Treatment of Prodromal Bipolar Disorder

Long-term pharmacotherapy should be initiated after a single manic episode, together with psychosocial support.6 Lithium monotherapy is a first-line treatment, effective against both manic and depressive relapse. Combination treatment is recommended when monotherapy fails or subsyndromal symptoms are ongoing. Adjunctive antimanic agents (e.g., valproate and/or antipsychotics] for manic symptoms, and lamotrigine or quetiapine for predominantly depressive symptoms should be utilized.6 Antidepressant monotherapy is not recommended, due to increased risk of manic switch. Helpful nonpharmacologic interventions include cognitive behavioral therapy (CBT) and psychoeducation.6

The authors conclude, “a substantial and growing body of evidence exists that bipolar disorder . . . has a number of early clinical, biological, and neuropsychological features, which may represent a prodromal state and predict onset of the disorder.” They note that early diagnosis and treatment of BD may introduce “stigmatization and unnecessary side effects from the use of potentially harmful psychotropic medication.” However, “the benefits of robust early identification and intervention services are likely to outweigh these possible disadvantages.”

References

1.    McIntyre RS. Long-term treatment of bipolar disorder in adults. J Clin Psychiatry. 2011;72(2):e06.


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2.    Howes OD, Falkenberg I. Early detection and intervention in bipolar affective disorder: targeting the development of the disorder. Curr. Psychiatry Rep. 2011;13(6), 493–499.

3.    Smith DJ, Ghaemi N. Is underdiagnosis the main pitfall when diagnosing bipolar disorder?BMJ. 2010;340:c854.

4.    Angst J, Azorin J-M, Bowden CL, et al. Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode. Arch Gen Psychiatry. 2011;68(8):791-799.

5.    Leboyer M, Kupfer DJ. Bipolar disorder: new perspectives in health care and prevention. J Clin Psychiatry. 2010;71(12):1689-1695

6.    Martin DJ, Smith DJ. Is there a clinical prodrome of bipolar disorder? A review of the evidence. Expert Rev Neurother. 2013;13(1):81-98.

7.    Skjelstad DV, Malt UF, Holte A. Symptoms and signs of the initial prodrome of bipolar disorder: a systematic review. J. Affect. Disord. 126(1–2), 1–13 (2010).

8.    Morriss R. The early warning symptom intervention for patients with bipolar affective disorder. Adv Psychiatr Treat. 2004;10:18-26.

9.     Perugi G, Fornaro M, Marennani I, et al. Discriminative hypomania checklist-32 factors in unipolar and bipolar major depressive patients. Psychopathology. 2012;45(6):390-398.

10. Mitchell PB, Ball JR, Best JA, et al. The management of bipolar disorder in general practice. Med J Aust. 2006;184(11):566-570.

11. Hirschfeld RMA. et, al. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. Am J Psychiatr. 2000, 157:1873-1875.

12. Ghaemi NS, Miller CJ, Berry DA. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Disord. 2005 Feb;84(2-3):273-297.