Disease of the Month: Bipolar Disorder

With improved diagnostic techniques and less stigma attached to mental illnesses, bipolar disorder has become more commonly heard about - helped no doubt by the fact numerous celebrities, including Stephen Fry, Caroline Aherne, Catherine Zeta-Jones and Rowan Atkinson, have openly discussed their diagnosis in the media.

What is Bipolar disorder?

Since ancient times, scholars have described the symptoms of mania and its associated illness, and Hippocrates (460BC to 377BC) is widely credited with the first classification of mania.

Bipolar disorder affects moods, causing swings from one extreme to the other. There are periods of depression as well as periods of highly elevated mood - or mania - and either phase can last for weeks or months at a time.

There can be any number of episodes of highs and lows throughout life, but the average is thought to be around 10 episodes of either phase in total. In between episodes of highs or lows there may be gaps of weeks, months or years when the mood is normal.

Variations of the Condition

A diagnosis of bipolar disorder requires the experience of at least two mood episodes, one of which must be manic or hypomanic (a less severe form of mania). But the term bipolar disorder actually covers a range of conditions:

Bipolar 1

Patients with bipolar 1 display the most severe and classic features of the condition. Full-blown manic episodes will be interspersed with episodes of major depression. While many people will be familiar with the typical symptoms of major depression, mania is generally less well known.

It causes an abnormally high or irritable mood, lasting for at least one week but usually for much longer.

Episodes of mania will usually include at least three or four of the following features;
• Grand ideas about self and own self-importance.
• Increased energy, quick movements and less sleep than usual.
• More talkative and talking quickly.
• Flight of ideas, i.e. a tendency to change quickly from one idea to another.
• Easily distracted.
• Full of new grandiose and unrealistic ideas and plans.
• Irritation or agitation.
• Wanting to do lots of pleasurable things such as spending a lot of money, being less inhibited about sexual behaviour, taking part in risky exciting adventures, drinking or taking recreational drugs.

Severe mania may also cause psychotic symptoms where contact with reality is lost.

Bipolar 2

In this variant the patient experiences depressive episodes and less severe manic symptoms, classed as hypomanic episodes. A diagnosis of bipolar 2 disorder requires the experience of at least one major depressive episode and at least one hypomanic episode.

Rapid cycling

Some people with either bipolar 1 or bipolar 2 disorders swing from highs to lows quite quickly without a period of normal mood in between. This is called rapid cycling and is a feature of the condition if there are at least four mood swings per year. It occurs in about one in six cases.

Cyclothymia

This is a condition in which the patient has recurrent hypomanic episodes and milder episodes of depression. The depressive episodes do not reach sufficient severity or duration to merit a diagnosis of a major depressive episode, but mood disturbance is a continuing problem for the patient and interferes with everyday functioning.

Hypomania

The precise definition of hypomania is still the subject of ongoing debate, but there is some consensus that a diagnosis of a hypomanic episode requires symptoms of hypomania to last for at least 4 days. Those who have hypomanic symptoms lasting between 1 and 3 days can be diagnosed with ‘bipolar disorder not otherwise specified'.

Who gets bipolar disorder?

About one in 100 people develop the condition. It can occur at any age, but usually first develops between 17 and 29. Late-onset bipolar disorder first appears in later life (after 40 years of age) and normally follows many years of repeated episodes of unipolar depression, or is secondary to other factors such as steroid medication, infection or neurological problems.

It occurs in the same number of men as women, though there is some evidence to suggest the symptom profile differs between the genders.

What causes bipolar disorder?

Despite its long history, little is known about what causes bipolar disorder. It is thought extreme stress, overwhelming problems and life-changing events can trigger episodes, as well as genetic and chemical imbalances in the brain.

Mood disorders often cluster in families, and bipolar disorder is no different in this aspect, which suggests there may be a genetic link. The inheritance pattern is not simple, however, and it is likely many genes are involved in susceptibility to psychiatric illnesses.

There may also be genes that reduce the risk of developing bipolar disorder.

Treating bipolar disorder

The course, pattern and outlook of the condition can be improved, but there is no once-and-for-all cure. Treatments include;
• Medication that aims to prevent episodes of mania, hypomania and depression. These are known as mood stabilisers and are taken every day, on a long-term basis.
• Medication to treat the main symptoms of depression and mania when they occur.
• Learning to recognise the triggers and signs of an episode of depression or mania.
• Psychological treatment - such as cognitive therapy to help deal with depression.
• Lifestyle advice - such as doing regular exercise, improving diet and getting more sleep.

Lithium is the most commonly used medicine for bipolar disorder in the UK. It is used to treat episodes of mania, hypomania and depression and can be taken as a long-term mood stabiliser to prevent episodes. One problem with lithium is that the dose for an individual has to be just right: too low a dose has little effect, while too high a dose could cause side-effects such as weight gain.

Antipsychotic medicines may also be used to treat episodes of mania or hypomania. Once one of these medicines is started, the symptoms of mania or hypomania often settle within a week or so.

Course and prognosis

For most patients, bipolar disorder is chronic and recurrent. There is an overall higher mortality rate among bipolar patients compared with the general population, which is not just due to the increased risk of suicide.

Bipolar disorder is associated with a higher rate of physical illnesses such as diabetes and heart disease, and the standardised mortality ratio for premature deaths from natural causes is estimated at 1.9 for males and 2.1 for females.

Clearly, suicide is the major risk. The mortality ratio for suicide is much higher at approximately 15 for males and 22.4 for females. The greatest risk of suicide attempts occurs during depressed or mixed episodes, and approximately 17% of patients with bipolar 1 disorder and 24% of patients with bipolar 2 disorder attempt suicide during the course of their illness. Annually around 0.4% of patients with bipolar disorder will die by suicide.

Substance misuse is common in patients with the condition and increases the suicide risk even further.

Underwriting bipolar disorder

Bipolar disorders are generally not suited to being underwritten in an automated environment, so such disclosures in an underwriting rules engine will usually trigger a request for a report from a GP.

This will then be manually assessed by an underwriter, who will usually begin by ascertaining the severity of the disorder.

Determining whether the case is mild, moderate or severe involves looking at the whole picture and weighing up the application against criteria such as the following;

• Frequency and number of depressive and manic episodes
• Hospitalisation and whether in-patient admission has been required
• Medication and compliance with recommended courses
• Occupation and work absences
• Lifestyle - alcohol and/or recreational drug use
• Time since last episode of depression or mania

If the condition is stable and well controlled and there have been no recent manic episodes, terms may be offered for life or serious illness benefits with a moderate loading.

If the individual has endured very recent episodes of mania or there is indication of alcohol or substance abuse, it is unlikely terms will be possible. The same applies where there is evidence of suicide attempts or self-harm.

Andy Smith is underwriting manager at VitalityLife (formerly PruProtect)