Although this comes as no surprise to me, there is now clear evidence that lithium is the most efficacious single agent for managing bipolar mania and bipolar depression. If, for whatever reason, lithium is not effective as monotherapy, combining Depakote with it does increase efficacy – although not markedly. The lithium/Depakote combination therefore is optimal in the treatment of bipolar mania.

From clinical experience, what are your impressions?

The seven classic symptoms of mania and hypomania are probably best summed up through the use of the acronym

D I G F A S T

Distractibility: Inability to maintain focus on tasks

Insomnia: Reduced need for sleep accompanied by increased energy in spite of little sleep

Grandiosity: Inflated self-esteem

Flight of ideas: Racing thoughts

Activities: Increase in goal-directed activity – work, social, school

Speech: Excessive, circumstantial, tangential chatter, pressure to keep talking or more talkative than usual

Thoughtlessness: Risky behavior, such as excessive involvement in pleasurable activities that have a significant potential for adverse consequences – excessive spending, risky sexual behavior, reckless driving, gambling, impulsive traveling

DIFFERENCES BETWEEN MANIA AND HYPOMANIA

Mania:

• - Marked occupational/social dysfunction
• - Often a need for hospitalization
• - 67% of patients have a lifetime history of psychosis
• - Minimum of one week duration according to DSM IV

Hypomania:

• – No significant occupational or social dysfunction
• - No hospitalization
• - No psychotic features
• - Minimum four-day duration (average is 2-3 days)

The manic phase of bipolar disorder carries a peculiar treatment challenge that most other mental disorders do not: Because mania is a desirable and enjoyable state for many, if not most patients, medication noncompliance is a particular hazard during these manic episodes. Repeatedly starting and discontinuing mood stabilizers results in erratic blood levels of these medications and a subsequent decrease in their overall effectiveness. This, in turn, can lead to an increased susceptibility for the occurrence of future episodes, a progressive worsening of symptoms and a heightened mortality risk. Clinicians should continually emphasize the serious risks of noncompliance with these patients and focus on coaching them to take these medications as prescribed.

Enlisting the assistance and cooperation of the bipolar client’s family members can prove to be a significant asset toward gaining medication compliance. Family members are our de facto healthcare specialists and are too infrequently utilized by prescribers and therapists as sources of information regarding the client’s progress (or lack thereof). They are often first to recognize the warning signs of symptom reemergence and can serve as our first-line allies in getting their de-compensating, medication noncompliant bipolar loved one back on the road toward progress.

In truth, bipolar disorder is quite difficult to diagnose in children, and the presentation of childhood mania differs dramatically from adults. Children in the manic phase of the disorder tend toward extreme agitation and destructive outbursts, as opposed to the euphoria more common among adults.

The most widely used medications in the treatment of pediatric bipolar disorder are lithium and Depakote. Although studies confirm the effectiveness of these medications, their safety is questionable due to the life-long nature of bipolar disorder. Long term lithium use is linked to weight gain, acne, tremors and kidney dysfunction. Prolonged Depakote use is associated with pancreatitis and liver failure. Both medications require stringent blood-level monitoring. The bottom line: The benefit-vs.-risk of medicating childhood-onset bipolar disorder is a considerable concern.

Irritability, frustration intolerance, aggression and inattentiveness are present in both disorders.

Did I miss anything? What are your experiences when it comes to differentiating Bipolar disorder and ADHD?