Evidence and implications for early intervention in bipolar disorder

Abstract

Aims: To review the evidence that supports early intervention in the treatment of bipolar disorder.

Background: Bipolar disorder is a pleomorphic condition, with varying manifestations that are determined by a number of complex factors including the “stage” of illness. It is consequently a notoriously difficult illness to diagnose and as a corollary is associated with lengthy delays in recognition and the initiation of suitable treatment.

Methods: A literature search was conducted using MEDLINE augmented by a manual search.

Results: Emerging neuroimaging data suggests that, in contrast to schizophrenia, where at the time of a first-episode of illness there is already discernible volume loss, in bipolar disorder, gross brain structure is relatively preserved, and it is only with recurrences that there is a sequential, but marked loss of brain volume. Recent evidence suggests that both pharmacotherapy and psychotherapy are more effective if instituted early in the course of bipolar disorder, and that with multiple episodes and disease progression there is a noticeable decline in treatment response.

Conclusions: Such data supports the notion of clinical staging, and the tailored implementation of treatments according to the stage of illness. The progressive nature of bipolar disorder further supports the concept that the first episode is a period that requires energetic broad-based treatment, with the hope that this could alter the temporal trajectory of the illness. It also raises hope that prompt treatment may be neuroprotective and that this perhaps attenuates or even prevents the neurostructural and neurocognitive changes seen to emerge with chronicity. This highlights the need for early identification at a population level and the necessity of implementing treatments and services at a stage of the illness where prognosis is optimal.

Keywords:

• Diagnosis
• early intervention
• bipolar disorders
• mania depression
• neuroprotection

Acknowledgements

Michael Berk has received Grant/Research Support from Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Organon, Novartis, Mayne Pharma and Servier, has been a peaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Pfizer, Sanofi Synthelabo, Servier, Solvayand Wyeth, and served as a consultant to Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck and Servier. Melissa Hasty has worked on clinical trials sponsored by Eli Lilly and Astra-Zeneca and will be presenting a poster at the AACBT conference in Melbourne. In the last five years, Christos Pantelis has received grant support from Janssen-Cilag, Eli Lilly, Hospira (Mayne), Astra Zeneca. He has provided consultancy to Janssen-Cilag, Eli Lilly, Hospira (Mayne), Astra Zeneca, Pfizer, Schering Plough. He has undertaken investigator initiated studies supported by Eli Lilly, Hospira, Janssen Cilag and Astra Zeneca. His research work has received major support from National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC), as well as AE Rowden White Foundation, Ramaciotti Foundation, Victorian Neurotrauma Initiative, Australian Nuclear Science & Technology Organisation (ANSTO), Melbourne Health and The University of Melbourne. Brendan Murphy has received Grant/Research Support from Diabetes Australia, Heart Foundation, Eli Lilly and Sanofi. He has participated in clinical trials sponsored by Sanofi, Eli Lilly, Astra Zeneca, Jannsen and Lundbeck. He has been a speaker for Bristol Myers Squibb, Lundbeck and Pfizer. Eduard Vieta has received gran support, consultancy fees, or CME-accredited speaking-related honoraria from the folloing companies: Almirall, Astra-Zeneca, Bial, Bristol-Myers-Squibb, Esteve, Glaxo-Smith-Kline, Forest Research Institute, Janssen-Cilag, Jazz, Johnson & Johnson, Lilly, Lundbeck, MSD, Novartis, Organon, Otsuka, Pfizer, Pierre-Fabre, Sanofi-Aventis, Servier, Schering-Plough, Takeda, Solvay, United Biosource Corporation, and Wyeth. Seetal Dodd has received Grant/Research Support from Stanley Medical Research Foundation, NHMRC, Beyond Blue, Geelong Medical Research Foundation, Rotary, Eli Lilly, Organon, Novartis, Mayne Pharma and Servier, and has been a speaker for Eli Lilly.

Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.