Current challenges and Indian perspectives in the diagnosis and management of bipolar disorders

Bipolar disorders (BDs) are episodic illnesses characterised by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. BDs present many diagnostic and therapeutic challenges because of their varying clinical course, symptoms, severity and the presence of comorbidities. They severely burden healthcare systems, particularly in low-income and middle-income countries. In India, managing bipolar disorder is challenging, due to inadequate resources, poor knowledge about the disorder or its treatment, and limited access to healthcare facilities. These disorders impact a large portion of the Indian population, thus highlighting an urgent need to effectively facilitate better diagnosis and management of mental disorders across the country. A careful assessment of previous manic or hypomanic episodes and early identification of comorbidities helps predict disease course and treatment options. Treatment of BDs usually combines medications and psychotherapy. In Indian clinical settings, the first-line treatment for BDs includes pharmacotherapy with mood stabilisers, such as divalproex, lithium, anticonvulsants, and antipsychotics. Psychotherapy, along with lifestyle approaches are useful adjuncts. To reinforce the overall management of BDs, focused group discussions were conducted among 87 psychiatrists across nine cities in India, to gather insights about the burden, diagnostic challenges, and treatment approaches. This review discusses expert insights on optimal diagnostic and treatment approaches for BDs, focusing on psychiatric and non-psychiatric comorbidities, prevalent among Indian patients with type I and II bipolar disorders. It also covers lithium adverse effects, divalproex-place in therapy, and the use of anti-depressant a risk factor for rapid cycling.