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Dr. Bill Ellien, North Mississippi Medical Center

According to the National Institute of Mental Health, approximately 5.7 million adults suffer from bipolar disorder — some 2.6 percent of the population over age 18. Though treatable, the disease has so far proven to be incurable.

"Surgeons can often cut out a disease and throw it away, in effect," said Dr. Grayson Norquist, professor of psychiatry and chair of the Department of Psychiatry at the University of Mississippi Medical Center (UMC). "Some diseases we can put into permanent remission — but not bipolar disorder. Still, it is easier to treat than, say, schizophrenia. There is greater hope of improved functionality."

Such a mixture of challenges and hopes is typical of physicians, like Norquist, who help patients manage this troubling psychiatric disease.

One of the greatest challenges with bipolar disorder is that it is notoriously difficult to assess. "In the United States," said Dr. Bill Ellien, a psychiatrist at North Mississippi Medical Center (NMMC), "there is a strong bias of under-diagnosing bipolar disorder. In fact, studies show that only about 20 percent of patients will be correctly diagnosed."

Ellien observes that often when patients with bipolar disorder are first diagnosed, they appear to be suffering from severe depression. "It's tragic," he said, "but about 31 percent of these patients are treated for depression. The tragedy is that antidepressants by themselves can trigger and exacerbate the cycling between moods that characterizes bipolar disorder."

On the other hand, a patient who is being diagnosed while in the manic phase basically appears as "a caricature of a 'type A' personality," Ellien noted. He observed that basically, if one is not viewing the behaviors in the overall context of a mood disorder, then it is very difficult to make the correct diagnosis.

In terms of the medications involved in treatment, there are both positive and negative aspects. Certainly, there is now an astounding array of medications available to help manage the symptoms of the disease, from Lithium® and other mood stabilizers, to antidepressants and anticonvulsants, to the so-called atypical antipsychotic medications, such as clozapine, olanzapine, and risperidone.

The case of these atypical antipsychotics is actually somewhat typical of the ambiguities inherent in managing bipolar disorder. They may be brought into play when a patient is not responding well to Lithium or an anticonvulsant, for example, and they can be quite effective. But they can be enormously expensive (in some cases as much as 10 times the cost of older antipsychotic medications), and their side effects can be significant.

Norquist — who was the director of the division at NIMH that initiated the implementation of CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness), as well as STAR*D (for depression) and STEP-BD (for bipolar disorder) — said, "The message about CATIE is that, on average, all the drugs are fairly similar in terms of symptom relief, but side effect profiles differ considerably. For any individual patient, there may be significant benefit from using, say, one of the newer drugs as opposed to an older one."

Ellien notes that in dealing with the atypical antipsychotics, it is especially important to take into account preexisting metabolic disorders, such as cholesterol levels or diabetes. "For example," he said, "the incidence of diabetes is about 8 percent in the general population; this rate must be doubled or even tripled for patients with bipolar disorder and schizophrenia."

He also notes another challenge with bipolar disorder: the fact that the illness often coexists with some form of addictive illness. He said that this is the case in approximately 50 to 60 percent of men with the disease, and with 30 to 35 percent of women with the disease. "The trap here," said Ellien, "is the tendency to think of one condition as causing the other, so that you treat just one, thinking that both conditions, the bipolar disorder and the addictive illness, will be cured. In fact, you can worsen both conditions if you treat just one."

Finally, physicians are still struggling to determine exactly the best way to handle the depressive phase of this illness. Typically, while treatment often involves the use of antidepressants, the patient receives other drugs to keep the antidepressants from triggering increased mood cycling. "We're tending to move away from using antidepressants because of the longer-term context," said Ellien. "Antidepressants increase mood cycling and can make things even worse."

In fact, Norquist observes that, over the long haul, treatment of the depressive phase is particularly difficult because the patients tend to relapse into this phase more than into the manic phase over time. Making matters harder for physicians is that it is quite challenging to develop effective clinical trials because of the polarity inherent in the disease and a relative lack of specialized analysts.

Still, despite the complexities, challenges, and ambiguities of treating bipolar disorder, Ellien sees reason for hope. "In general, there has been more and more education about major psychiatric disorders," he said. "In terms of diagnosis, we are seeing more and more recognition of the disease by physicians."

Norquist, too, is optimistic. "After 20 years of study, we have seen that patients don't relapse as often as we thought they would," he said. "If we treat them well with what we have good reason to think is going to work, then patients tend to do well."

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