Underwriting Bipolar Disorder
Clients with bipolar disorder (also called manic-depressive illness) have recurrent episodes of both depression and mania. In some cases, they can actually have both mood disorders at the same time. It is important to note that their demeanor will not necessarily reveal the nature or severity of the problem. In most cases these clients tend to be bright, driven and quick-witted. However, the underlying psychiatric disorder can prove lethal to their social relations (i.e. divorces are common) and to the individuals themselves (i.e. between 10% and 15% of persons with bipolar disorder commit suicide)
There are several types of bipolar disorder. They differ in the nature of the episodes and by their mood pattern:
Bipolar I disorder
This is the "classic" bipolar disorder and the one that is referred to as "manic-depressive illness." These individuals can present with "mixed" episodes in which they have extreme mood shifts (i.e. psychosis or suicidal speculation) over a period of a week or more. Clients with bipolar I disorder generally have significant personal and workplace problems.
Bipolar II disorder
This is really the "light" version of bipolar I disorder. These individuals possess much greater levels of self-control and exhibit milder mood swings and do not exhibit psychotic symptoms.
Bipolar I or II disorder with rapid cycling
These individuals have 4 or more episodes of mood disturbances within one year. They are in such turmoil that they mimic borderline personality disorder. Women are more likely than men to have rapid-cycling bipolar disorder.
How do you diagnose the mania phase of bipolar disorder?
There are no lab tests for mania. The diagnosis depends on the clinical history and presentation. In addition, medical and medication causes of the mania must be ruled out. The most common of these in a primary care setting are:
- Alcohol
- Cocaine
- Amphetamine
- Caffeine Intoxications
- Substance withdrawal syndromes
- Anxiety disorders
- Schizophrenia
- Delirium from medical conditions
If the medical and medication work-up are negative, then clues from the individual's history and their behavior in the examination room form the basis for a mania diagnosis
A mnemonic that can be helpful in the diagnosis of mania is DIGFAST. It is a convenient way to remember the components of the manic state:
D—distractibility
I—insomnia
G—grandiosity
F—flight of ideas
A—activity is increased
S—speech (anxiously pressured and talkative)
T—thoughtlessness (poor judgment and pleasure seeking)
How do you diagnose the depression phase of bipolar disorder?
The depression seen with bipolar disease has the classic features of a typical "major depressive episode." This includes:
- Sadness
- Loss of the capacity to experience pleasure (called anhedonia)
- Unresponsiveness (called anergy)
- Loss of appetite (called anorexia)
- Weight loss
- Insomnia or hypersomnia (i.e. sleeping all the time)
- Sense of worthlessness
- Decreased concentration
- Suicidal ideation
Individuals with bipolar disease are more likely to appear physically ill and depressive symptoms can be profound.
How do you treat bipolar disease?
Medications known as "mood stabilizers" usually are prescribed to help control bipolar disorder. Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.
Lithium (Eskalith, Lithonate, Lithotab, Lithium Carb), the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.
Anticonvulsant medications, such as valproate (Depakote) or carbamazepine (Tegretol), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.
Newer anticonvulsant medications, including lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax), are being studied to determine how well they work in stabilizing mood cycles.
Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.
Underwriting Comment
Clients with bipolar disorder are insurable but require careful screening to determine the extent and severity of their condition. Use the following questions to screen clients with a history of bipolar disorder:
1. When was the client diagnosed with bipolar disorder?
Try and find out as much details about the event surrounding the diagnosis such as: "Was the client hospitalized?"
2. When was their last acute episode?
The underwriter needs to verify the "rate" (i.e. how often do the acute episodes occur?). It is also important to find out what happened with the last acute episode. Was the client hospitalized?
3. What medications are being used to treat the client’s bipolar disorder and how well are they working?
The underwriter needs to know the medications and if they are managing the disorder.
4. Does the client have any other medical problems and is the client taking any other medications?
The underwriter needs to know if there any other issues that are impacting the clients insurability.
5. Is the client gainfully employed and living independently?
Bipolar disorder can dramatically impact all aspects of a client's life (i.e. high divorce rate, unemployment). This question can help the underwriter get a clear picture of the client's personal and occupational functional status.
