50 - Rapid cycling bipolar affective disorder

Rapid-cycling bipolar affective disorder

316 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 2 Rapid-­cycling bipolar affective disorder Rapid-­cycling bipolar affective disorder is usually defined as bipolar disorder in which four or more episodes of (hypo-­)mania or depression (or four clear switches in polarity) occur in a 12-­month period. It is generally considered to be less responsive to drug treatment than non-­rapid-­cycling bipolar illness1 and entails considerable depressive morbidity and suicide risk.2 Bipolar patients with rapid cycling have more depressive morbidity, a higher incidence of anxiety disorders, addiction, bulimia and borderline personality disorder, as well as atypical features during depression and symptoms such as irritability, risky behaviour, impulsivity and agitation. Rapid-­cycling patients have poorer overall functioning, more obesity and are treated with a greater number of drugs.3 Drug doses tend to be somewhat higher in rapid-­cycling than in other bipolar patients.4 Recent electroconvulsive therapy (ECT) treatment is associated with greater risk of rapid cycling.5 Table 2.8 outlines a treatment strategy for rapid cycling based on rather limited data and few direct comparisons of drugs.6 This strategy is broadly in line with the findings of published systematic reviews.7,8  NICE concluded that there is no evidence to support rapid-­cycling illness being managed any differently from that with a more conventional course.9 There is no formal first choice agent or combination –­ prescribing depends partly on what treatments have already been used to prevent or treat mood episodes. Lithium is less likely to be effective in rapid cycling than in non-­rapid cycling,10 a finding supported by psychiatrists’ experiences.11 In practice, response to treatment is sometimes idiosyncratic: individuals may show significant response to a particular drug. Spontaneous or treatment-­related remissions occur in around a third of rapid cyclers12 and rapid cycling may come and go in many patients.13