With so many scale tools, how exactly do you identify bipolar disorder with rapid cycling?

▶ These seizures can occur
in any combination or order.
These episodes must meet diagnostic criteria for the course or number of symptoms of a major depressive, manic, or hypomanic episode, and must be completely relieved over a period of time or transitioned to episodes of opposite polarity
.

▶ Manic and hypomanic episodes are treated as the same polarity
.

▶ Apart from occurring more frequently, these episodes did not differ
between fast-loop and non-fast-loop patterns.

▶ Mood seizures identified as rapid-cycling patterns should exclude episodes
directly attributable to substances (e.
g.
, cocaine, corticosteroids) or other medical conditions.

Clinically, rapid cycling is a transitional stage of bipolar disorder that is easily confused
with mixed states.
To distinguish, the DSM-5 defines mixed characteristics as the presence of 3 or more depressive symptoms during a manic episode, or 3 or more manic symptoms during a depressive episode (Figure 1) ^[3].

Figure 1 Schematic diagram of rapid cycling and mixed state of bipolar disorder^[3].

Rapid cycling states are common in patients with bipolar disorder, and a systematic review has shown a lifetime prevalence of 25.
8 to 43 percent in patients with bipolar disorder with rapid cycle features ^[4].

Bipolar patients with rapid circulation features are associated with
female, hypothyroidism, depression, worsening disease severity, and prolonged duration compared with patients without rapid circulation.
Screening for rapid circulation is important and, where possible, should address factors that may contribute to or exacerbate circulation, such as antidepressants, substance abuse, and related medical conditions such as hypothyroidism ^[3].

The key to the treatment of bipolar disorder with rapid cycling features is to block the onset
of circulation.
Overall, there is currently limited evidence-based evidence for rapid cycle therapy, and as there is no evidence to support any particular drug for the treatment of acute depressive episodes in the rapid cycle phase, appropriate pharmacotherapy
should be selected based on the effectiveness of acute and maintenance medications.
The Guidelines for the Prevention and Treatment of Bipolar Disorder in China (Second Edition) states^[5]:

▶ Tricyclic antidepressants can cause rapid cycling and should be avoided in such patients;

▶ There is currently no convincing evidence from RCTs that mood stabilizers are effective;

▶ Valproate has been shown to be effective in open-label studies and may be preferred for long-term treatment with mood stabilizers alone;

▶ Previous studies of lithium carbonate monotherapy for rapid cyclic seizures had a high early dropout rate and were unconvincing; Lithium carbonate combined with valproate also did not show good efficacy, as did poor tolerability, lack of efficacy, and high early shedding rate (level 2 evidence);

▶ RCT studies of atypical antipsychotic monotherapy in fast-cycle patients had problems with small sample sizes, high early dropout rates, and high incidence of adverse effects, which reduced the value of the results obtained
.

Overall, bipolar disorder with rapid cycling features represents a rapidly transitioning clinical state with at least four mood episodes
per year.
As a common clinical feature, bipolar patients with rapid cycling have more severe symptoms, longer course of disease, and greater difficulty in management
.
The key to the treatment of bipolar disorder with rapid circulation features is to block the onset of circulation and address factors that may cause or exacerbate circulation (e.
g.
, antidepressants).

Evidence-based evidence for rapid cycle therapy is limited, and Chinese guidelines point to valproate as a treatment option
.

References:

1.
Maj M, Pirozzi R, Formicola AM, Tortorella A.
Reliability and validity of four alternative definitions of rapid-cycling bipolar disorder.
Am J Psychiatry.
1999; 156(9):1421-4.

2.
Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).
2013.

3.
Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, et al.
Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders.
Aust N Z J Psychiatry.
2015; 49(12):1087-206.

4.
Carvalho AF, Dimellis D, Gonda X, Vieta E, McLntyre RS, Fountoulakis KN.
Rapid cycling in bipolar disorder: a systematic review.
J Clin Psychiatry.
2014; 75(6):e578-86.

5.
Guidelines for the Prevention and Treatment of Bipolar Disorder in China (2nd Edition).
2015.

Caution: Valproic acid should not be prescribed to girls, adolescent girls, women of childbearing age, or pregnant women unless other treatments are ineffective or tolerated, as detailed on the Valproic Acid Safety Information Update page
.