Twenty-five or so years ago, most people diagnosed with bipolar disorder were middle-age adults who had distinct euphoric episodes. Today most people identified with manic-depression present a remarkably different picture of the condition: Not only is depression the most pervasive feature of the illness, the manic phase is usually a mix of irritability, anger and depression, with or without euphoria. In fact, euphoric mania is the exception, not the rule.
Today the average age of onset of bipolar disorder is 19. It’s not clear whether there is a rising incidence of the disorder in younger people or it is just being recognized more in children and adolescents.
But now as then, bipolar disorder most often remains undiagnosed and untreated. Experts say that severe manic depression afflicts 1 percent of the population and 5 percent of Americans have a less florid form of the disorder.
Consider these statistics:
- It takes an average of 20 years for a person with bipolar disorder to be correctly diagnosed.
- In 37 percent of patients the disorder is mistakenly diagnosed as unipolar depression — even after a manic episode.
- Two-thirds of manic episodes do not involve elation but rather irritability or even depression.
Should a manic depressive be lucky enough to learn that his suffering has a name and an array of treatment possibilities, there are still formidable hurdles. Surveys show that 50 percent of sufferers do not take the prescribed medications.
The problem may not always lie with the patient, although the manic-side energy and impaired judgment provide powerful incentives to skip medication. Getting the disorder under control typically requires use of multiple drugs, each with an array of side effects from weight gain to cognitive dulling. Prescribing tolerable drugs in tolerable dosages for each case is a psychiatric high-wire act.
The condition is still so challenging to tame that 90 percent of marriages involving a partner with bipolar disorder end in divorce. Researchers estimate that more than 40 percent of persons with bipolar disorder abuse alcohol or drugs; 15 to 25 percent die by suicide, accident, or are killed in altercations triggered in a manic phase. Most attempted and completed suicides occur during depressive or mixed phases.
The summer of 2003 brought a major treatment advance — FDA approval of the anti-seizure drug lamotrigine (Lamictal) for bipolar disorder. It is the first drug since lithium to be approved for long-term maintenance treatment of bipolar disorder. Studies indicate that the anticonvulsant delays significantly the occurrence of repeat episodes — and especially depression — in patients treated for acute mood episodes with standard therapy.
What has many psychiatrists especially excited is that the drug appears to be a new kind of mood stabilizer — a mood-elevating mood stabilizer. “We used to just be able to bring people down from mania,” explains Andrew L. Stoll, M.D., associate professor of psychiatry at Harvard and chief of the psychopharmacology research lab at Harvard’s McLean Hospital. “With lamotrigine we can stabilize mood from below, bringing the person up from depression. A few years ago we would not have believed that possible. There’s been a paradigm shift in a way.”
Lamotrigine addresses a major concern of many experts: It may obviate the need for conventional antidepressants in treating the depressive phase. Used alone, antidepressants can induce mania. There is also concern that they accelerate mood cycling. Increasingly, psychiatrists minimize the value of conventional antidepressants for bipolar depression, although they are still widely prescribed.
Unlike most other drugs for manic depression, lamotrigine seems to cause few side effects and is well tolerated by patients. There’s no weight gain, no drowsiness, no cognitive dulling, no hormonal changes. And no blood tests are required for continued treatment.
The only potentially serious problem is a kind of skin rash, but evidence indicates it is averted if doctors start the drug at extremely low doses. Nevertheless, many doctors are afraid to use the drug. Some sources report that fear of lamotrigine is deliberately whipped up by representatives of pharmaceutical companies pitching rival drugs for the disorder.
Exactly how lamotrigine works is not clear. The drug was approved for epilepsy nearly a decade ago. On the grounds that there seem to be similar electrical processes at work in the brain in both disorders, anything that works against epilepsy is now tried in bipolar disorder, although not every anti-epilepsy agent works in bipolar disorder as well.
It is a fact that every effective mood stabilizer blocks the brain process known as kindling, a sensitizing of nerve cells so that they react to even minor provocations with a full-blown mood episode. All mood stabilizers curb hyperactive signaling in pathways that lead from neurotransmitter receptors to the nerve cell interior.
Last reviewed: By John M. Grohol, Psy.D. on 19 Sep 2007
