Bipolar Disorder: The Upswing in Research and Treatment PDF

Preface

Bipolar disorder is a recurrent illness which, without appropriate treatment, can have a devastating impact on the lives of those affected and their families. The World Health Organization has estimated that bipolar disorder is the sixth leading cause of years lived with disability (schizophrenia came ninth) and yet historically it has been relatively under-researched. This situation has greatly changed in recent years as bipolar disorder has become a focus for research, with consequent advances in our understanding of the aetiology and management of the disorder. This ‘upswing' in the research and treatment of the illness was discussed at a recent European Foundation for Psychiatry at the Maudsley (EFPM) meeting held at the Institute of Psychiatry. The theme of the conference, and of this resultant volume, is the new research and clinical developments in bipolar disorder research across multiple disciplines.

The book comprises six sections. In the first, studies are presented that employ the powerful tools of epidemiology to identify how the incidence and age of onset of bipolar disorder are influenced by temporal variation and demographic variables. The long-term course of the disorder is also considered with a particular emphasis on the relative failure of treatments to affect important functional outcomes for patients, as distinct from the symptomatic improvements which clinicians tend to emphasize.

The second section is devoted to investigations attempting to locate the brain regions that are structurally and functionally impaired in bipolar disorder at a macroscopic and microscopic level. Although Kraepelin considered the syndrome of ‘manic depressive insanity' that he described as a brain disease, for much of the past century the neurobiological basis of the illness has been denied or ignored. However, the application of recent neuroimaging techniques has reinvigorated this field, and bipolar disorder has been associated with subtle deviations of brain structure, and with evidence of impaired functioning of critical brain regions implicated in the processing of cognitive and affective stimuli. In the final chapter of this section, these neuroimaging findings are integrated with the emerging neuropathological literature, most of which emanates from the invaluable resource of postmortem tissue provided by the Stanley Medical Research Institute, to develop an understanding of the structural and functional abnormalities at a cellular level.

It has long been known that bipolar disorder is highly heritable but, as with many other psychiatric syndromes, progress in identifying the susceptibility genes has been slow. Section 3 includes chapters which review the genetics of the disorder. The topics covered include the genetic overlap between bipolar disorder and its related syndromes, schizophrenia and unipolar depression, how abnormalities of brain structure reflect the impact of susceptibility genes, the depressive-like behaviour of transgenic mice, and the associations of allelic variation in candidate genes within linked regions and the clinical syndrome.

A central strand of research into affective disorders has been dysfunction of the hypothalamic–pituitary–adrenal axis. There is clear evidence for impaired regulation of cortisol secretion from the adrenal glands in both unipolar and bipolar disorder, and the precise mechanisms whereby this emerges and its interaction with other components of the axis are exciting areas of current research. Section 4 deals with excessive cortisol secretion in bipolar disorder, addressing its origins, how it is sustained, and its neurotoxic effects. Whether it causes or compensates for the clinical syndrome, as well as its potential for manipulation to therapeutic benefit, is also reviewed.

Section 5 addresses the psychology of bipolar disorder, including the manner in which impaired cognitive processing of emotionally coloured stimuli can contribute to the symptoms of affective disorder. There is abundant evidence for cognitive dysfunction during episodes of bipolar illness, but even in remission neurocognitive abnormalities frequently persist. This reflects trait-like dysfunction in the neural networks subserving these functions and these are explored using functional imaging studies. The final chapter of this section considers the role of psychological treatments in the management of bipolar disorder, and in particular the evidence that cognitive behavioural psychotherapy can help to prevent patients relapsing into episodes of illness.

The last section is devoted to management of the illness. Bipolar disorder is clinically heterogeneous and optimal treatment strategies must pay heed to the individual patient's characteristics. Although the number and type of medications available is expanding, important roles remain for lithium and for monotherapy in maintenance treatment. Other issues discussed include the use of antipsychotics and valproate as monotherapy or in combination for the treatment of mania. Novel strategies such as repetitive transcranial magnetic stimulation for bipolar depression and the use of long-term efficacy studies to tailor treatment on the basis of patients' clinical characteristics are also reviewed. The final word from Rachel Perkins communicates a unique perspective since she suffers herself from bipolar disorder and is also employed as a senior manager of mental health services within the UK National Health Service. She discusses the practical problems of living with manic depression which are really of importance to patients, most of which are ignored by standard services, with a focus on the critical issue of protecting employment.

The aim of the EFPM is to provide high-quality postgraduate education in psychiatry. It is an independent body aiming to provide up-to-date knowledge to Europe's foremost clinical and academic professionals in mental health. Eli Lilly and Company provided a non-restrictive educational grant for the conference. This book will be of interest to clinicians and academics within psychiatry, psychology and neuroscience as well as other mental health professionals interested in bipolar disorder. The editors believe that the expert contributions capture the considerable progress that has been made in our understanding of this devastating condition in recent years. We are very grateful to all the contributors and hope that the reader will also be stimulated and informed by the wide range of research approaches that this book encompasses.