BIPOLAR AFFECTIVE DISORDER (BPAD)

• Bipolar disorder is a psychiatric illness characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly disturbed. This disturbance can occur on two occasions; one with an elevation of mood and increased energy and activity ( mania or hypomania) and the second with lowering of mood and decreased energy and activity. The recovery is usually complete between the episodes.
• Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months. Depressive episode tend to last longer about 6 months
• Women have an increased risk of manic and depressive episodes and are more inclined to the rapid cycling subtype. The average age of onset is 20 years and prevalence in the general population is 1-3 %. A first degree relative with bipolar has 20 % chances of having the disease

• Genetic: Lifetime risk for children of one parent with Bipolar mood disorder is 27% and of both parents with a bipolar mood disorder is 74%
• Biochemical theories: Abnormality in catecholamine and serotonin system in the CNS at one or more sites
• Neuro Endocrine Theories: Present in disorders such as Hypothyroidism, Cushing's disease and Addison's disease
• Triggers: Psychosocial stress, Sleep disturbances, Physical illness, Childhood traumatic experiences.

• Features of manic episode, hypomanic episode, or a major depressive episode with periods of normal mood and functioning. These episodes can be with or without psychotic symptoms

Types

• Bipolar I disorder At least one Episode of Mania. Major depressive or hypomanic episodes usually occur but is not required for diagnosis
• Bipolar II disorder: At least one episode of Hypomania and one major Depressive episode, no previous episode of mania
• Rapid Cycling – 4 or more episodes of depression, mania, or hypomania occurring in a single year
• Differential diagnosis
• Bipolar I disorder
• Bipolar II disorder
• Cyclothymia – Mood Instability with numerous periods of depression and hypomania. Symptoms are not severe or persistent to diagnose bipolar disorder
• Substance / Medication-induced bipolar and related Disorder

• Clinical diagnosis is done based on ICD11 or DSM 5 criteria
• Young Mania Rating Scale for Mania
• Mood disorder questionnaire for manic episodes
• Hamilton Depression Rating Scale (HAM-D) for depressive episodes

BPAD with current episode Mania is Pittonmada and BPAD with current episode depression is Kaphonmada. Treatment is done according to the current episode

MANIA

• Acute mania is a psychiatric emergency and requires immediate management

Internal medicines

• Sweta sankhupuspi choorna + Sarpagandha choorna + Gokshura choorna
• Aswagandha + Sweta sankhupuspi choorna + Yashti choorna
• Samana snehapana -Thiktaka ghtita, Kalyanaka ghrita
• Manasamitra vataka to control impulsivity and agitation
• Somalata churna in Sleep disturbances.

Procedures

• Sadyo virechana to reduce the impulsivity and increased PMA(Psychomotor activity)
• Talam - kachuradi choorna + Ksheerabala / Chandanadi taila to improve sleep
• Siropichu
• Snehapana -Thiktaka ghtita, Kalyanaka ghrita
• Teekshna virechana - Avipathy choorna
• Yogavasthi – Doshahara kashaya vasthi + Aniuvasana vasthi with Tikataka ghrita
• Nasya with Tiktaka ghrita / Ksheerabla 101
• Sirolepa to control agitation and increased PMA

DEPRESSION

• Psychotherapy
• Cognitive-behavioural therapy (CBT)
• Interpersonal therapy
• Psychodynamic psychotherapy
• Family and couples therapy
• Lifestyle changes (aerobic exercise, nutrition, sleep hygiene, social support, stress reduction)

Mild to moderate depression can be treated with the following medications.

Internal Medicines:

• Aswagandha choorna + Sankhupushpi Choorna + Kushta Choorna in equal quantity
• Saraswatha choorna for associated cognitive complaints
• Somalatha churna for associated sleep disturbances
• Panchagavya ghrita,Mahatpanchagavya ghrita and Brahmi ghrita - Samana snehapana
• Drakshadi kashaya

Procedures

• Snehapana and Vamana or Teeksha virechana
• Yogavasthi - Doshahara kashaya vasthi and Snehavasthi is done with Panchagavya ghrita
• Vilwadi teekshna Nasya and Anjana
• Dhoopana and Dhoomapana
• Siropichu - Sankhupushpyadi taila
• Gudardraka prayoga after shodhana procedures