranoid delusion: Belief by the patient that others are conspiring against them, watching them, or trying to harm them.

Symptoms of Depressive Episode (please see)

  • Low and depressed mood. 
  • Loss of interest or lack of enjoyment from usual leisure activities. 
  • Poor sleep.
  • Appetite changes.
  • Low energy and a constant feeling of fatigue.
  • Poor motivation. 
  • Reduced libido. 
  • Poor concentration and difficulty in making decisions.

Management of Hypomanic/Manic Episode

If patients with mania (hypomania) pose an immediate risk to their own health (e.g. extreme agitation, severe sleep deprivation, not attending to personal hygiene, use of illicit drugs or harmful use of alcohol), risk to their own safety (e.g. accidents and reckless behaviour, provoking others, inappropriate financial decisions, being vulnerable to sexual exploitation) or risk to others (e.g. aggression, sexually inappropriate behaviour), they should be in a place of safety (psychiatric hospital) and they should be monitored and treated by professionals. Sometimes the risk can be managed while patients stay at home and reviewed frequently by mental health professionals (e.g. Home Treatment Team).

The valid approach in the management of mania (hypomania), and all other mental health problems, is the one known as Bio-Psycho-Social:

Biological: considering the high risk that patients with mania/hypomania may post to themselves or to others, it is imperative that these patients are treated with suitable medication(s) in order to reduce length and severity of their symptoms; and the consequent risk caused. 

Lithium and Sodium Valproate (and other antiepileptics): Lithium and Sodium Valproate are first-line and most commonly used mood stabilisers. They are equally effective in preventing severe fluctuations in mood and other associated symptoms in bipolar disorder; both in manic and depressive episodes. Common side effects of Lithium are sedation, dry mouth, polyuria, tremor, gait and balance problem, kidney and thyroid impairment (hence need for regular blood tests) and abnormal heart rhythm. Lithium should not be taken during pregnancy, as it can cause congenital heart disease in the foetus. Sodium Valproate can cause sedation, lethargy, increased appetite and weight gain, and anaemia as a side effect. It causes severe neurological damage in the foetus as early as the first week of conception. Hence Sodium Valproate should NOT be prescribed in women of childbearing age unless any chance of pregnancy is eliminated (e.g. tubal ligation).  Like Sodium Valproate, there are other antiepileptics (Carbamazepine, Lamotrigine) which are licenced as mood stabilisers. They are not as widely prescribed as Sodium Valproate and Lithium. 

Antipsychotics:  Older antipsychotics (e.g. Haloperidol, Zuclopenthixol), as well as newer generation (e.g. Olanzapine, Risperidone), are licenced as mood stabilisers. They can be prescribed with strict monitoring during pregnancy. They are also available in injectable form for managing severely agitated and aggressive patients. Furthermore, they can be given as long-acting injections (administered every few weeks) to ensure compliance. Antipsychotics have their own side effects.

Benzodiazepines and Hypnotics: Benzodiazepines (Lorazepam, Clonazepam) and Hypnotics (Zopiclone) are usually used in the acute management of mania to manage severe agitation and to help with sleep.

Psychological: Patients with a manic episode are unlikely able to engage with therapy. These patients (and their families) benefit significantly from therapy in the form of psychoeducation (increase awareness of early signs of relapse) and coping with consequences of an episode (feelings of shame and guilt).

Social: like depression, it is crucial that patients receive appropriate social support following a manic episode to ensure and expedite their re-integration in different aspects of life.

Management of Depressive Episode

If patients with depression pose an immediate risk to their own health (e.g. not eating or drinking, not taking essential medications, not attending to personal hygiene), risk to their own safety (e.g. suicide) or risk to others (e.g. suicidal attempt by road accident or fire), they should be in a place of safety (psychiatric hospital) and they should be monitored and treated by professionals. Sometimes the risk can be managed while patients stay at home and reviewed frequently by mental health professionals (e.g. Home Treatment Team). There is no cure for depression; nevertheless, depression in the majority of patients can be well managed with an appropriate approach. The valid approach in the management of depression, and all other mental health problems, is the one known as Bio-Psycho-Social:

Central London Bipolar Clinic

Face to face appointments at our medical clinic can be booked by visiting our contact page here. Dr Basit also offers virtual appointments.

Yes, Dr Basit has admission privilege with Nightingale Hospital. During office hours, admissions are through his secretary or directly contacting Patient Services (Nightingale switchboard). If someone needs to be admitted under his care out of hours (in particular known patients), they can contact Nurse Coordinator via switchboard.

Yes, BUPA, AXA, Aviva, Vitality, Cigna, Healix.

Address

Nightingale Hospital 11-19 Lisson Grove, Marylebone, London NW1 6SH

VIRTUAL Appointments

Virtual Appointments are available with Dr Basit

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