Bipolar Disorder: A Physician’s Perspective

SUDHAKAR SELVARAJ, MD, PhD, is an assistant professor in the Department of Psychiatry and Behavioral Sciences at McGovern Medical School at The University of Texas Health Science Center at Houston. He is active in several professional organizations, including the American Society of Clinical Psychopharmacology, Houston Academy of Medicine and more. He has also received several awards and honors throughout his career, including the 2016 Dean’s Teaching Excellence Award.

BSTQ: For those not familiar, can you define bipolar disorder?

Dr. Selvaraj: Bipolar disorder is a serious illness characterized by recurrent periods of changes in mood, activity and energy levels, and sleep patterns. At one extreme, individuals may suffer from mania symptoms that include elevated mood or irritable mood, increased activity levels and poor sleep or less need for sleep. With mania, patients may feel they have more energy, and they may feel grandiose about their ability. During periods of depression, individuals may feel sad and tired, and they sleep less or more. There are also cognitive symptoms such as difficulty making decisions and thinking things over again and again. Sometimes, patients may have both of the depression and mania symptoms, called “mixed.” Bipolar disorder is a severely disabling condition for many patients for long periods and sometimes many episodes throughout life. Many patients do well with treatment and continue to function well and achieve their life potential.

BSTQ: How is bipolar disorder diagnosed?

Dr. Selvaraj: Bipolar disorder is diagnosed mainly based on clinical symptoms and history and an assessment performed in the clinic by psychiatrists or mental health clinicians. Sometimes, the diagnosis may need several visits. Currently, there are no tests available to diagnose bipolar disorder.

BSTQ: What are some barriers to accurate diagnosis?

Dr. Selvaraj: Delays in seeking help with mental health difficulties is a very important barrier to be addressed. Stigma about mental illness, availability of mental health resources, costs, family and social perception are all factors that impact accurate and early diagnosis. Also, many symptoms overlap with other psychiatric conditions such as anxiety, depression, attention deficit hyperactivity disorder, substance abuse, etc. People often experience depression or other symptoms for a longer period before being diagnosed with bipolar disorder. For accurate diagnosis, patients have to be carefully followed for a long period. More research is needed to improve the early and accurate diagnosis of this condition.

BSTQ: Can you tell us about treatment strategies?

Dr. Selvaraj: Education about the illness, involving the patient and family in treatment planning, appropriate choice of medications, and making sure the patient is in a safe place and takes part in treatment are the key points of treatment. For mania symptoms, the standard treatments are use of a mood stabilizer or antipsychotic medication. Lithium is one of the gold standards in treating bipolar disorder since it works for both treating and preventing mania and preventing depression, but it is not as good at treating acute depression. There are also other drugs used to treat mania, usually antiepileptic drugs such as sodium valproate, carbamazepine and lamotrigine. Antipsychotic drugs or lamotrigine are increasingly used for treating depression symptoms in bipolar disorder. Traditional antidepressants are only given along with mood stabilizers or antipsychotic medications to reduce the risk of flipping the depression into mania symptoms. Continuing medication for long periods may be necessary to prevent relapses. And, education about helping to recognize life stressors, developing strategies to cope with stress, maintaining a healthy lifestyle (exercise, sleep hygiene, avoiding excess alcohol use and illegal drug use, etc.) are very important.

BSTQ: What are the newer developments in the treatment of bipolar disorder?

Dr. Selvaraj: A lot of research is being conducted to improve the early diagnosis of this condition in childhood and adolescence. We are beginning to understand how this illness overlaps with many other conditions and how symptom dimensions emerge early in life. Many researchers are interested in the course of early symptoms and are incorporating digital strategies such as using smartphones to monitor symptoms. In addition, smartphone-based apps are improving educational aspects and providing self-help psychological treatments that are improving the ways people seek treatment.

BSTQ: What role does the patient play in a successful treatment plan?

Dr. Selvaraj: The patient’s awareness of symptoms and illness and their motivation to get better are vital in the successful outcome of bipolar disorder treatment. Therefore, patients should be involved in decision-making from the beginning to improve their participation in treatment. They need to be comfortable with treatment approaches — not only about medications but also understanding the illness and the ways to reduce the risk of relapses.