Rapid Cycling Bipolar Disorder

The DSM-IV defines rapid cycling bipolar disorder as a pattern of presentation accompanied by 4 or more mood episodes in a 12-month period, with a typical course of mania or hypomania followed by depression or vice versa. The episodes must be demarcated by a full or partial remission lasting at least 2 months or by a switch to a mood state of opposite polarity.^[4] Research shows that it is common for rapid cyclers to have frequent brief depressive episodes that do not necessarily meet duration criteria for full depressive episodes as per DSM-IV.^[5]

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Some investigators have further classified rapid cycling into ultrarapid (cycling every few days) and ultradian (cycling that occurs daily).^[6,7] Kraepelin referred to these patterns of cycling as being the inherent mood lability seen in almost all patients with bipolar disorder; consequently, these additional specifiers have never been incorporated into the DSM-IV

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Rapid cycling patients usually tend to be younger,^[13] with illness onset before the age of 17 years.^[14] Women are more likely than men to be rapid cyclers,^[15] with prevalence rates of 70% (range, 58% to 92%) or even higher.^[12,16,17] The higher prevalence of rapid cycling in women could be attributed to increased occurrence of hypothyroidism or menstrual cycle irregularities.

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in patients with no psychiatric history, rapid cycling can emerge after varying kinds of trauma to the brain, such as subarachnoid hemorrhage,^[26] diffuse cerebral damage following closed head injury,^[27] or focal temporal pole damage.^[28]

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Rapid cyclers also suffer higher morbidity, which is evident in more serious suicide attempts,^[14] more frequent hospitalizations,^[13] and a greater tendency to seek treatment later in the course of illness.^[15] Episodes also consist of more severe depression, less severe mania, and fewer psychoses compared with nonrapid cyclers.

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rapid cyclers usually have a prior history of rapid cycling, substance abuse, and childhood physical and/or sexual abuse

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growing impression that highly recurrent treatment-refractory depression is the hallmark of rapid cycling bipolar disorder.^[23]

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Sleep patterns are reliable indicators of relapse, and if these patients have regular sleep, they may avoid cycling into mania.

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In patients who have never been treated, mood stabilizers such as lithium are the first line of treatment.^[9] Permissive definition of mood stabilizers characterizes medications as effective in the long-term management of at least 1 phase of bipolar disorder without worsening any other phase of the illness

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Lamotrigine is particularly efficacious in patients with predominant depression and rapid cycling bipolar II, while divalproex is a first-line option in rapid cycling bipolar I.

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combination of lithium with carbamazepine, valproate, or lamotrigine for maintenance along with olanzapine as an adjunct also has some support from controlled studies.^[9] Quetiapine monotherapy has also shown effectiveness in treating depression in patients with a rapid cycling course

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the emerging consensus is that lithium and divalproex have similar efficacy in the long-term treatment of rapid cycling bipolar disorder

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he dosage of quetiapine for acute illness ranged from 720 ± 84 mg/day for mania vs 183 ± 29 mg/day for depression.

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Lithium and divalproex are considered first-line treatments for acute and long-term management of rapid cycling in bipolar I (especially for mania) and lamotrigine for bipolar II patients who usually present with depression. Prior notions that lithium is ineffective in rapid cycling are not supported by recently conducted maintenance studies

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There is emerging evidence to suggest that highly recurrent, treatment-refractory depression is the hallmark of rapid cycling bipolar disorder, and that many patients presenting in this way are being incorrectly diagnosed and treated with selective serotonin reuptake inhibitors used as monotherapy.

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