Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

Displaying 1-8 out of 8 published

10 April 2014

This is a very interesting review of bipolar disorder. However, more needs to be said on the reasons of noncompliance to medication among patients with bipolar disorder. Patients´perspective should be taken into account, and management of bipolar disorder needs understanding of patients´viewpoints. Plenty of useful information available online on this topic: Bipolar expert info ( and national institute of mental health (

Competing interests: None declared

Peyman Fazeli, psychiatrist

Beheshti University, Beheshti Uni, Tehran

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Interesting article. I read a systematic review on psychosocial management of bipolar disorder by Dr Eden Fazel ( which compared different modes of therapy and their effectiveness compared to standard pharmacotherapy alone, and the results were staggeringly different. I suspect it is time for all of us to be more open minded and combine different methods to help long term remission of an illness that is preventable with good care.

Competing interests: None declared

Nick Netto, Psychotherapist

Private, Newcastle NE4 5AB

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I found this article really interesting and informative but was disappointed to read the perinatal section. The chances of women suffering from relapses of bipolar disorder in pregnancy and suffering puerperal psychosis (PP) consequently are significantly raised, yet this specific diagnosis was not mentioned, just psychosis vs depression. I think PP should be specifically identified and the familial link highlighted.1

Recent media coverage has shown the devastating consequences when PP is not picked up, arguably this case may well not have been linked with bipolar disorder but it highlights the fatal and awful outcome that PP can present. 2

PP has a direct impact on the mother and the safety of the mother and child, not to mention later bonding and developmental affects to the child. These high risk women need to be made aware of the increased risk of developing PP and need multidisciplinary intervention as soon as possible and preconception advice as mentioned. It is imperative that trusts offer a dedicated perinatal mental health service and ideally access to mother and baby units (MBU) when appropriate. An area we all know is currently a postcode lottery. These dedicated services can then offer the important advice regarding preconception which in keeping with this article is a very difficult area with hard choices to make regarding risks to the developing foetus but also to mother perinatally. Mothers may also benefit from information of organisations offering invaluable support to the dilemmas faced regarding conception and pregnancy.3

1. Am J Psychiatry 2001;158:913-917. 10.1176/appi.ajp.158.6.913
2. (accessed 31/01/13)

Competing interests: None declared

Victoria A Ribbons, Final Year Medical Student

Peninsula College of Medicine and Dentistry, PCMD, Knowledge Spa, RCHT, TR1 3LJ

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Anderson and colleagues [1] state “Bipolar 1 disorder has a heritability of 0.75 explained largely by common variant alleles, which partly overlap with those of schizophrenia”. In fact very little of the heritability of bipolar disorder is explained by common polymorphisms. The largest genome wide association study (GWAS) of bipolar disorder[2] with 4387 cases and 6209 controls revealed an odds ratio of 1.45 for ANK3 (a gene involved in the function of voltage gated sodium channels) and 1.18 for CACNA1C (a gene which encodes a protein which is part of a voltage dependent calcium channel). Only the former achieved the GWAS threshold significance of less than 5 X 10-8.

The genetic basis of both bipolar disorder and schizophrenia is likely to be explained by the synergistic interaction of a small number of rare heterozygous deleterious mutations rather than the interaction of common variant alleles (3, 4). This will be revealed in the next generation of genetic studies using whole exome or whole genome screening.

Frances S Price
Medical Student
Faculty of Health and Medicine
Lancaster University

James A Morris
Consultant Pathologist
Associate Director of Undergraduate Medical Education
University Hospitals of Morecambe Bay NHS Foundation Trust
Royal Lancaster Infirmary
LA1 4RP.

The authors state they have no conflicts of interest

1. Anderson IA, Haddad PM, Scott J. Bipolar disorder. BMJ 2013;346: 27 – 32.
2. Ferreira MAR, Meng YA, Jones IR et al. Collaborative genome-wide association analysis supports a role for ANK3 and CACNA1C in bipolar disorder. Nat Genet 2008; 40; 1056 – 58.
3. Morris JA. Synergistic interaction of heterozygous deletions impairs performance and confers susceptibility to disease at all ages. Medical Hypotheses 2005; 65: 483 – 493.
4. Price FS, Morris JA. Rare variants interact synergistically to impair complex networks and cause common disease: a model of the genetics of schizophrenia. Journal of Pathology 2012; 226: S14

Competing interests: None declared

James A Morris, Consultant Pathologist

Frances S Price

University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster LA1 4RP

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The six-page review of the management of bipolar disorder (1) gives a comprehensive appraisal of the subject for Britain except in one important respect – the omission of what is commonly but slightly misleadingly called ‘self management’. (The term ‘partnership management’ is more accurate.)

To be fair, the review did note, under the heading Resources for patients, the contact details for five organisations and in relation to one of them (Bipolar UK) it stated that the organisation “provides a range of self help groups and self management courses”. Having attended one of these 3-day self management courses and having participated in meetings of two of their self help groups in North London I would like to briefly outline the essential features. The focus is on developing ‘expert patients’ though this is not the description they normally use.

In the 3-day courses, a group of about 12 patients with a moderator discuss the assessment of moods and key features of hypomania, mania and depression with a view to helping patients to quickly recognise their current mood and status. Also discussed are ‘triggers’ for elevated or depressed states – and how to avoid or reduce them. A fundamental aim is to recognise significant change early and act promptly to recover equilibrium.

Also discussed is self medication, which is typically of great interest to course members but is rarely practised since it depends on the collaboration of GPs and psychiatrists.

Given current NHS policies and financial pressures to maximise treatment in the community rather than in hospital, it seems likely that over the next few years in Britain there may be more courses for suitable bipolar patients to become expert patients.

Peter Draper public health consultant (retired).

1 Anderson I, Haddad P, Scott J. Bipolar disorder BMJ 2012;345:e508 doi:10.1136/bmj.e8508 (5 January.)

BMJ BP letter

Competing interests: None declared

Peter A Draper, Public health (retired)

Guy's Hospital Medical School, 68 Southwood lane London N6 5DY

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6 January 2013

Disguised Bipolarity

Bipolarity in disguise raises specific diagnostic and therapeutic challenges. Bipolar depression does not only differ from unipolar depression in clinical presentation; there is also a significant difference in optimum treatment. The condition is commonly misdiagnosed because of the similarities between its symptoms and
those of major depression. There is a popular misconception that manic symptom manifests first and depression follows later; such a misunderstanding has its roots in the earlier terminology of “manic depression”. It is now well recognised that depression could start in early adult life and they declare hypomania or mania at a later period.

A subset of patients diagnosed with unipolar depression in fact suffers from bipolar depression.1 Monopolar depression needs to be readily differentiated from bipolar depression because the inappropriate use of antidepressants may precipitate a hypomanic or manic episode. Misdiagnosis can lead to unfocused treatment that may exacerbate the disease. Bipolar depression incognito differs from other forms of depression because of the high risk both of completed suicide and of psychotic features.

Atypical depressive features are more noticeable in hidden bipolar depressives, as is psychomotor retardation. 2 Bipolar depression is associated with more mood lability and a relatively acute onset. There is more cognitive blankness and emotional flatness in bipolar depression. 3 When a young person presents with psychotic depression or psychomotor retardation, bipolar depression should be ruled out. Non-specific psychological symptoms and behavioural disturbances may be the precursor of bipolar disorder in young people. 4 Any patient presenting with depressive symptomatology should be interrogated about their past history of mood elevation, and the family history of affective disorders should also be explored. Bipolar depression can occur with or without precipitating factors. Bipolar depression should be especially ruled out when depressions occur without an identifiable psychogenic stressor. Recently there has been uproar about the link between modern antidepressants and higher incidence of suicides. Most of these suicides could be due to treatment emergent hypomania in disguised bipolar depression.

In general, features of undetected/undetectable bipolarity in depression are(1) non response to antidepressants, (2)history of drug induced hypomania, (3)family history of bipolar disorder, (4)psychotic features,(5) atypical symptomatology, (7)retarded presentation, (8)postpartum onset, (9)early onset, (10) higher suicidal risk,(11) violent mood swings,(12) co-morbid anxieties,(13)past history of mood elevation,(14)isolated anti social acts and (15) legal problems. 5 Bipolar disorder is narrowly defined in DSM-IV. 6 It is also getting increasingly recognised that many of the personality disorders are larval forms of Bipolar disorder. As it can take up to ten years to confirm bipolar disorder, discovery of psycho-physiological parameters may be the solution for earlier diagnosis.

Bipolar disorder itself may be essentially a type of depressive disorder with episodic manic expression and efficient management of depression seems to hold the key to controlling and preventing the disorder. The early part of hypomanic phase could be creative and dramatic. The creative “Big bang” attributed to hypomania is short lived and is usually confined to artistic abilities, but ends up most often as a “Big crunch” if treatment is delayed.

1.Hirschfeld RM, Calabrese JR, Weissman MM(2003) Screening for bipolar disorder in the community. J.Clin Psychiatry 64: 53-59.
2.Mitchell PB, Wilhelm K, Parker G, Austin MP, Rutgers P, Malhi GS,(2001)The Clinical features of bipolar depression: a comparison with matched major depressive disorder patients. J Clinical Psychiatry 62:212-216.
3.Marneros Andreas, Goodwin Frederick (2005) Bipolar Disorders. Cambridge: Cambridge University Press.
4.Goodwin G.M (2003) Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 17:2149-173.
5. JP. Pandarakalam (2007) Clinical Challenges of Bipolar Depression,British Journal of Hospital Medicine Vol 68, pp234-240
6.Angst J, Azorin JM, Bwden CL, et al (2011) Undiagnosed Bipolar depression in patients with a major depressive episode. Arch Gen Psychiatry 68:792-798.

Dr. James Paul Pandarakalam,
Locum Consultant Psychiatrist,
5 Boroughs Partnership NHS Foundation Trust,
Alternative Futures Group Hospitals,
Hollins Park , Hollins Lane, Warrington WA2 8WA,

Competing interests: None declared

James Paul Pandarakalam, Consultant psychiatrist

5 Boroughs Parnership NHS Foundation Trust.& Alternative Futures Group Hospitals., Hollins Park Hospital, Hollins Lane, Warrington WA2 8WA

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6 January 2013

This is a very comprehensive review of all the stages of bipolar disorder, including all the recent significant literature. A trial of typical antipsychotics is worth considering for Bipolar. In third world countries, where cost of medication is big issue, economical and safe alternatives are a huge relief for carers and patients.

I think that the literature search was vigorous but could have searched other search engines like Psycinfo to gather more evidence. A criterion for selection of high quality studies needs more elaboration. Studies like STEP-BD need a special place specifically when one thinks of predictors of relapse and their importance in the management of illness. Scientific evidence is reporting Quetiapine as an emerging medicine for treatment of bipolar disorder, specifically for the depressive phase, but a lot more time is needed to win the confidence of doctors. To consider efficacy of haloperidol superior to lithium is a bit premature; more high quality data are needed.

Treatment in difficult settings and issues like pregnancy and breast feeding in bipolar disorder have no single answer. From mood stabilizers to atypical antipsychotics like olanzapine, each has its own benefits and perks. Typical antipsychotics advocated in pregnant women in schizophrenia might find a role in bipolar effective disorder as well. A criterion specifically for bipolar disorder in children and adolescents has been criticized, and hopefully has a stringent criterion to prevent over diagnosis in DSM-5, which is expected to be released in May 2013.


Perlis RH, Ostacher MJ, et al. Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Focus. 2006;4(4):553.

Competing interests: None declared

TAYYAB ARFEEN, Psychiatrist

Department of Psychiatrist, Aga Khan University Hospital, Karachi

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5 January 2013

Mental health problems remain a leading cause of maternal morbidity and mortality in the UK[1], so I was pleased to see that Ian Anderson and colleagues included a section about pregnancy in their interesting article, Bipolar Disorder[2]. They are however being simplistic and misleading when they state that ‘breastfeeding is contraindicated on lithium, lamotrigine and clozapine’. They rightly say that it is ‘crucial that patients are engaged and enabled to make informed choices’ about maintenance or prophylactic treatment; this should extend to decisions about lactation. The National Institute for Health has an excellent and up to date website about drugs in breastfeeding[3], and reference to this allows the clinician to use accurate information to inform the discussion with the patient. For example, there is much experience of women breast feeding whilst taking lamotrigine and olanzipine, and lithium use and breastfeeding are not always incompatible.

The numerous maternal and neonatal benefits of breastfeeding are as valuable to a woman with bipolar disorder as to the rest of the population, and doctors caring for such woman must make sure they advise these patients effectively .

1. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal
deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203.
2. BMJ2012;345:e8508

Competing interests: None declared

Joanna C Girling, Consultant Obstetrician

West Middlesex University Hospital, Twickenham Road, Isleworth TW7 6AF

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