World Bipolar Day: how a lack of awareness impedes early diagnosis

Life always has its ups and downs and our mood follows accordingly. But when a person swings between extremes of feeling on top of the world and falling into the depths of despair for an extended period, it may be a sign of bipolar affective disorder.

In Hong Kong, local research has estimated the prevalence of the disorder - which has a very wide spectrum from mild to severe - to be as high as one in 20 people. Yet, experts say awareness of the condition remains low and social stigma surrounds the disorder, which impedes early diagnosis and effective treatment.

To combat this, a trio of international organisations - the Asian Network of Bipolar Disorder, International Bipolar Foundation, and International Society for Bipolar Disorders - came together to launch the first World Bipolar Day yesterday. The date was picked to coincide with the birthday of Vincent Van Gogh, the painter who was posthumously diagnosed as probably having bipolar disorder.

To commemorate the day in Hong Kong, the Society for the Advancement of Bipolar Affective Disorder (Sabad) has published a Chinese-language manual on the condition, translated from the Psychoeducation Manual for Bipolar Disorder by Eduard Vieta and Francesc Colom of the Bipolar Disorders Programme of Hospital Clinic Barcelona.

Society chairman and specialist in psychiatry Dr Michael Wong Ming-cheuk says Chinese language resources on bipolar disorder have been limited, resulting in notably low awareness of the condition among the Chinese community.

"This manual provides detailed information on bipolar disorder for preparing appropriate treatment plans, from understanding the causes, symptoms, related medication and drug risks, warning signs for early self-detection, to providing tips on lifestyle modifications and proper stress management," says Wong.

"We hope the manual will help the public to acquire deeper understanding of this disorder and in turn, to render their support to the patients. This can definitely help patients to embrace life with a more positive attitude."

A 2007 telephone survey conducted by Hong Kong University found that among nearly 1,500 respondents, 5.5 per cent showed symptoms of bipolar affective disorder. A third of sufferers were under 30 years old, and came from all walks of life.

Another survey done in 2009 by Sabad polled nearly 1,000 patients at 11 private clinics. The estimated prevalence rate of bipolar affective disorder was 3.6 per cent among the primary medical care patient population and 2.5 per cent among Hong Kong's general population. The high-risk periods of the onset of the disease are from ages 15 to 25, and 90 per cent of sufferers experience onset before age 50.

Bipolar affective disorder patients may experience bouts of both mania and depression. During manic episodes, they can feel extraordinary elation, excitement, confidence, they are filled with ideas and experience restlessness; during depression, they lose interest in everything, lack energy and can be plagued with thoughts of death or even suicide.

About 0.5 to 1 per cent of the general population has bipolar I (type one) disorder, says Dr Eric Cheung Yat-wo, a specialist in psychiatry and Sabad council member. This involves one or more mood swings continuing for at least one week, sometimes causing severe mania, hallucinations and delusions. About 1 to 2 per cent of the general population has the less severe bipolar II (type two) disorder, with milder episodes of hypomania lasting about four days.

Patients are diagnosed through a detailed psychiatric assessment, which checks clinical symptoms against international standard criteria. However, there can be a significant delay in diagnosis - sometimes up to 10 years - due to the complex clinical presentation of the illness. It can easily be misdiagnosed, mistaken for other disorders, including depression and schizophrenia.

In a study led by Cheung published last year in the Journal of Affective Disorders, some 100 subjects - half with bipolar I disorder and the other half healthy controls - were put through cognitive tests on a computer. It was found that 46 per cent of sufferers in remittent state failed to regain pre-morbid cognitive functioning.

"That means that every time a sufferer has a relapse, there are some consequences on his or her brain processes, such as deterioration in memory, slower processing, and reduction in executive function that turns thoughts into actions," says Cheung. "This therefore highlights the importance of early intervention and treatment."

Treatment of the disorder commonly includes drugs, such as mood stabilisers, and psychotherapy, such as having patients keep a diary of their thoughts and activities, says Dr Queenie Wong Sze-man, a specialist in psychiatry and Sabad council member. Doctors and psychiatrists have to work closely with patients to modify the treatment plan according to the mood change and drug reaction.

Popular local radio host Hung Chiu-fung, 54, has been suffering from bipolar disorder since 1987 and has experienced four episodes, the latest being in 2005. In his depressive state, he felt anxious, thought life was meaningless and lost all self-confidence. He would feel exhausted and powerless, leading to difficulty in daily activities such as going to work and ordering food in a restaurant. He also experienced insomnia, nausea, headache and shaking hands.

He would often then swing into a manic state, where he'd feel extreme self-confidence and full of inspiration and creativity. In 1999, this led to investing several million dollars in an antique business - which eventually failed. In 2005, he penned a Cantonese opera script in three weeks and made plans for performances and a series of high-profile promotional events.

His family finally decided to send him for treatment. Hung spent 22 days in hospital, where doctors gave him medication, psychotherapy, and encouraged him to hold concerts at the hospital. Hung has not stopped taking his medication since and has regular follow-ups with his doctors. He also started practising mindfulness and meditation to help stabilise his mood.

Hung advises fellow sufferers that they should "face life's ups and downs with a positive attitude".

While environmental and social factors contribute towards one's risk of developing bipolar disorder, scientists have been gathering compelling evidence that genes affect predisposition to the disorder.

Most recently, in an international study that appears in the journal Nature Communications this month, a research team led by University of Bonn Hospital scientists searched for the foundations of the disorder in about 24,000 people. They discovered two new gene regions connected to the disease, and confirmed three additional suspect genes.

The growing knowledge of the contribution of genetics to bipolar disorder means that, in future, it may be possible to identify some of the biological systems that lead to the illness, which, in turn, could lead to substantial improvements in diagnosis and treatment.
 

10 common misconceptions

The myths surrounding bipolar disorder in Chinese culture have been a barrier to early diagnosis and effective treatment of patients, says the Hong Kong Society for Advancement of Bipolar Affective Disorder. Here, they highlight misunderstandings about the disorder.

1. Doctors made the disorder up.

2. It is a disorder found only in Western societies.

3. It is an illness of this century.

4. Only weak people have it.

5. It is contagious.

6. Psychoanalysis and homeopathy are useful treatments.

7. It is a gift from God.

8. You cause it yourself.

9. It can be controlled without medication.

10. It is an incapacitating disorder.

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