COURSE AND

OUTCOME OF BIPOLAR
DISORDER
Dr. Sachin N.S

Dept. of Psychiatry
Govt. Medical College,
Thrissur
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 INTRODUCTION
• Chronic and recurrent psychiatric illness with a
lifetime prevalence of just under 4%.
• 6th leading cause of disability worldwide
• The natural course – constant risk of
recurrences over a patient’s life span.

• While considered to have a more favorable

prognosis than schizophrenia, it is not
uncommon for BD to include persisting
alterations of psychosocial functioning
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DISORDER LIFETIME PREVALENCE

Bipolar 1 disorder 0 - 2.4%

Bipolar 2 disorder 0.3 - 4.8%

Cyclothymia 0.5 - 6.3%

•
Hypomania 2.6 - 7.8%

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 BRIEF HISTORY
• Farlet-1851: “folie circulaire”: manic and melancholic
episodes separated by symptom free intervals

• Baillarger-1854: “folie a’ double forme” (dual form

insanity)

• Kraeplin-1899: Manic Depressive Insanity

– Envisaged a continuum between manic and
depressive states.
– His unitary view of mood disorders dominated
psychiatry until the late 1960s.
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 BRIEF HISTORY
• In the 1970s, the Bipolar-Unipolar dichotomy
replaced it : first in the research literatures of Karl
Leonhard (1957), Jules Angst (1966), George
Winokur (1969), Paula Clayton (1969)

• Formally introduced into diagnostic classifications in

1980 with the publication of DSM–III and has been
carried forward.
• However, the concept of bipolar spectrum, originally
representing a minority position, is gaining
momentum (Hagop Akiskal). 5
 ONSET
• Bipolar disorder clearly manifests earlier than
recurrent depression (by about 10 year).

• Bipolar-I disorder manifests earlier than

bipolar II and psychotic bipolar disorder.

• Late onset bipolar disorder: Rare; may be

associated with specific neuropathology
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 ONSET
• Bipolar disorder generally begins during
adolescence but may start earlier

• Age of onset between 15 and 19(Mean =18) in

epidemiological studies; studies in hospitalized
patients the date of onset is in early twenties
or even thirties.

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Gender Differences in Course & Outcome

• Women have more depressive episodes(2x)

• Men have more manic episodes.

• Mixed picture more seen in Women.

• Bipolar I are equal prevalence

• Women predominate among rapid cyclers

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 DURATION OF EPISODES
• From data collected before advent of mood
stabilizers and antidepressants median length
of manic episode calculated to be about 4-5
months (Mendel, Ziehen)

• Similar duration obtained in recent studies also

• Episode Duration decreases with increasing

number of episodes. (Subramanian K, Kattimani S)
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 RECURRENCE
• In both bipolar and unipolar depression the
time from the first to second episode is on an
average much longer than that from second to
third

• The progressive shortening of cycles then

levels off and fluctuates around a certain
individual limit.

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 RECURRENCE
• Precipitating events play an important role in
the first few affective episodes, thereafter
episodes become more autonomous.
• Stressors may not only precipitate episodes, but
also increase a pre-existing vulnerability
(kindling effect).
• In bipolar illness there is no difference in quality
of stressors precipitating depressive vs manic
episodes.
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 RECURRENCE
• The pattern of recurrence is irregular

• In a 22-26 year follow up study, bipolar patients

experienced a median of 10 episodes.

• 0.44 episodes per year in bipolar

• Patients having mixed features have higher

recurrence rates than pure manics
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COURSE & OUTCOME

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• Studies of the course and prognosis of mood
disorders have generally concluded that mood
disorders tend to have long courses and that
patients tend to have relapses.
• Although mood disorders are often considered
benign in contrast to schizophrenia, they exact
a profound toll on affected patients.

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 BIPOLAR I
• Bipolar I disorder most often starts with
depression (75% in women, 67% in men) and is
a recurring disorder.
• Most patients experience both depressive and
manic episodes, although 10 to 20 percent
experience only manic episodes.
• it is often useful to make a graph of a patient's
disorder and to keep it up to date as treatment
progresses
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• The manic episodes typically have a rapid onset
(hours or days) but may evolve over a few weeks.
• An untreated manic episode lasts about 3 months
• 90% are likely to have another after a single manic
episode.
• The time between episodes often decreases during
course
• After about 5 episodes, however, the inter-episode
interval often stabilizes at 6 to 9 months.
• 5 to 15 percent have four or more episodes per
year – RAPID CYCLERS
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 BIPOLAR I DISORDER IN CHILDREN AND
OLDER PERSONS.
• The incidence of bipolar I disorder in children
and adolescents is about 1%
• Onset can be as early as age 8 years.
• About 90% have symptoms that persist into
adulthood
• Children and adolescents with bipolar disorder
almost always have comorbid disorders (ODD,
conduct disorder, ADHD) – Start earlier than
manic symptoms
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• Psychotic symptoms are more common
• Associated with a POOR PROGNOSIS,
refractory to treatment.

• The onset of true bipolar I disorder in older

persons is relatively uncommon. – Non-
psychiatric medical conditions, dementia, and
delirium,

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 OUTCOME
• Patients with bipolar I disorder have a poorer
prognosis than do patients with major
depressive disorder.
• About 40 to 50 % of patients with bipolar I
disorder may have a second manic episode
within 2 years of the first episode
• Only 50 to 60 percent of patients achieve
significant control of their symptoms with
lithium.
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 POOR PROGNOSTIC factors

• Premorbid poor occupational status

• Alcohol dependence
• Psychotic features
• depressive features
• Interepisode depressive features
• Male gender

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• BETTER OUTCOME -:
– Short duration of manic episodes
– Advanced age of onset
– Fewer suicidal thoughts
– Fewer coexisting psychiatric or medical problems.

• Lithium prophylaxis improves the course and

prognosis

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LONG TERM OUTCOME STATISTICS
• Only 7% of patients with bipolar I disorder do not
have a recurrence of symptoms;
• 45% have more than one episode,
• 40% have a chronic disorder.
• Patients may have from two to 30 manic
episodes, although the mean number is about
nine.
• About 40 percent of all patients have more than
ten episodes.
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LONG TERM OUTCOME STATISTICS
– 15 percent of all patients with bipolar I
disorder are well,
– 45 percent are well but have multiple
relapses,
– 30 percent are in partial remission,
– 10 percent are chronically ill.
– One third of all patients with bipolar I
disorder have chronic symptoms and
evidence of significant social decline
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 BIPOLAR II
• The course and prognosis of bipolar II disorder
indicate that the diagnosis is stable 5 years
later.
• Warrants long-term treatment strategies
• Bipolar-II has a better outcome than bipolar-I
in terms of re-hospitalizations…(Coryell et al)
• Episode frequency is comparable between
Bipolar-I and bipolar-II

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 Course of Bipolar disorder in rural India
Chopra MP, et al., NIMHANS. 2006

Community based cohort of 34 patients followed up longitudinally after

8 years

 26% refused any pharmacological treatment - rapid cycling occurred

more often in them

 72% mania, similar to developing countries

 5 (17%) had a single manic episode

 Patients without rapid cycling: 0.22 episodes/ yr

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 MAJOR DEPRESSIVE DISORDER
• The first depressive episode occurs before age 40
years in about 50 % of patients
• Exhibits significant depressive symptoms before the
first identified episode – scope for early identification
• An untreated depressive episode lasts 6 to 13
months; most treated episodes last about 3 months.
• Patients tend to have more frequent episodes that
last longer as course progresses.
• Over a 20-year period, the mean number of episodes
is 5 or 6.
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 DEVELOPMENT OF MANIC EPISODES.

• About 5 to 10 percent of patients with an

initial diagnosis of MDD have a manic episode
6 to 10 years after the first depressive
episode.
• The mean age for this switch is 32 years.
• Often occurs after 2 to 4 depressive episodes

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 FEATURES PREDICTIVE OF BIPOLAR
DEPRESSION
• Early onset
• Hypersomnia.
• Rapid Onset & Offset
• Psychomotor retardation.
• >5 episodes
• Psychotic symptoms.
• H/O postpartum episodes.
• Family history of bipolar I disorder.
• Loss of efficacy of Anti Depressants
• H/O antidepressant-induced hypomania.
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 GOOD PROGNOSIS
• Mild episodes.
• Absence of psychotic symptoms.
• Short hospital stay
• Solid Friendships during adolescence,
• Stable family functioning
• Sound social functioning
• Absence of a comorbid psychiatric disorder & of a Personality
Disorder,
• No more than one previous hospitalization for major depressive
disorder,
• An advanced age of onset.

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 BAD PROGNOSIS
• Coexisting dysthymic disorder.
• Abuse of alcohol and other substances
• Anxiety disorder symptoms.
• A history of more than one previous
depressive episode

• Men are more likely than women to

experience a chronically impaired course.
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 REFERENCES
• CTP 11TH EDITION
• SYNOPSIS 11TH EDITION
• SHORTER OXFORD TEXTBOOK OF PSYCHIATRY
• STEPHEN M. STAHL
• VARIOUS ARTICLES AND REVIEW ARTICLES

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THANK YOU…
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