Core issues

Bipolar affective disorder is a long-term mental disorder presenting remittent depressive, hypomanic, manic or mixed episodes of illness and low symptomatic or asymptomatic intermediate periods.

Treatment focuses on preventing the recurrence of episodes. The basis for the care of bipolar affective disorder is formed by mood stabiliser medication and second generation antipsychotic medication in accordance with the illness’ current phase.

Patients suffering from bipolar affective disorder are usually cared for in psychiatric specialised health care.

Progress and prognosis

In general, the illness begins in young adulthood but the age can vary from childhood to old age. During hypomanic, and particularly manic episodes, the patient can cause him- or herself serious problems by seeking inappropriate sexual relationships, behaving recklessly in traffic, through reckless substance abuse or by behaving unwisely in financial affairs. Bipolar affective disorder is related to a serious risk of self-destructive behaviour.

A minority of patients suffering from bipolar affective disorder actively seek treatment during the early part of the illness, although during hypomania, patients rarely seek help. In particular, patients suffering from serious and long-term depression seek treatment on their own. During episodes of mania, treatment is sought through the initiative of others and often irrespective of the patient’s will. The delay between the onset of symptoms to the correct diagnosis is approximately eight years.

After its onset, bipolar affective disorder is a chronic illness usually connected to relapsing episodes. Patients typically have symptoms between episodes and suffer from them approximately half of the time. As patients become older, the share of depressive symptoms grows and these symptoms are more typical of type I than type II.

Bipolar affective disorder can also be associated with impairments in executive functioning and linguistic memory. The majority of patients seeking treatment for bipolar affective disorder concurrently suffer from some other psychiatric syndrome.

Diagnosis and differential diagnostics

Bipolar affective disorder should be distinguished from pure depression because the use of antidepressants as a treatment for the depression episodes of a bipolar disorder may turn depression into mania, or change the clinical picture into one in which the illness frequently recurs.

A differential diagnosis is difficult when the bipolar affective disorder begins with an episode of depression. Knowledge of bipolar affective disorder among next of kin may direct the diagnosis towards the correct conclusion. No reliable differential diagnosis based on the clinical picture is possible.

When evaluating patients with depression, you should always ask if the patient has previously presented episodes of elevated activity. For a more accurate screening, the Mood Disorder Questionnaire (MDQ) can be used.

Treatment and rehabilitation

The core treatment of bipolar affective disorder consists of mood stabilising medication (lithium and other mood stabilisers and antipsychotic medication).

The aim of psychosocial care is to support the patient, improve his or her commitment to medical treatment and facilitate recognition of the early symptoms of mood episodes while helping the patient and his or her family cope with the disease.

When treatment is planned, the focal issue is to find out which illness phase is currently underway and to cater for the progress of the illness. To coordinate care, each bipolar affective disorder patient should have a designated case manager. Serious self-destructiveness, psychosis, inability to take care of oneself and the significant weakening of functionality, are often grounds for hospital care. If necessary, hospital care is implemented against the patient’s will, in accordance with the Mental Health Act.

Should outpatient care be estimated as sufficient in the acute phase, the patient’s condition must be monitored through regular meetings every 1-2 weeks, or more frequently if necessary, should there be a significant risk of suicide, for example. The aim of acute care is to render the patient symptom free. After this phase, maintenance care begins. In euthymia, the patient is symptom-free or has only very mild and passing symptoms.

During the monitoring meetings, we recommend that, in addition to a mood diary, the effectiveness of care be evaluated based on indicators of the depression and mania symptoms. A life chart can be used as a tool when monitoring the response to the treatment.

We recommend using the SOFAS scale to evaluate functionality.

Patients suffering from bipolar affective disorder are usually cared for in psychiatric specialised health care.

Working group set up by the Finnish Medical Society Duodecim and the Finnish Psychiatric Association

Kirsi Suominen

Jukka Hintikka

Erkki Isometsä

Olli Kampman

Tuula Kieseppä

Katariina Korkeila

Esa Leinonen

Jorma Oksanen

Marja Pirinen

Marko Sorvaniemi

Annamari Tuulio-Henriksson

Hanna Valtonen