Treatment Considerations for Patients Experiencing Rapid-Cycling Bipolar Disorder

Perspectives in Psychiatric Care, Feb 2006 by Antai-Otong, Deborah

Question: I work with several patients who have frequent "mood swings" and they are poor responders and have responded poorly to lithium which I initiated 6 months ago. Initially their symptoms remitted, but they have not achieved optimal response to current treatment. Are they considered "rapid cyclers" or just poor responders to current treatment? Please explain "rapid cycling" bipolar disorders and treatment considerations.

Deborah Antai-Otong responds: It is difficult to answer your question without more information about the frequency of mood episodes, length of euthymia, or their psychiatric and medical history. However, the following discussion may clarify rapid-cycling bipolar disorder and treatment considerations.

What is Rapid-Cycling Bipolar Disorder?

This term is actually a specifier of bipolar disorders. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000), this specifier is applicable to both bipolar I and II disorders. An essential characteristic of a rapid-cycling bipolar disorder is the incidence of four or more syndromal depressive, manic, or hypomanic episodes per 12 months. Episodes can occur in any combination or sequence. But must meet clinical criteria both the duration and symptom for a major depression, manic, mixed, or hypomanic episode with distinct separate periods of either a period of full remission or partial or a switch to an episode opposite polarity (e.g., manic, depressed, hypomanic). The episode of rapid-cycling is seen as a biological marker for high risk of recurrence and resistance to traditional pharmacotherapy (Calabrese, Rapport, Findling, Shelton, & Kimmel, 2000). Rapid-cycling bipolar disorder differs little from other bipolar disorders except for the frequency or mood counts towards distinguishing a rapid-cycling pattern (APA, 2000).

Prevalence

About one in six patients who seek treatment for bipolar disorder have a rapid-cycling pattern (APA, 2000). The prevalence of rapid-cycling bipolar disorders varies, with incidence ranging from 13 to 56% (Joffe, Kutcher, & MacDonald, 1988; Tondo, Baldessarini, Hennen, & Floris, 1998). Findings from a meta-analysis (n = 20 clinical studies) comparing rapid-cycling with non-rapid-cycling bipolar disorder indicated the incidence of rapid-cycling bipolar disorder in unselected research populations is approximately 16.3% and significantly higher incidence in females and bipolar II disorder (Kupka, Luckenbaugh, Post, Leverich, & Nolan, 2003; Maj, Pirozzi, Formacola, & Tortrella, 1999). These data support other studies that show that women comprise 70 to 90% samples of rapid-cyclers (Calabrese et al., 2000).

Consistent findings confirm that patients with rapid-cycling bipolar disorder are also more likely to suffer from bipolar II than bipolar I disorders; experience more severe illness, with a dominance of depression (Calabrese et al., 2001; Schneck, Miklowitz, Calabrese, Allen, & Thomas, 2004); begin cycling at a younger age (before 17 years of age); have comorbid drug or alcohol use (McElroy et al., 2001); are poor responders to conventional pharmacotherapy; and have a higher incidence of serious suicide attempts (Coryell et al., 2003) than non-rapid-cyclers.

Pathophysiology

The phenomenon of rapid-cycling is grounded in several assumptions. The first assumption is the kindling theory, in which rapid-cycling is linked to sensitization caused by repeated episodes (Post, 1992). Sustained changes produced by recurrent illness may also be predictive of rapid-cycling bipolar disorder. There are inconsistent data about the kindling theory and predictability of rapid-cycling bipolar disorder. Rapid-cycling bipolar disorder has also be associated with antidepressant use during a depressive episode and thus believed to increase vulnerability to phase shifting (Coryell, 1993). Finally, inconsistent data link hypothyroidism (Esposito, Prange, & Golden, 1997; Kupka et al., 2002), steroid hormones (Becker, Rasgon, Marsh, Glenn, & Ketter, 2004; Price & DiMarzio, 1986), the use of antidepressants and drug or alcohol use to rapid-cycling.

Treatment Considerations

Prior to implementing a plan of care for patients presenting with rapid-cycling bipolar disorder the nurse must make a differential diagnosis based on a comprehensive psychiatric evaluation and physical examination that includes questions about prescribed and over-the-counter medications, treatment compliance, substance abuse, and treatment history. (See Table 1, Suggested Diagnostic Studies.)

Additional Medical Information

* A history of previous drug rash or dermatological problems

* Method of birth control

* Mood changes during menstrual cycles, pregnancies, postpartum, premenopause, and menopause

Initially general medical conditions, such as hypothyroidism and substance-related disorders that may contribute to rapid-cycling, must be treated. Anti-depressants must be tapered when possible if identified as a causative factor and mood stabilizers must be slowly titrated to prevent mood destabilization.