Bipolar Disorder

MED 2017

Objectives

• Learn how to make the diagnosis of bipolar in a time efficient manner
• Learn how to use psychopharmacology to treat Bipolar Disorder, using current guidelines
• Learn about issues of psychopharmacology and pregnancy

Table of contents

• Bipolar Therapeutics

  • Lithium
  • Valporic Acid
  • Lamotrigine
  • Carbamazepine
  • Olanzapine
  • Atypical Neuroleptics Therapy plans for
  • Bipolar Depression
  • Acute Treatment of Mania, Mixed State, Rapid Cycling
  • Bipolar & Pregnancy treatment

Bipolar Disorder

MANIC

• 7 days or more, unless hospitalized
• Interferes with life greatly
• Increased mood
• Increased energy
• Decreased sleep

HYPOMANIC

• 4 days or more

• Somewhat interferes with life, seen by others as uncharacteristic

• Same features as manic, no marked impairment in functioning

• IMPORTANT: Separate Bipolar II from Axis II, cluster B mood lability

  • Remember time line, days vs. hours or a day
  • Out of the blue vs. response to stressors

Bipolar I vs. Bipolar II

Bipolar I

• Manic phase(s) +/- depression phase(s)
• 1% lifetime prevalence

Bipolar II

• Hypomanic phase(s) + depression phase(s)
• 1.1% lifetime prevalence

Bipolar Disorder

• Mean age of onset - early to mid 20’s
  • Peak age is 15-19
• Usually 3-10 year lag between onset and treatment
• Initially
  • Depression in women
  • Mania in men
• Twin studies and first degree relative studies support the fact of heritability

Bipolar Terms

• Bipolar
  • Manic phase
  • Hypomanic phase
  • Depressed
  • Mixed phase - depression and mania essentially coexist, switching over hours, or every 1 - 2 days. Also has been called ultra rapid cycling. Must last at least one week. Causes marked impairment in functioning.
• Rapid Cycling
  • 4 or more episodes/year
  • Going from manic to depressed - counts as two episodes

Figure 2.1 Bipolar disorder diagnoses

• BIPOLAR I
  • Presence of at least one episode of mania with a minimum duration of one week with or without major depressive episodes.
• BIPOLAR II
  • Presence of one or more episodes of hypomania accompanied by at least one episode of major depression with no psychotic features.
• CYCLOTHYMIA
  • One or more episodes of hypomania and periods of depressive symptoms that do not meet criteria for a major depressive episode.
• RAPID CYCLING
  • The occurrence of four or more episodes of depression or mania during 12 months.
  • Episodes can occur in any combination or order but must satisfy duration & symptom criteria for Major Depression, Mania or Hypomania and must be separated by either a period of remission or by a switch to the opposite pole (for at least 2 months) of illness.
• MIXED EPISODES
  • Concurrent symptoms of depression and mania.
  • Must also be at least two of six of the following:
    • Mania
    • Hypomania
    • Euthymia
    • Depressive symptoms
    • Major Depression

THINGS TO DO:

• Assess for organicity
• Harm to others (e.g., driving)
• EtOH/Substance abuse
  • High co-morbidity rate
  • Can worsen
• Suicidality
  • 17-19% lifetime prevalence of completed suicide
  • More often in depressed state
• Educate
  • Inadequately treated patient may have 10 or more episodes
  • Intervals between episodes narrows as person ages
  • Sleep deprivation can provoke hypomanic/mania

Disability Issues

• Stable bipolar is not disabling
  • Most people should hit their normal “life arc”, including working
  • Let patients know this!
• A minority of treatment resistant cases may require disability