Research findings have unveiled a notable overlap between BMD and CD, underscoring the complexity of diagnosing and managing these conditions. For instance, studies revealed that a significant proportion of individuals living with CD also had comorbid BMD, with 55% of boys living with CD and 71% of those living with BMD simultaneously meeting criteria for the other disorder. Similar comorbidity patterns have been observed in adolescents, where 40% had comorbid BMD, and 41% living with BMD presented with comorbid CD.¹

Individuals diagnosed with BMD, especially when accompanied by other psychiatric comorbidities, often experience an earlier onset of the illness and an increased frequency of mood episode recurrences compared to those with BMD alone.²

Furthermore, patients with recurring mood episodes tend to exhibit higher rates of comorbidity compared to individuals experiencing their first manic episode. Patients living with BMD and comorbidities are at greater risk of experiencing mixed features during mood episodes and are more prone to engage in suicide attempts.²

Distinguishing BMD from CD

BMD, as defined by the 2020 Council for Medical Scheme’s (CMS) prescribed minimum benefits guidelines, is characterised by significant alterations in mood, energy levels, and overall functioning.³

It encompasses episodes of mania, hypomania, and depression, leading to severe mood swings that can persist for weeks, months, or more extended periods.³

A manic episode, a hallmark feature, manifests as extreme irritability, elevated energy levels for at least one week, and a marked deviation from the individual's usual behaviour.³

These mood fluctuations often impair the individual's ability to function effectively in various aspects of life. Hypomanic episodes, while similar to manic episodes, are less severe and typically last for a shorter duration, around four consecutive days.³

In contrast, CD is associated with adverse life outcomes, including criminal behaviour and the development of antisocial personality disorder. It is characterised by a consistent pattern of aggressive behaviours that violate the rights of others, often emerging before the age of 18.^4,5

Notably, patients with attention deficit hyperactivity disorder (ADHD) frequently present with symptoms of CD. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, classifies CD as a disruptive, impulse-control disorder, encompassing conditions such as oppositional defiant disorder, intermittent explosive disorder, kleptomania, and pyromania.^4,5

Treatment approaches to BMD

One of the critical concerns in the management of BMD is the risk of misdiagnosis leading to the prescription of antidepressants. When administered as monotherapy, antidepressants can potentially trigger rapid cycling, as highlighted by Dell’Osso et al.⁶

While some studies suggest the use of antidepressants as adjunctive short-term treatment in BMD, available data are inconsistent, and antidepressant monotherapy carries a high risk of inducing manic episodes. Therefore, mood stabilisers and atypical antipsychotics are generally recommended for managing BMD.⁶

A recent systematic review and network meta-analysis conducted by Kishi et al, evaluated the efficacy, acceptability, tolerability, and safety of various drugs in the treatment of acute BMD mania.⁷

Their findings indicated that risperidone exhibited a superior treatment response compared to placebo, with lower discontinuation rates due to inefficacy. Risperidone also demonstrated better improvement in the mania rating scale score, clinical remission, and psychotic symptoms compared to placebo. Consequently, it appears to be a promising treatment option for acute BMD mania.⁷

Furthermore, in the management of BMD, it is crucial to consider adjunctive psychosocial therapies early in the course of the illness. These therapies aim to enhance medication adherence, identify prodromal signs of relapse, and reduce residual symptoms.³

Psychoeducation, which focuses on recognising early warning signs of relapse, has proven to be an effective adjunct to medication management and should be offered to all patients living with BMD.³

Additionally, more intensive psychotherapies, including cognitive-behavioral therapy, family-focused therapy, and interpersonal and social rhythm therapy, have demonstrated benefits in improving both symptoms and overall functioning and should be considered as part of a comprehensive treatment plan.³

Treatment approaches to CD

The management of CD involves a multifaceted approach that encompasses both psychosocial and pharmacological interventions. Recommended psychosocial treatments include:⁸

• Parent management training: This approach aims to equip parents with the skills to establish consistent discipline, appropriately reinforce positive behaviours, and promote prosocial behaviours in their children.
• Multisystemic therapy: Focusing on family, school, and individual dynamics, this therapy aims to enhance family relationships, improve academic functioning, and address problematic behaviour within the context of multiple systems.
• Anger management training: This intervention helps individuals develop strategies for managing anger and responding to provocation more constructively.
• Individual psychotherapy: Targeting the development of problem-solving skills, strengthening relationships through conflict resolution, and teaching assertive skills to resist negative external influences in the community.
• Community-based treatment: This approach involves the establishment of therapeutic schools and residential treatment centres that provide structured programmes to reduce disruptive behaviours.

Pharmacological treatment options for CD may include addressing comorbid psychiatric conditions with appropriate medications, such as stimulants and non-stimulants for ADHD, antidepressants for depression, and mood stabilisers for aggression, mood dysregulation, and BMD. Mood stabilisers encompass conventional agents like antiepileptic drugs and second-generation antipsychotics.⁸

Conclusion

The complex interplay between BMD and CD underscores the importance of comprehensive assessment and tailored treatment plans. Clinicians must be vigilant in identifying comorbidities and choosing appropriate interventions to enhance the well-being of individuals facing these challenging conditions.

References

1. Wozniak J, et al. Comorbidity of bipolar I disorder and conduct disorder: a familial risk analysis. Acta Psychiatr Scand, 2019.
2. Altinbaş K. Treatment of Comorbid Psychiatric Disorders with Bipolar Disorder. Noro Psikiyatr Ars, 2021.
3. Council for Medical Schemes. PMB definition guidelines for bipolar mood disorder Version 1: 30.09.2020. https://www.randwater.co.za/RW%20Medical%20AID%20Communique/CMS/PMB_Definition_Guideline_for_Bipolar_Mood_Disorder_v1.pdf
4. American Psychiatric Association.Diagnostic and statistical manual of mental disorders, 5th ed. Arlington: American Psychiatric Association, 2013.
5. Woodward D, et al. Examining the clinical correlates of conduct disorder in youth with bipolar disorder. Journal of Affective Disorders, 2023.
6. Dell’Osso B, et al. Has Bipolar Disorder become a predominantly female gender related condition? Analysis of recently published large sample studies. International Journal of Bipolar Disorders, 2021.
7. Kishi T, et al. Pharmacological treatment for bipolar mania: a systematic review and network meta-analysis of double-blind randomized controlled trials. Molecular Psychiatry, 2021.
8. Mohan L, et al. Conduct Disorder. [Updated 2022 Jul 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.