Bipolar Disorder in Singapore
About 1 in 100 Singaporeans suffer from Bipolar Disorder which is characterized by episodes of mania and depression. Like Major Depressive Disorder, it is also a chronic disease of high burden. Bipolar Disorder has a high social impact. Patients with Bipolar Disorder often end up losing their jobs and their marriages. It has also been found that sufferers will take to excessive drinking of alcohol as a result of the illness.
Symptoms of Bipolar Disorder
For a diagnosis of Bipolar Disorder to be made, a person has to have at least one manic or hypomanic (a less severe form of manic episode) episode. However, a patient with Bipolar Disorder can also have depressive episodes not unlike those in Major Depression and he may become suicidal. A patient with Bipolar Disorder can also experience depressive and manic symptoms concurrently in what is known as a Mixed State.
Symptoms of a Manic Episiode in Bipolar Disorder include (based on Diagnostic Statistical Manual 5):
- unusually high or irritable mood for at least one week
- inflated self esteem or grandiosity; thinking that one is more important than he really is
- more talkative than usual or pressured speech
- feeling that thoughts are racing
- easily distractable
- increase activity to make grand and unattainable plans
- reckless behaviours such as spending sprees and impulsive sexual indiscretions
During a manic episode, the affected person will have an unusually high or irritable mood. He or his family may describe him as being “hyper” or “high” and this is not in keeping with his usual self. If presenting with an irritable mood, he may get into unnecessary arguments with the people around him such as his family, friends or colleagues. These mood states are persistent and will last for more than a week. The individual may also experience a variety of other symptoms such as feeling that oneself is especially important or have ability that others do not. He may think that he is an important person and in severe cases, be deluded that he has supernatural power. He may feel that he has less need for sleep and is well rested after only a few hours of sleep. He will experience racing thoughts and may start to talk excessively or talk so fast that others cannot understand him. He is easily distractible and can be hyperactive or restless. Commonly, when suffering from a manic episode, he will engage in pleasurable activities and ignore the risks or consequences, eg. having sex indiscriminately or indulging in spending sprees. During the manic episode, he may also experience psychotic symptoms such as auditory hallucinations and delusions.
Some patients with mania may hear things that are not there or have false beliefs. These usually involve them thinking they have superhuman or godlike abilities. Some may indulge in drugs and alcohol when they are unwell.
Ms W is a 20 year old female. She was studying in the university and was staying in the hostel. Initially, her friends found her to be increasingly talkative and more energetic than usual. She stayed up late at night to complete her project and would sleep an hour a day. Despite this, she continued to tell her friends that her mood was “high” and that she was on top of the world and was full of energy. Her condition worsened and she started putting on very thick makeup and frequented night spots almost every night. Her friends noticed that she was bringing different men back to her hostel room.
One night, she was arrested for swimming in the reservoir naked. The police brought her to a psychiatric hospital where she was involuntarily admitted. In the ward she reported to the psychiatrist that she had acquired special power from heaven and was cleansing herself in the reservoir. Her parents were alerted to the admission and treatment was started. In the ward, she was irritable and agitated at times.
After almost two weeks of treatment with an antipsychotic medication and a mood stabilizer, her condition improved and her mood stabilized. Psychoeducation was provided for her and her family. She was discharged back to her family and was seen at the outpatient clinic.
However, her mood turned low quickly and she felt guilty about being sexually promiscuous when unwell. She was readmitted again for depression after she tried to attempt suicide by overdosing on her medications. Her medications regime was adjusted and she was finally discharged well two weeks later.
The main stay of treatment are mood stabilising medications. Mood stabilizers such as Sodium Valproate, Lithium, and Lamotrigine are effective in Bipolar Disorder. Increasingly, antipsychotic medications, especially the second generation medications such as Olanzapine, Risperidone and Quetiapine has been found to possess mood stabilizing properties and are useful for Bipolar Disorder particularly in children and youths. Occasionally, an antidepressant may be used during the treatment of a depressive episode in Bipolar Disorder. However, the antidepressant is usually tailed off once the mood is lifted as it can potentially switch the patient into a manic state.
Psychological and social interventions are also critical in the treatment of Bipolar Disorder. Providing education to patient and his or her family is crucial in letting them understand the nature of the illness. Often patients have a similar pattern prior to the relapse and this is known as the relapse signature. An example can be a subtle elevation in mood or the onset of poor sleep. Patient and family can be taught to look out for the relapse signature and to seek help early before a full blown episode. Other than education, other forms of therapy such as cognitive behavioural therapy, family therapy or interpersonal social rhythm therapy can be helpful.
In severe manic or depressive episodes, electroconvulsive therapy can be carried out. ECT is effective and can greatly shorten the duration of the acute stage of the illness.