Rapid Cycling in Bipolar Disorder

What Is Rapid in Cycling Bipolar Disorder?

Rapid cycling is a pattern of frequent, distinct episodes in bipolar disorder. In rapid cycling, a person with the disorder experiences four or more episodes of mania or depression in one year. It can occur at any point in the course of bipolar disorder, and can come and go over many years depending on how well the illness is treated; it is not necessarily a "permanent" or indefinite pattern of episodes.

Who Gets Rapid Cycling Bipolar Disorder?

Virtually anyone can develop bipolar disorder. About 2.5% of the U.S. population suffers from some form of bipolar disorder - nearly 6 million people. A rapid cycling pattern may occur in about 10% to 20% of people with the disorder. Women, and people with bipolar II disorder, are more likely to experience periods of rapid cycling.

Most people are in their late teens or early 20s when symptoms of bipolar disorder first start. Nearly everyone with bipolar disorder develops it before age 50. People with an immediate family member with bipolar disorder are at higher risk.

What Are the Features of Bipolar Disorder?

The major features of bipolar disorder include:

• At least 1 episode of mania or hypomania in the patient's lifetime
• Episodes of depression (major depressive disorder), which are often recurrent

Mania is a period of abnormally elevated mood and high energy, usually accompanied by erratic behavior lasting at least seven days at a time. Hypomania is an elevated mood not reaching full-blown mania and lasting a minimum of four days.

A few people with rapid cycling bipolar disorder alternate between periods of hypomania and major depressive disorder. Far more commonly, though, repeated and distinct episodes of depression dominate the picture. Repeated periods of depression are punctuated by infrequent, shorter periods of elevated or normal mood.

How Is Rapid Cycling Bipolar Disorder Identified?

Bipolar disorder is diagnosed after someone experiences a hypomanic or manic episode along with multiple additional episodes of either mania, hypomania or depression. Rapid cycling in itself is not a diagnosis, but rather a "course specifier" or descriptor of the course of illness. In bipolar disorder rapid cycling is identified when four or more distinct episodes of depression, mania, or hypomania occur during a one year period.

Rapid cycling bipolar disorder can be difficult to identify, because a single mood episode can sometimes simply wax and wane without resolving. As a result, they don't necessarily represent multiple separate and distinct episodes. Rapid cycling may seem to make the changing mood states of bipolar disorder more obvious, but because most people with rapid cycling bipolar disorder spend far more time depressed than manic or hypomanic, they are often misdiagnosed with unipolar depression.

For example, in one study of people with bipolar II disorder, the amount of time spent depressed was more than 35 times the amount of time spent hypomanic. Also, people often don't take note of their own hypomanic symptoms, mistaking them for a period of unusually good mood.

How Is Bipolar Disorder with Rapid Cycling Treated?

Because symptoms of depression dominate in most people with a rapid cycling course of bipolar disorder, treatment is usually aimed toward stabilizing mood, mainly by relieving depression while preventing the comings-and-goings of new episodes.

Antidepressants such as fluoxetine (Prozac), paroxetine (Paxil,) and sertraline (Zoloft) have not been shown to treat the depression symptoms of rapid cycling bipolar disorder, and may even increase the frequency of new episodes over time. Many experts therefore advise against the use of antidepressants (especially long term) in bipolar patients with rapid cycling.

Mood-stabilizing drugs -- such as carbamazepine (Tegretol), lamotrigine (Lamictal ), lithium (Lithobid), and valproate (Depakote)-- are the core treatments of rapid cycling. Often, a single mood stabilizer is ineffective at controlling episode recurrences, resulting in a need for combinations of mood stabilizers. Several antipsychotic medicines such as olanzapine (Zyprexa) or quetiapine (Seroquel) also have been studied in rapid cycling and are used as part of a treatment regimen, regardless of the presence or absence of psychosis (delusions and hallucinations).

Treatment with mood stabilizers is usually continued (often indefinitely) even when a person is symptom-free. This helps prevent future episodes. Antidepressants, if and when used, are generally tapered as soon as depression is under control.

What Are the Risks of Rapid Cycling Bipolar Disorder?

The most serious risk of a rapid cycling course in bipolar disorder is suicide. People with bipolar disorder are 10 times to 20 times more likely to commit suicide than people without bipolar disorder. Tragically, 8% to 20% of people with bipolar disorder eventually lose their lives to suicide.

People with a rapid cycling course may be at even higher risk for suicide than those with nonrapid cycling bipolar disorder. They are hospitalized more often, and their symptoms are usually more difficult to control long term.

Treatment reduces the likelihood of serious depression and suicide. Lithium in particular, taken long term, has been shown to reduce the risk.

People with bipolar disorder are also at higher risk for substance abuse. Nearly 60% of people with bipolar disorder abuse drugs or alcohol. Substance abuse is associated with more severe or poorly controlled bipolar disorder.

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