8

Bipolar Disorder

DEFINITION

One of the first descriptions of mania dates from 30AD,[1] but it was not until the conceptual separation of schizophrenia from other psychoses and the description of mania by Kraepelin in 1921 [2] that focused research and attempts to define mania accurately began. The discovery of lithium therapy as an effective treatment for mania argued for the origins of this disorder as being biological. The subsequent research precipitated by these findings revealed bipolar disorder (also known as manic-depressive illness) as a distinct diagnosable condition.

Despite the strong neurobiological indicators that have been discovered for bipolar disorder,[3,4,5 and 6] diagnosis is made on the basis of characteristic symptoms of mood disorder, which include alternating episodes of extreme elevation of mood (mania) and severe depression.[7] Elevated mood can be accompanied by delusions, hallucinations, insomnia, and extreme excitement, and depressive states by persistent low mood or sadness that is accompanied by both physical and psychological symptoms of at least 2 weeks duration and an associated impact on social functioning.

Kraepelin characterized manic psychosis by its periodic course, good prognosis, and mood symptoms in the acute phase.[2] It is important to note that bipolar disorder remains a clinical syndrome and that the neurobiology underlying its causes is not yet fully known. There is at present no biological test or marker that can identify the disease (or a predisposition to it) independently of clinical assessment (e.g., recognizing a family history of the disorder). Both standardized diagnostic mechanisms for disease, the Tenth Revision of the International Classification of Diseases (ICD-10) ,[8] and the (APA) Diagnostic and



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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 8 Bipolar Disorder DEFINITION One of the first descriptions of mania dates from 30AD,[1] but it was not until the conceptual separation of schizophrenia from other psychoses and the description of mania by Kraepelin in 1921 [2] that focused research and attempts to define mania accurately began. The discovery of lithium therapy as an effective treatment for mania argued for the origins of this disorder as being biological. The subsequent research precipitated by these findings revealed bipolar disorder (also known as manic-depressive illness) as a distinct diagnosable condition. Despite the strong neurobiological indicators that have been discovered for bipolar disorder,[3,4,5 and 6] diagnosis is made on the basis of characteristic symptoms of mood disorder, which include alternating episodes of extreme elevation of mood (mania) and severe depression.[7] Elevated mood can be accompanied by delusions, hallucinations, insomnia, and extreme excitement, and depressive states by persistent low mood or sadness that is accompanied by both physical and psychological symptoms of at least 2 weeks duration and an associated impact on social functioning. Kraepelin characterized manic psychosis by its periodic course, good prognosis, and mood symptoms in the acute phase.[2] It is important to note that bipolar disorder remains a clinical syndrome and that the neurobiology underlying its causes is not yet fully known. There is at present no biological test or marker that can identify the disease (or a predisposition to it) independently of clinical assessment (e.g., recognizing a family history of the disorder). Both standardized diagnostic mechanisms for disease, the Tenth Revision of the International Classification of Diseases (ICD-10) ,[8] and the (APA) Diagnostic and

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Statistical Manual, fourth edition (DSM-IV) still rely on the course of the illness (see table 8-1 and table 8-2) [9]: Bipolar I = at least one manic (elevated mood) episode (hypomania = less severe presentation without the need for hospitalization or impediment to occupational or social functioning). Bipolar II = at least one episode of mania or hypomania and a full major depressive episode. In contrast with other psychoses, the psychotic symptoms of bipolar disorder must be congruent with the prevailing elated or depressed mood state. For these purposes, irritability is presumed to be congruent with an elated or elevated mood state. SCOPE OF THE PROBLEM Mortality The evidence clearly reveals the exceedingly high mortality rate from suicide exacted by bipolar disorder. Evidence from developed countries has shown varying rates for attempted suicide of between 25 and 50 percent among patients with the disorder.[10,11] Follow-up studies have found that as many as 15 percent were completed suicides. This rate is approximately 30 times greater than the rate for general populations.[11,12] In developing countries, similar rates of suicide have been observed.[ 13,14] High rates of attempted suicide (24 percent) were found in a study conducted in a psychiatric hospital in Taiwan.[15] An earlier age of onset, interpersonal problems with partners and close family members, and occupational maladjustment rather than demographic characteristics are suggested as collectively identifying those with bipolar disorder at high risk of suicide attempt. Social and Economic Costs In light of the findings of the 1996 Global Burden of Disease study and more recent estimates of the same measurements of disability-adjusted life years (DALYs), neuropsychiatric conditions have been recognized as a significant social and economic burden (see Chapter 2).[16,17] Bipolar disorder is considered to represent 11 percent of the disease burden from neuropsychiatric conditions in low- and-middle income countries. Moreover, within these estimates for low- and middle-income countries, bipolar disorder is estimated to account for a full 1.1 percent of all categories of disease burden. When estimating the disability weight measurements for the Global Burden of Disease study, the burden of bipolar disorder was weighted somewhere between that of paraplegic and quadriplegic physical disability.[16]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 8-1 Overview of the DSM-IV Criteria for Diagnosis of Bipolar Disorder Bipolar Disorder I Bipolar Disorder II Presence of only one manic episode (see Table C) and no past major depressive disorders The manic episode is not better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, of psychotic disorder not otherwise specified. Presence of one or more major depressive episodes (see Table D). Presence of at least one hypomanic episode (see Table E). There has never been a manic episode (see Table C) or a mixed episode (see Table F). The mood symptoms in Criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed in schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. or impairment in social, occupational, or other important areas of functioning. Specify if: Mixed: if symptoms meet criteria for a mixed episode.   Specify (current or most recent episode): Severity/Psychotic/Remission specifiers With catatonic features With postpartum onset. Specify (current or most recent episode): Hypomanic: if currently in a hypomanic episode Depressed: if currently (or most recently) in a major depressive episode.   Specify (for current or most recent major depressive episode only if it is the most recent type of mood episode): Severity/Psychotic/Remission specifiers Chronic With catatonic features With melancholic features With atypical features With postpartum onset.   Specify: Longitudinal course specifiers (with and without interepisode recovery) With season pattern With rapid cycling. Source: [9]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 8-2 Overview of the ICD-10 Criteria for Diagnosis of Bipolar Disorder F.30 Manic Episode Three degrees of severity are specified here, sharing the common underlying characteristics of elevated mood, and an increase in the quantity and speed of physical and mental activity. All the subdivisions of this category should be used only for a single manic episode. If previous or subsequent affective episodes (depressive, manic, or hypomanic), the disorder should be coded under bipolar affective disorder. F.32 Depressive Episode In typical depressive episodes of all three varieties described below (mild, moderate, and severe), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are: reduced concentration and attention; reduced self-esteem and self-confidence; ideas of guilt and unworthiness (even in a mild type of episode); bleak and pessimistic views of the future; ideas or acts of self-harm or suicide; disturbed sleep; diminished appetite. The lowered mood varies little from day to day, and is often unresponsive to circumstances, yet may show a characteristic diurnal variation as the day goes on. As with manic episodes, the clinical presentation shows marked individual variations, and atypical presentations are particularly common in adolescence. In some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression, and the mood change may also be masked by added features such as irritability, excessive consumption of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations. For depressive episodes of all three grades of severity, a duration of at least 2 weeks is usually required for diagnosis, but shorter periods may be reasonable if symptoms are unusually severe and of rapid onset. Source: [8] Bipolar disorder is a chronic disease with high frequencies of relapsing symptoms that often worsen over time, even when appropriate pharmacotherapy is administered.[18] During both manic and depressive states, sufferers are often limited in their social, familial, and employment roles.[19,20] Several recent studies in developed countries found that patients with bipolar disorder had substantial impairment in health-related quality of life in comparison with the general population.[21,22] Bipolar patients were less compromised in areas of physical functioning than chronic back pain patients, but had similar impairment in overall mental health and social functioning.[23] Despite the identification of bipolar disorder early in the 20th century and prevalence rates in developed countries that are higher than those for nonaffective psychoses, less research has been conducted in these countries on this disorder in comparison to other psychiatric conditions (including those discussed elsewhere in this report). In developing countries, an even smaller and similarly inconclusive body of research exists. For the purposes of this report, we include, where applicable, data from one or both settings and where possible make comparisons

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World between them. After reviewing the literature, the committee concluded that more investigation into the etiology of and interventions for bipolar disorder are needed to reduce its long-term debilitating effects. Recent advances in genetic research have greatly increased the potential for unraveling the complex neurobiology of bipolar disorder and meeting the challenges involved in its treatment. PREVALENCE AND INCIDENCE According to the U.S. National Comorbidity Survey,[24] bipolar affective disorder is nearly three times more prevalent than nonaffective psychoses. However, bipolar disorder has not been investigated on the same scale, for example, in a large-scale international comparative study on schizophrenia (such as the study described in Chapter 7), to validate the cross-cultural reliability of diagnosis between developed- and developing-country settings. Nevertheless, in a cross-cultural study that included two developing countries and used a single, standardized diagnostic method, lifetime rates of bipolar disorder were found to be similar across populations (0.3/100 in Taiwan and 1.5/100 in New Zealand).[25] Another study in India using standard DSM-III-R criteria found rates of diagnosis and course of illness in children and adolescents to be similar to the findings in developed countries.[26] However, when comparisons are made both within and between countries the evidence points to some variation in both the incidence and prevalence of the symptoms of bipolar affective disorder.[27,28,29,30,31,32 and 33] In the United States, the Epidemiologic Catchment Area Study used DSM-III criteria.[27] It reported a lifetime prevalence of 2.7 percent for a manic episode. Manic symptoms were more common in the 18,19,20,21,22,23,24,25,26,27,28 and 29 age group and more common in men than women. Yet there was no significant sex difference in actual bipolar disorder. The lifetime prevalence of Bipolar I was 0.8 (0.7 male, 0.9 female), and that of Bipolar II was 0.5 (0.4 male, 0.5 female). There was also no ethnic difference in the rate of these disorders. However, there was a difference in the rates of illness among study sites. Population-based studies in Italy showed a higher 1-year prevalence in women (1.86 percent) than in men (0.65 percent), with an overall Bipolar II rate of 0.2 percent.[28] In Taiwan, the prevalence for a manic episode was found to be between 0.7 and 1.6 percent, depending on whether a city or small town was studied.[29] In Puerto Rico, the prevalence of a manic episode was 0.7 for males and 0.4 for females,[30] and similar rates were found in Alberta, Canada.[31] A study in the Netherlands found much lower rates of 0.1 percent for a manic episode in both genders.[32] Prevalence is dependent not only on the rate of new illness, but also on the availability of medical interventions and social buffers to the development of symptoms. Incidence studies are a better index of illness rates, but there are few such studies. Incidence studies in Scandinavia have reported rates of 9.2–15.2

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World cases per 100,000 for men and 7.4–32.5 cases per 100,000 for females.[33] A retrospective study of hospital admission rates in Denmark and the United Kingdom has been used as a proxy measure for incidence —virtually identical rates of 2.6 per 100,000 were found in both centers.[ 34] A recent WHO study found comparable rates of mood disorders in Mexico and Brazil as compared with the United States, Canada, Germany, and the Netherlands.[35] However, the results included no indication of the proportion of mood disorders that were unipolar and bipolar. Research has shown significant variations among countries in the ratio of unipolar to bipolar illness, but even the most conservative estimate would identify bipolar illness as a significant health problem in the developing countries. Few studies of bipolar disorder have been conducted in developing countries and many of these have offered inconclusive and variable evidence, as illustrated by the examples described below. In India, Brown et al. looked at affective psychosis in Chandigarh and found that all 24 patients with mania experienced full recovery within a 1-year period. At 1-year follow-up, 75 percent of manic patients demonstrated no symptoms or social impairment. The mean episode duration was 10.2 weeks, and the rate of relapse was 21 percent. Overall, these outcomes are considerably more favorable than those found in comparable studies of affective disorders in developed-country settings.[36] Higher rates of bipolar disorder were found among some Indonesian groups and the Hutterites in North America [37] as compared with their overall population rates. Among Jewish people of European background in the United States, the rates are higher than among those of North African background.[38] Bazzoui found that 44 percent of patients admitted with affective disorder in Iraq suffered from bipolar disorder.[39] Though only a fifth of people suffering from affective disorders in Sweden suffer from bipolar disorder, one in three such patients in Jerusalem suffers from the disorder.[40] Khanna et al. investigated the course of bipolar disorder in India. In their consecutive admission sample, they found that recurrent mania was common, and there was a significantly greater frequency of manic compared with depressive relapses.[41] They also found a marked preponderance of male subjects. This finding may have been due in part to their methodology, but this is unlikely to be a complete explanation. It may be that the low female admission rates reflect sociocultural determinants of admission. The greater tendency for men to display aggressive behavior may mean that their symptoms are less well tolerated socially than in females. Moreover, the greater economic impact of men's incapacity to work may influence their admission rate, and the stigma of mental illness in a culture in which marriages are arranged may decrease the rate of female admission.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World RISK FACTORS Genetic Evidence for high aggregates of familial risk and results of recent research conducted in developed countries to elicit genetic linkage in families with bipolar disorder supports the argument for a significant genetic contribution to the etiology of bipolar disorder.[42,43,44,45,46,47 and 48] However, the findings reported to date are inconsistent and larger-scale replication of many of these studies will be required before the evidence is conclusive.[3] Data from a recent French study suggest that early- and late-onset bipolar disorders differ in clinical expression and familial risk, and may therefore foreshadow findings of different subforms of the disorders within genetic research.[49] It is known that there is a 1.5 percent lifetime risk for the children of an affected person, 6 percent for brothers, 4.1 percent for mothers, and 6.4 percent for fathers.[24] In a recent U.S. study, the offspring of parents with early-onset bipolar disorder were found to experience high levels of psychopathology.[ 50] Studies in both developed and developing countries showing high familial risk for bipolar disorder indicate that establishing the diagnosis of a family member with the disorder can be an important factor in attempting to diagnose children who may present with symptoms common to other disorders, such as attentiondeficit hyperactivity disorder as well as adults who may present only with symptoms of unipolar depression.[26,51,52 and 53] Correct diagnosis is, of course, essential to ensure the appropriate course of treatment, which differs significantly among these disorders. Substance Abuse Data from both developed and developing countries countries reveal high levels of comorbidity in bipolar illness. Data collected on bipolar disorder show rates of substance abuse that are 5–6 times greater than those among general populations.[13,54] Three studies found the rate of substance misuse in those with Bipolar I disorder to be over 60 percent, and at least 35 percent of total bipolar disorder cases were complicated by alcohol abuse.[ 24,55] A diagnosis of an underlying bipolar illness may be missed because of the high rate of comorbidity and the more conspicuous signs and symptoms of substance abuse.[56] Strakowski and DelBello's recent review of the existing literature on the co-occurrence of bipolar disorder and substance abuse found evidence to support four distinct hypotheses to explain this association: 1) substance abuse occurs as a symptom of bipolar disorder; 2) substance abuse is an attempt by bipolar patients to self-medicate symptoms; 3) substance abuse causes bipolar disorder; and 4) substance use and bipolar disorders share a common risk factor. The variability in findings from the existing evidence suggests that additional studies to examine the relationship between substance abuse and bipolar disorder are

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World needed. Future studies that increase the understanding of this frequent co-occurrence may eventually provide guidance toward improved prevention and treatment strategies for both conditions.[57] Environmental Several studies have indicated that social conditions and experiences contribute to both the onset and recurrence of relapse in bipolar disorder. Striking urban–rural differences have been found, with the illness being three times more common in urban than in rural populations.[58] It is still unclear whether variations in the rates of mania among different populations are due to genetic loading or societal factors. Associations with Age and Gender Findings of recent studies in developed as well as developing countries estimate the peak age of onset for bipolar disorder between 18 and 24.[26,58,59] Though the age of onset and number of affective episodes of each polarity have not been shown to differ between men and women,[24] some studies have shown that women experience depressive episodes of the disorder more frequently and men have been shown to be at greater risk for manic episodes.[60,61,62 and 63] Several studies have yielded similar findings for childhood-onset bipolar disorder. Irritability was the predominant affective disturbance in younger manic children, but prepubertal bipolar children began their illness with cycles of dysphoria, hypomania, and agitation intermixed, and increasingly extreme cycles of manic and depressive states became more common with the onset of puberty.[64,65] Adolescents who are early into their illness are often prone to highly elevated mood states and grandiose delusions resulting in poor adherence to treatment.[11,53] Similar findings on the course of bipolar disorder in children have been reported in India.[25,51] Factors Affecting Course and Outcome Bipolar disorder is quite disabling because of its recurrent course, frequency of suicidal ideation, and significant impact on social functioning during acute episodes of both polarities.[66] Data on the frequency of variable levels of recurrence are inconsistent, yet telling. An older study found that patients averaged as many as 12 episodes during a 25-year period.[67] Winokur et al. (1994) estimated that over a 10-year period, patients averaged three episodes and five hospitalizations.[68] Even with pharmacological intervention, those suffering one manic episode almost always go on to have another.[69,70] Ongoing and significant symptoms between major episodes occur even in individuals who suffer infrequent acute episodes.[71]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Figure 8-1 Increasing probability of relapse with each episode of manic-depressive illness. Source: [11] Despite the likely significant mortality, morbidity, and burden on families developing countries is very limited. If the epidemiology in the developed world is applicable, the burden in developing countries would be significant. The impact of social and environmental factors on the presentation, course, and incidence of the illness argues for the need for much more work to delineate the treatment needs in developing countries. This work could also lead to vital etiological data that could inform primary prevention interventions in both developed and developing countries. Recommendation 8-1. Research to determine the applicability of current diagnostic methods in the local settings of developing countries should be conducted to better understand the epidemiology of bipolar disorder in developing countries and to ensure the effectiveness of efforts to identify and treat the disease within various health care settings. Research to determine the local risk factors and patterns of heredity for bipolar disorder should also be undertaken to further inform effective courses of intervention.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Recommendation 8-2. Large-scale population-based studies in developing countries should be carried out to expand and validate the findings of previous studies relative to bipolar disorder, particularly in the area of genetic research. The existence of isolated populations and extended family environments in parts of the developing world may provide uniquely appropriate settings for such research. Collaborative efforts between researchers in developing countries and well-equipped research institutions in developed countries should be emphasized, in part to build the research capacity of developing-country centers. INTERVENTIONS Prevention Currently, there is no known method or strategy of primary prevention for bipolar disorder. Even for those at risk because of familial history, no method to eliminate or preempt the origins of the disease exists. Once the disorder has been diagnosed, risk factors and the physical and psychological symptoms can be reduced and controlled, but not eliminated. Nevertheless, research into presymptomatic detection of bipolar disorder is important,[72] and the prospect of prevention is likely to become increasingly realistic with advances in knowledge of the genetic basis for the disorder and its neurodevelopmental pathophysiology. Treatment Though no current data are available, the conspicuous lack of research on bipolar disorder in developing countries would support the argument that effective treatments currently available in developed countries are not reaching those suffering from the disorder elsewhere. Even in developed countries, the treatment of bipolar disorder is underinvestigated. The complexity of the disorder and the variability of its symptoms make clinical treatment a complicated endeavor.[72] Treatment often requires a combination of medications, and caution must be exercised because of the high rate of significant side effects. Because of the lack of available data from developing countries, the following discussion on treatments for bipolar disorder is based on the research literature of developed countries. Where very limited information from developing countries is available, it is noted. The difficulty of clinical diagnosis for bipolar disorder is twofold. First, those who are experiencing the manic phase of the disorder do not usually seek treatment because this period is characterized by highly elevated mood states. Often it is only when patients present with high levels of agitation or aggression that treatment will be pursued. Second, those who seek treatment when experiencing the depressed state of the disorder are frequently diagnosed with unipolar

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World depression. Though bipolar and unipolar disorders are clinically recognized as distinct, the lack of research on distinguishing the pathophysiology of the conditions provides little support for more accurate diagnosis.[41,61] Moreover, the stigma associated with mental illness in developing countries (see Chapter 2) is often a major deterrent in individuals seeking treatment for psychological problems or feelings of emotional distress. For the majority of patients in developed countries, treatment and care need to be provided on a lifelong basis, with periodic reviews of outcome and adjustment of the mix of interventions according to need and the phase of the illness. It is of overriding importance to recognize that the symptoms and behavioral impairments associated with bipolar disorder are shaped by interactions between intrinsic vulnerabilities caused by the disease and the psychosocial environment. Good practice in the management and treatment of bipolar disorder requires addressing both sides of this interaction. TABLE 8-3 Critical Challenges in the Stages of Pharmacological and Psychosocial Treatment Stage Goals of Treatment Issues for Patient/Family Acute Gain control over severe symptoms Trauma and shock, dealing with police and/or hospitalization (in some cases), making sense of what has happened Stabilization Hasten recovery from the acute episode, address residual symptoms/impairment, encourage medication compliance Adapting to post-episode symptoms and social–occupational deficits, financial stress, accepting a regular medication regime, uncomfortable discussions about medication and illness, denial about the realities of the disorder Maintenance Prevent recurrences, alleviate residual affective symptoms, continue to encourage medication compliance Fears about the future, accepting the illness and the vulnerability to future episodes, coping with ongoing deficits in social–occupational functioning, issues surrounding long-term medication adherence SOURCE: [66]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World consider this essential feature of bipolar disorder and engage the system as a whole—the patient, the family, and the community. Programs to limit the chronicity of bipolar disorder should also address substance abuse and suicidal behavior frequently associated with patients suffering from this disorder. Recommendation 8-6. Randomized controlled trials (in the form of large-scale demonstration projects) of pharmacotherapeutic and psychosocial treatments should be conducted to identify locally cost-effective methods of treatment. CAPACITY The generic primary health care model (see Chapter 3) is probably the single most important vehicle for providing essential care within the community to the majority of patients with bipolar disorder in the developing world. The model is well adapted to the acute shortage of medical staff in rural areas and redefines the role of psychiatrists and other mental health professionals as being focused primarily on providing training; designing methodological tools, such as problem detection and treatment guidelines; and offering tertiary consultation.[27,28,29 and 30] The primary health care model has been implemented in a number of developing countries. The lack of systematic data collection and exchange of information across the developing world, however, makes it impossible to determine if bipolar disorder is being properly diagnosed or treated within these settings. The findings of large-scale epidemiological studies would inform the process of priority setting and health planning for developing countries. Currently, the high prevalence and significantly disabling effects of bipolar disorder, found in developed countries and a limited number of developing countries along with the disproportionately high rates of suicide associated with the disease, argue for placing effective interventions on the public health agenda of national and local planners. Recommendation 8-7. Randomized controlled trials of the efficacy and feasibility of affordable community-based management programs for those with bipolar disorder (within the context of the extended health care system) should be conducted to determine the most appropriate programs for treatment. Using the evidence from developed countries as a guide, initial trial programs should have three specific aims: Reduce the frequency of manic and depressive relapses; Reduce the risk of premature mortality due to suicide; and Reduce stigma, and protect the patient's human rights.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Such a program should involve at least three operational components: Adaptation of existing screening and diagnostic tools for bipolar disorder, with a view to accounting for differences in the local presentation of the disorder and making them suitable for use by personnel in the primary care setting. Pharmacological treatment, with specific guidelines for symptom control in acute episodes, maintenance of stabilization and prevention of relapse, and means of ensuring adherence to the treatment protocol. Mobilization of family and community support, including providing education on the nature of the disorder and its treatment, involving the family in simple problem-solving training, and involving the local community in providing a supportive and nonstigmatizing environment. REFERENCES 1. F. Adams. The extant works of Aretaeus, the Cappadocian. London, The Syndenham Society 1856. Reprinted in the Classics of Medicine Library Series. Gryphon Editions Inc.: Birmingham, AL, 1990. 2. E. Kraepelin. Manic-depressive insanity and paranoia. E&S Livingstone: Edinburgh, 1921. 3. C. Friddle, R. Koskela, K. Ranade, J. Hebert, M. Cargill, C.D. Clark, M. McInnis, S. Simpson, F. McMahon, O.C. Stine, D. Meyers, J. Xu, D. MacKinnon, T. Swift-Scanlan, K. Jamison, S. Folstein, M. Daly, L. Kruglyak, T. Marr, J.R. DePaulo, and D. Botstein. Full-genome scan for linkage in 50 families segregating the bipolar affective disease phenotype. American Journal of Human Genetics 66:205–215, 2000. 4. D.H.R. Blackwood, L. He, S.W. Morris, A. McLean, C. Whitton, M. Thomson, et al. A locus for bipolar affective disorder on chromosome 4p. Nature Genetics 12:427–430, 1996. 5. E.I. Ginns. A genome-wide search for chromosomal loci linked to bipolar affective disorder in the Old Order Amish. Nature Genetics 12:431–435, 1996. 6. N.B. Freimer, et al. Genetic mapping using haplotype, association and linkage methods suggests a locus for severe bipolar disorder (BPI) at 18q22–q23. Nature Genetics 12:436–441, 1996. 7. A.L. Stoll, M. Tohen, Baldessarini, D.C. Goodwin, S. Stein, S. Katz, et al. Shifts in the diagnostic frequencies of schizophrenia and affective disorders from 1972 through 1998; A combined analysis from four North American psychiatric hospitals. American Journal of Psychiatry 151:130–132, 1994. 8. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. World Health Organization: Geneva, 1992. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association: Washington D.C., 1994.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Summary of Findings: Depression in Developing Countries Depression, estimated to be the leading cause of disability worldwide, accounts for more than 1 in 10 years of life lived with disability, as well as for significant premature mortality due to suicide and physical illness. By 2020, unipolar major depression will rank second only to ischemic heart disease as the leading source of disease burden worldwide. Major risk factors for depression appear similar in developed and developing countries and include family history of the disease, life events, chronic social adversity, poverty, and gender. The course of depression is influenced by several factors, including the type, causes, severity, duration prior to treatment, and underlying presence of chronic minor depression. Depression in children and adolescents is often chronic and continues into adulthood with higher rates of overall impairment and significant rates of attempted suicide. Because depression typically results from a combination of causes, effective prevention and treatment demands a multifaceted approach. In developing countries, this may translate into a combination of health care, health education, community care, and socioeconomic development. Effective pharmacotherapies and psychosocial treatments exist for depression. Though no treatment has been shown to cure all forms of the illness, a large number of efficacious and low-cost treatments are available.