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Bipolar disorder is notoriously difficult to diagnose and can be a great challenge to manage. If, as a casework specialist, any of your clients suffer from it, you’ll already know this, but it’s also worth pointing out that you might have bipolar clients that are as yet undiagnosed and being treated for something else, such as depression.

 

Professor of Psychiatry and Community Health at the University of Nottingham Richard Morriss describes a recent case.

The patient is a 20-year-old student being treated for depression by her GP, which caused her to have to retake her first year of studies. A course of antidepressants, namely citalopram and sertraline, saw no improvement, and a course of cognitive behavioural therapy saw only minor progress.

A marked personality change in recent weeks alarmed her housemates sufficiently to seek urgent attention from the GP.

Morriss says that, “uncharacteristically, she has been staying up all night partying with alcohol and drugs, wandering out in the middle of the night in bare feet in the cold, getting lost, overspending on clothes and shoes, getting into arguments and never keeping still”.

A mental state examination found her to be “giggly”, speaking quickly and unable to stay still. “She says she has never felt better,” says Morriss, “and she is happy to put the friends’ minds at ease because they had not previously met the ‘new me’.”

This is a classic example of “mania”: a bipolar episode. It’s important to watch out for it because if a patient has depressive symptoms at the same time as mania (“mixed affective episode”) or switches from mania to depression and back again, there is a greatly enhanced risk of suicide and self-harm. Mania and mixed affective episodes can be brought on by use of antidepressants, steroids and illicit drugs, including strong cannabis.

So what should you watch out for? Morriss says that the core feature is “persistent, uncharacteristically elated, euphoric or irritable mood”, combined with overactivity. Added to that, there must be three further symptoms for a minimum of seven days.

These include:
  • inflated self-esteem or confidence
  • a reduced requirement for sleep
  • Excessive talkativeness
  • Racing thoughts or speech that are hard to follow or interrupt
  • Being ‘distractible’ and unable to concentrate on one task for long before moving on to another
  • Being agitated or hyperactive in purposeful-type activity
  • Excessive or reckless involvement in recreational activities that could cause serious harm or upset

Added to this can be a profound belief that one has special powers, in extreme cases such as the ability to fly or a strong belief in one’s ability to have great influence and charisma.

Your immediate actions should be:
  • stop your client taking anti-depressants, gradually
  • Seek an urgent referral to a local mental health services team
  • if your client will not agree, consider an assessment under the Mental Health Act

Morriss concludes: “Early management often results in much better outcomes; well-controlled bipolar disorder is compatible with normal functioning and lifespan.”

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