Evidence-Based Strategies for Diagnosing and Managing Bipolar Disorder (Podcast)

An estimated 4.4% of U.S. adults experience bipolar disorder, a chronic mental illness marked by extreme shifts in mood, energy, activity levels and concentration. An accurate diagnosis, which is paramount for distinguishing the complex condition from other mood disorders, requires a nuanced understanding of its unique symptoms and patterns.

“The big differentiating factor between bipolar I disorder and bipolar II disorder is the presence of mania, which can cause intense, rapidly shifting moods – usually euphoria or irritability, a decreased need for sleep, heightened speech production or an inability to stop speaking, increased motor activity, elevations in goal-directed activity, and increased risk-taking behaviors,” explains psychiatrist Edward Kilbane, MD, Medical Director of Emergency Psychiatry in Cleveland Clinic's Neurological Institute. “People commonly assume that the extreme mood elevations caused by manic episodes can be somewhat enjoyable, but the reality is that these episodes can quickly become quite scary and difficult to manage.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Kilbane shares practical insights for diagnosing and managing bipolar disorder. He addresses:

• Common presentations and risk factors
• Differentiating between bipolar disorder and other mood-related conditions
• Addressing symptoms with multidisciplinary outpatient and inpatient care
• Using mood stabilizers and cognitive behavioral therapy to improve outcomes
• Connecting patients with lifestyle management resources

Click the podcast player above to listen to the 20-minute episode now, or read on for a short, edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Podcast excerpt

Podcast host Glen Stevens, DO, PhD: [Let’s say] I’ve received a bipolar diagnosis. I'm doing my therapy, I've gotten off the substances that I shouldn't be taking, and my family's being supportive. I’ve tried a few medications, but they’re still not working. What's the next step? How many drugs do we try before we [attempt] another intervention?

Dr. Kilbane: It's a great question. We tend to start with mood stabilizers – something like lithium salts or an antiseizure medication – but there's also a whole other category of potential treatments: atypical antipsychotics. These agents came to market in the ‘90s, initially as an [alternative therapy for] schizophrenia. Over the past 20-plus years, however, [many] have received FDA approval for the management of bipolar depression and mania.

[We often treat bipolar disorder] with a combination of mood stabilizers and atypical antipsychotics, especially if the patient's presenting with psychotic symptoms. There is a lot of room to try different agents simultaneously.

Most patients can be treated in the outpatient setting, but if that's not working and symptoms are worsening, there are other options. Before we [resort to] inpatient psychiatry, we might explore intensive outpatient programs, which can [last for] several weeks or months. Patients usually attend all-day appointments Monday through Friday, [where they] receive pharmacological and therapy management.

If a patient needs to be admitted to the inpatient psychiatric unit, there are two ways to do that. A patient [might] say, "Hey, I'm not doing well. I'm depressed," or "I'm not sleeping, and I'm concerned I'm getting more manic. I need some medication adjustments done in a secured setting in a more expeditious fashion." That certainly is one way…they can voluntarily sign themselves into the hospital with the help of the accepting physician.

The other way that most patients come into the inpatient psychiatric unit is involuntarily – not of their own free will. According to current Ohio State law, [the provider has] to demonstrate that the patient meets one of three criteria. They must pose an acute danger to themselves (usually because they're suicidal); they must be an acute danger to others by being homicidal or aggressive; or they're so decompensated from their symptoms that they're considered gravely disabled – they can't really tell us how they'd manage their basic needs like shelter or food or hygiene.

Once the patient is on the unit, [staff is focused on] trying to treat their symptoms pharmacologically. ...medication can be managed more effectively on an inpatient unit, where dose adjustments can be made much faster…and patients can be observed for improvements and side effects on a daily basis.

If a patient’s not sleeping well, the use of sleep agents can be used to get them back on a good sleep schedule. And most importantly, [the inpatient unit] is a safe environment. Patients are in a setting that's locked, that's secure, that's monitored, and where they have a reduced risk of ending up in harm's way.