Bipolar Disorder

DIGFAST
D - distractability
I -increased activity / psychomotor agitation / impulsivity
G - grandiosity
F - flight of ideas
A - activities (increased goal directed activities)
S - sleep
T - talkativeness

Bipolar diathesis
- Risk for bipolar disorder
- There is a Harvard diagnostic tool (link needed)

See

MDQ = Mood disorder Questionnaire ( 7 of 13 or higher)
Altman Self-rating Mania Scale ASRM (5 - item)
BSDS Bipolar Spectrum Diagnostic Scale - pt fills with checkmarks
K-SADS mania rating scale
YMRS Young Mania Rating Scale (evaluator rating)

Bipolar d/o is almost always recurrent and chronic.  There is no tendency for pt to mature out of the dz.

Bipolar d/o is the mental illness that consistently displays the highest rate of substance use.

Abrupt d/c of Li+ is followed by high relapse rate - usually manic.

1/2 of manic pt's will have psychotic sx's.  Pt's with psychotic features respond less favorably to Li+, more favorably to Depakote.

Treatment is the same (and equally effective) for bipolar I and bipolar II.

Depressive episodes in bipolar pt's are generally shorter than in pt's with major depression.

Bipolar depression is MORE likely to include:
- hypersomnia
- psychomotor retardation

Bipolar depression is LESS likely to include:
- anxiety
- agitation

As many as 25% of bipolar pts have 3-4 depressive episodes before their first manic episode.

The younger the pt at the first depressive episode, the greater the likelihood of an underlying bipolar d/o.
- Median onset bipolar d/o is 19 yo.
- Median onset MDD is 25 yo.

CYCLOTHYMIA might be a mild form of bipolar d/o (Hypomania but no major depressive episodes).

COMORBIDITY:
BIPOLAR D/O STRONG A/W
- Migraine (improved by Depakote)
- OCD
- Panic d/o
- ADHD

MIXED MANIA
- respond less well to lithium than those with "pure" elated mania.
- typically older age at onset
- typically fewer episodes per unit time
- less likely to have fam hx of mood d/o

ELATED ("PURE") MANIA
- Li+ is the most effective tx.

RAPID CYCLING
- 4 or more episodes (any combo of depression or mania) in 12 mo.
- The rapid cycling form is associated with HYPOthyroidism.
- About 12pc of those with bipolar d/o are considered rapid cyclers.
- First, treat hypothyroidism, drug or EtOH abuse that may contribute to cycling.
- More common in women than men (intuitive b/c of monthly hormone cycle)
- Antidepressants may contribute to cycling and should be tapered off
- When you see patients failing multiple antidepressants, don't keep trying them, use a mood stabilizer.
- Traditional view is that Lithium is not as good as Depakote for rapid cycling.  Some data is more favorable for Li+

SECONDARY BIPOLAR D/O
- Most late-onset bipolar d/o more likely to be secondary.
- Li+ is relatively ineffective (responds better to Depakote or Tegretol).

SOME TX STRATEGIES
- The large majority of bipolar pts should have maintenance tx.  (Consider no maintenance if manic episode was brief).
- These pt's are sensitive to sleep deprivation.  Give a few PRN BZD's in case they need to sleep.
- Help them sleep while waiting for mood stabilizer to work!  (with BZD's).
- Do not give sedating antidepressants such as Trazodone --> risk of cycle acceleration.
- Use antidepressants just for acute depression.  Taper off and just use mood stabilizer for prophylaxis.
- Lamictal also works to prophylax against depression.

European collegues argue against our emphasis on polarity rather than cyclicity.

Best 2 screening questions (?)
- Racing thoughts ("I'm depressed but my thoughts can't slow down - could be mania)
- Increased activity (Not "increased mood").

Cyclothymia
- subsyndromal
- bipolar pts tend to have these even with best control

These 5 characteristics are seen with bipolar pts  but not unipolar.  Even when "euthymic", pts  have these characteristics.
Extraversion
Perceiving
Novelty seeking
Moment  to moment impulsivity
Disorderliness

Most common manifestations  of hypomania
Increased:
activity 97pc
energy  96pc
plans,  ideas  91pc
self confidence 
(there are a few more)

Relative severity of  bipolar sx's in MANIA
-  Bowden et al
#1:  insomnia
#2 somatic  anxiety
#3 racing thoughts
#4 energetic
Average severity of these  are  lower than others:
#22 (Last) elated
#21  Grandiose
#20  sharpened thinking

To find bipolar in the depressed: MDQ (Mood Disorder Questionnaire) 7 of 13 or higher.  Also if agitated (needs to be calmed down) or hypernating (need to be stimulated) depression, ask if they've ever had the other type.  If just depression, the depression should be the same type every time??

The  most striking element of a bipolar depression is decreased ENERGY.   (Charles Bowden MD)
Reduced sexual interest and social withdrawal are very characteristic of bipolar depression.

Irritality is the distinguishing characteristic of mixed manic state. 

Psychotic mania has high euphoria.

Bipolar features a/w high  function
- increased  range and speed of associated concepts
- perseverance
- high energy
- heightened perceptual sensitivity
- exuberance  and playfulness
- optimism
Andreasen N,  Br J Psy

35pc of persons with bipolar disorder seek  no treatment  within 10yr of first  symptoms
- 34pc are incorrectly diagnosed initially
- average time to  correct diagnosis is 8yr from first seeking tx

Tx principles
- Pure mania: depakote works great
- If depression or psychotic features are present, do not rely on divalproex alone
- divalproex and  lithium are equal for tx of (some listed) manic sx's
- goal is functional recovery
- Several weeks (rather than days) are required to assess the effect of new treatment.
- As monotx: antidepressants have never outperformed mood stabilizers.

 Olanzapine add-on (to  Li or Depakote) for mania works, but early weight gain.

 Change in Haldol dose when depakpte is added in mania: allows haldol dose to be decreased by 50pc.

Lamictal is 2x more tolerable than Li.
Valproate is 2x more tolerable than Li.

Stopping Lithium is big risk of depression.

Bipolar disorder:

Lifetime prevalence is 1-2%

Lifetime suicide rate is 15%

Only 27% of patients receive treatment.

Incidence is equal among males and femal.

Average age of onset is 19 years old
(as compared to 29 years old for major depressive disorder).

Rare to begin after 50's.

60% of bipolar patients have substance abuse during their lifetime.

For diagnosis of Bipolar I, only one manic episode is needed.  Do not necessarily need a depressive episode to make the diagnosis.

An episode of hypomania is not sufficient for a diagnosis of Bipolar II - also need a major depressive episode.

Cyclothymia - hypomania and depression, but the depression never met the criteria for a major depressive episode (i.e., never lasted 2 weeks).

How to differentiate between mania and hypomania is dysfunction.

50% of bipolar patients will have psychotic features during a manic or mixed episode.

The receptor polymorphism a/w bipolar disorder is.....
- D2 receptor

The enzyme abnormality a/w bipolar disorder is.....
- Tyrosine hydroxylase (rate limiting step in catecholamine synthesis?)

MANAGEMENT OF EUTHYMIA
- psychoeducation increases
- side effects
- talk about cognitive dysfunction which worsens with more mania - executive function, memory, sustained attention
- need to stay on mood stabilizer
- may not need to continue antipsychotics or antidepressants

Tx Refractory Bipolar:

#- Augment with high dose T4
  --> T4 = Levothyroxine = SYNTHROID
  --> for rapid cyclers
  --> need to bring T4 to supranormal level

#- Lithium + carbamazepine
  --> appears to be a true potentiation
  --> Carbamazepine lowers WBC alone, but this combination raises WBC count slightly

#- Augment with antipsychotic (if prominent psychotic features or schizoaffective d/o)

#- BZD's as long-term adjunct
- Studies examining BZD's for bipolar d/o are inconsistent.
It is hard to distinguish specific anti-manic effects from sedative effects.
- Lorazepam (ATIVAN) is safe and effective alternative to neuroleptics in the initial management of manic agitation while waiting from the mood stabilizer to work. Works for catatonia, which is oten a manifestation of the manic phase of bipolar d/o
- Clonazepam (KLONOPIN) is the BZD that may actually have mood-stabilizing properties.

#- Augment with Topiramate (TOPAMAX)
   --> This has been added mostly to counteract the weight gain with Li+, Depakote or Tegretol


An Overview of Bipolar Disorder and Its Diagnosis


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