Assessment

Formal systems for the diagnosis of mental illness (1,2) describe a number of different types of bipolar disorder, including:

• Bipolar I disorder (manic episodes have occurred)
• Bipolar II disorder (hypomanic episodes have occurred)
• Cyclothymia (chronic, fluctuating mood symptoms that are milder than those in Bipolar I or II disorder)
• Bipolar disorder not otherwise specified (NOS)

Assessment Tools

To decide whether a young person may be experiencing bipolar disorder, a comprehensive assessment by a mental health professional is required.  As a first step, the assessment involves asking questions about a range of aspects of a person's life including their:

• Home and environment;
• Education and employment;
• Activities;
• Drugs and alcohol;
• Relationships and sexuality;
• Conduct difficulties and risk-taking;
• Anxiety and eating;
• Depression and suicide;
• Psychosis and mania

To specifically assess for the presence of manic symptoms consistent with bipolar disorder, a comprehensive Mental State Examination by a mental health professional trained in clinical assessment is required. It may also be beneficial to use a standardized assessment rating scale, such as the Young Mania Rating Scale (YMRS) (3) to comprehensively assess symptoms of mania.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

2. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

3. Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: reliability, validity and sensitivity. The British Journal of Psychiatry, 133(5), 429-435.

Treatment

Early detection and treatment of bipolar disorder can improve its long-term outcome (1,2).  Accurate diagnosis is essential to provide appropriate treatment, but this can be difficult in the early stages of bipolar disorder as (3,4):

• There can be an overlap in symptoms with other disorders (for example, psychosis or ADHD)
• Bipolar disorder can only be diagnosed after a full episode of mania or hypomania has occurred. Therefore, people whose bipolar disorder commences with an episode of depression and/or hypomanic symptoms that do not meet diagnostic threshold may be diagnosed initially with a depressive disorder
• Co-existing disorders (eg, medical illness, substance use) can complicate the process

Every person is different, but treatment of bipolar disorder could include (5):

• Assertive case management
• Appropriate medication (using mood stabilizers, antidepressants or antipsychotics as needed)
• Psychological therapy
• Family and group therapy (including family psychoeducation)
• Vocational interventions

The importance of early intervention has been noted. Young people with bipolar disorder have been found to have a higher rate of response to treatment with appropriate medication, as compared to adults (6). The long-term use of medication may also be needed to prevent relapse.

In areas where specialised early intervention services do not exist, general practitioners have an opportunity to make an early diagnosis and provide initial treatment before review by a psychiatrist (7). A psychiatrist will generally develop a treatment strategy and may provide continued clinical management individually or in conjunction with the GP (see (8) for further information).

References

1. Berk, M., Hallam, K., Malhi, G. S., Henry, L., Hasty, M., Macneil, C., ... & McGorry, P. D. (2010). Evidence and implications for early intervention in bipolar disorder.  Journal of Mental Health, 19(2), 113-126.

2. Kapczinski, F., Magalhães, P. V. S., Balanzá-Martinez, V., Dias, V. V., Frangou, S., Gama, C. S., ... & Berk, M. (2014). Staging systems in bipolar disorder: an International society for bipolar disorders task force report. Acta Psychiatrica Scandinavica, 130(5), 354-363.

3. Danner, S., Fristad, M. A., Arnold, L. E., Youngstrom, E. A., Birmaher, B., Horwitz, S. M., ... & LAMS Group. (2009). Early-onset bipolar spectrum disorders: Diagnostic issues. Clinical Child and Family Psychology Review, 12(3), 271-293.

4. Berk, M., Moss, K., Berk, L., Malhi, G. S., & Dodd, S. (2006). Diagnosing bipolar disorder: How can we do it better. Medical Journal of Australia, (9). 459.

5. Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 3811672-1682. doi:10.1016/S0140-6736(13)60857-0

6. Mao, A., & Findling, R. (2007). Growing evidence to support early intervention in early onset bipolar disorder. Australian & New Zealand Journal Of Psychiatry, 41(8), 633-636.

7. Faust, D. S., Walker, D., & Sands, M. (2006). Diagnosis and management of childhood bipolar disorder in the primary care setting. Clinical Pediatrics, 45(9), 801-808.

8. Bipolar Disorder: Australian treatment guidelines for consumers and carers 2009. Royal Australian and New Zealand College of Psychiatrists

Guidelines