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Bipolar disorder (BPD) is a chronic mental illness that is debilitating and life threatening. NIMH defines BPD (formerly manic-depressive illness) as “a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.” (NIMH Bipolar, 2015). In similar fashion NAMI defines BPD as “a chronic mental illness that causes dramatic shifts in a person’s, mood, energy and ability to think clearly.” (NAMI Bipolar, 2015). BPD is a chronic mental health disorder that can cause extreme social dysfunction, and BPD is estimated to cost “$45 billion (Kleinman et al.)” as cited by Miller (2006). The DSM-5 lists four major categories of BPD those being BPD1, BPD2, Cyclothymic Disorder and BPD NOS (not otherwise specified). Each of these disorders are related to mania and or depression occurring or interacting differently in each of the subgroupings. For the purposes of this paper we will be examining BPD1 specifically. “Bipolar I and bipolar II disorders have combined prevalence rates of approximately 1.5%. In the DSM-5, 12-month prevalence rates are estimated to be 0.6% for bipolar I and 0.8% for bipolar II disorders.” (Schatzberg, & DeBattista, 2015). Given the American population of about 314 million at (.6 prevalence rate) that amounts to an estimate of 1.884 million sufferers with BPD1. Kupfer (2004) reports higher estimates as much as 1.2% of the adult population of the United States (2.3 million Americans) may have BPD1 (as cited by, Miller, 2006). Bipolar disorder (BPD) is a lifetime mood disorder described by repeated manic or hypomanic and depressive episodes. As cited by Kleinman et al. (2003), “the lifetime prevalence by race and ethnicity for BPD I and BPD II, respectively, was: Caucasian 0.8% and 0.4%, African American 1.0% and 0.6%, and Hispanic 0.7% and 0.5%. No gender difference is seen in BPD I, although BPD II disorder is more common in women. The mean age of onset in BPD I is 18 years and for BPD II is 22 years. It is ranked sixth in the top 10 causes of disability worldwide for individuals between 15 and 44 years of age (Bauer, 2001). A U.S. prevalence-based cost-of-illness study on BPD estimated, “a total annual cost of $45 billion (Kleinman et al.)” as cited by Miller (2006), and given prevalence of BPDI which seems to account for nearly half that number ($20 billion). Bipolar disorder genetically is an exceedingly heritable disease, as high as 80-85%, “Concordance rates between monozygotic twins are 40 -70% and 5-10% for dizygotic twins. The children of two affected parents have a lifetime-risk of 50-65% to fall ill with bipolar disorder, while children with one parent with bipolar disorder only show a risk of 25% to get bipolar disorder. If one first-degree relative suffers from bipolar disorder, one has the risk of 5-10% to develop bipolar disorder” (Bengesser, & Reininghaus, 2013). Pediatric BPD (PBPD) is certainly diagnosable in young children but the course of the illness has different manifestations. Irritability was discovered in 80% of consumers and fundamental to the diagnosis of PBPD; additionally, aggression is essential `presenting problem,' and treatments should lessen aggression to be seen as operational among PBPDs (Axelson, Birmaher, Strober, Gill, Valeri, Chiappetta, Ryan, Leonard, Hunt, Iyengar, Bridge, & Keller, 2006). NAMI reports, the identification of Disruptive Mood Dysregulation Disorder (DMDD-DSM-5:296.99) will affect how bipolar disorder is diagnosed in children; however, those with DMDD do not have an increased risk of developing bipolar disorder as adults. DMDD refers to children who are extremely petulant, have temper outbursts, but do not have characteristic symptoms of mania (NAMI Bipolar, 2015). In the DSM-5 BPD1 (Codes 296.40-70) is typified by the following cognitive behavioral criteria (DSM-5 Bipolar 1, 2015): Bipolar I disorder criteria characterizes the modern taxonomy of what was traditionally manic-depressive disorder or affective psychosis over 100 years previous. The only difference being that psychosis and or the experience of a major depressive episode is not a requirement. Nevertheless, individuals who become fully syndromal experiencing a manic episode will usually or eventually experience a major depressive episode (DSM-5 Bipolar 1, 2015). For a diagnosis of BPD1, it is necessary to meet the criteria for a manic episode. Such manic episode may have been preceded or may be followed by hypomanic or major depressive episodes (DSM-5 Bipolar 1, 2015).

Treatment Considerations for BPDI Suffers. MFT practitioners should note that family focused therapies have an evidence base that shows psychoeducation to be the most efficacious treatment for chronic severe mental illnesses like BPDI (Axelson, Birmaher, Strober, Gill, Valeri, Chiappetta, Ryan, Leonard, Hunt, Iyengar, Bridge, & Keller, 2006). The popular psychopharmacological treatment approach for overall mood stabilization of these disorders has involved lithium carbonate or lithium citrate. (Schatzberg, & DeBattista, 2015). Carbamazepine, oxcarbazepine, valproic acid, some benzodiazepines, and atypical antipsychotics have also been shown to have mood-stabilizing effects, most prominently in acute mania (Schatzberg, & DeBattista, 2015). Treatment of acute hypomania or mania includes the mood-stabilizing drugs noted above as well as antipsychotics and sedative-hypnotics for sleep. (Schatzberg, & DeBattista, 2015). Treatment of bipolar depression often requires combining lithium or valproate with treatments used for major depression (Schatzberg, & DeBattista, 2015). There are three agents approved for bipolar depression: olanzapine-fluoxetine combination, quetiapine, and lurasidone. (Schatzberg, & DeBattista, 2015). Lamotrigine is approved for the prevention of depressive episodes. At one time, mixed states were more responsive to anticonvulsants than to lithium, but this is no longer clear (Schatzberg, & DeBattista, 2015).

“Four different types of medication have been found to be effective in improving the symptoms of bipolar disorder and reducing the likelihood of relapses (Francis, Docherty, & Kahn, 1996; McElroy & Keck, 2000): Lithium, valproic acid (Depakote), carbamazepine (Tegretol), and antipsychotic medications (such as risperidone, olanzapine, and clozapine.). The first three medications are generally considered the treatment of choice for the pharmacological management of bipolar disorder, although antipsychotic medications have also been shown to be effective. The primary drawback to antipsychotic medications is their propensity to cause tardive dyskinesia (with the exception of clozapine), an irreversible neurological syndrome that involves involuntary movements in the oralfacial region (e.g., lips, tongue) and extremities (fingers, toes). “ (Mueser, 2003)

Sparks & Duncan (2008) point to five major re and then informs that with bipolar clients medication has three additional major disadvantages: • The medication cannot always be taken by the client; • Side effects are not always known or tolerated; • In pediatric behavioral interventions medication is not shown to have an advantage over nonmedication options.

References

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Mueser, K. T. (2003) Clinical update: Bipolar disorder. Family Therapy Magazine, 2(2) Attachment: Mueser (2003) - Clinical Update- Bipolar disorder.pdf

O’Hanlon, W. H., & Rowan, T. (2003). Solution-oriented therapy for chronic and severe mental illness. New York Norton. ISBN: 9780393704235 Schatzberg, Alan F., and DeBattista, Charles. (2015). Manual of Clinical Psychopharmacology (8). Washington, D.C., US: American Psychiatric Publishing, 2015. ProQuest ebrary. Web. 22 June 2016.

Schatzberg, Alan F., and DeBattista, Charles. (2015). Manual of Clinical Psychopharmacology (8). Washington, D.C., US: American Psychiatric Publishing, 2015. ProQuest ebrary. Web. 22 June 2016.

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Sparks, J. A., & Duncan, B. L. (2008). Do no harm: A critical risk/benefit analysis of child psychotropic medication. Journal of Family Psychotherapy, 19(1), 1-19. doi:10.1080/08975350801904072