Perils and pitfalls of the diagnosis of the bipolar disorders
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Perils and Pitfalls of the Diagnosis of The Bipolar Disorders. Discuss the recognition of bipolar disorder in the clinic setting Discuss the treatment options for bipolar depression Describe the efficacy and safety of treatment options for bipolar depression.

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Perils and Pitfalls of the Diagnosis of The Bipolar Disorders

  • Discuss the recognition of bipolar disorder in the clinic setting

  • Discuss the treatment options for bipolar depression

  • Describe the efficacy and safety of treatment options for bipolar depression

Q: Is this episode of depression really due to Major Depression or due to Bipolar Disorder?


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Bipolar Disorders are Diagnoses of Inclusion Disorders

According to DSM-IV-TR:

Major Depression should only be DX’d after a H/O of mania/hypomania has been excluded and the bipolar disorders have been ruled out

Screening for H/O mania/hypomania is essential in order to differentiate the bipolar disorders from the depressive disorders


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Bipolar Disorders are Diagnoses of Inclusion Disorders

According to DSM-IV-TR :

Bipolar Disorder – manic, mixed, depressed

Bipolar Disorder – type II

Bipolar Disorder NOS, & Cyclothymia

There is no exclusion other than the ascription of a General Medical Condition or Drug Intoxication or Withdrawal Syndrome.


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Why is Screening Necessary? Disorders

  • 1. Patients don’t report manic symptoms

  • 2. Evaluation may not use outside sources

  • 3. The Antidepressant Problem:

  • Patients often request antidepressants

  • Antidepressants worsen the course and may lead to more depressive episodes


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Screening for Mania and Mixed States Disorders

The Mood Disorder Questionnaire (MDQ) is a validated screening instrument for bipolar I and II disorders

Hirschfeld RM, et al. Am J Psychiatry. 157:1873, 2000


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DIGFAST Disorders:Symptoms of Hypomania and Mania

D Distractibility: poorly focused

I Insomnia: decreased need for sleep

G Grandiosity: inflated self-esteem

F Flight of ideas: c/o racing thoughts

A Activities: increased activities

S Speech: pressured or more talkative

T Thoughtlessness: “risk-taking” behaviors sexual, financial, travel, driving

Ghaemi et al, World J Biol Psych 2: 65, 2000


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The Unmistakable Triad DisordersGeorge Winokur, Classification of Mania & Depression, 1991

EuphoriaPressured Speech Hyperactivity3 Signs in 3 Days in 3 Settings


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The Questionable Quad – Disordersthe 4 I’sGeorge Winokur, Classification of Mania & Depression, 1991

IrritabilityInsomniaImpulsivityImpaired Social/Vocational Life>4 Days – Hypomania<4 Days – Bipolar NOS


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Longitudinal Assessment of the Course of Bipolar Disorders Disorders

Mania

Hypomania

Euthymia

Polarity of Symptoms

Subsyndromal

Depression

Depression

Depression


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Medications for Bipolar Disorder DisordersMood Stabilizers

Divalproex DR Divalproex ER

Carbamazepine ER

Lamotrigine - M

Lithium - M

Depakote Depakote ER

Equetro

Lamictal

Eskalith, Lithobid

FDA Approvals – Depression or Maintenance


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Mood Stabilizers Disorders

  • Lamotrigine - increase slowly may increase Divalproex levels & vice versa, Watch out for Rashes

  • Carbamazepine – Monitor levels, autoinduces itself & reduces APs, Dizzy, Double Vision, Dropping, Decreased Sodium, Agran.

  • Lithium – Monitor levels, Chem 7, drug-drug interactions, Tremor, Thirst, Thyroid, Toxicity

  • Divalproex – Monitor levels, LFTs, Tremor, GI side effects, Alopecia, Pancreatitis


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Medications for Bipolar Disorder DisordersSecond Generation Antipsychotics

Aripiprazole - M

Olanzapine - M

Quetiapine - Depr

Risperidone

Ziprasidone

Abilify

Zyprexa

Seroquel

Risperidal

Geodon

Olanzapine/Fluoxetine – Depr Symbyax


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SGAs Guidelines Disorders

  • Baseline:

    • Weight (BMI) – monthly for the first 3 months

    • Waist circumference

    • Blood pressure

    • Fasting plasma glucose (and Hemoglobin A1c if hyperglycemia is detected)

    • Fasting lipid profile

    • AIMS (Abnormal Involuntary Movement Scale) or other screening tool for tardive dyskinesia

  • Opthalmologic screening should be obtained for those on Quetiapine and those with diabetes mellitus


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    SGA Guidelines Disorders

    • Q3months:

      • Weight (BMI)

      • Blood pressure

      • Fasting plasma glucose (and Hemoglobin A1c if hyperglycemia is detected)

      • Fasting lipid profile

  • Q6 months:

    • AIMS (Abnormal Involuntary Movement Scale) or other screening tool for tardive dyskinesia

    • Opthalmologic screening should be obtained for those on Quetiapine and those with diabetes mellitus.


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    Optimal TX of Bipolar Depression Disorders

    • Clear Rationale for MS vs AP

    • Balance Efficacy versus Tolerability

    • Screen for Manic Sx, Non-Response

    • Psychosocial Therapies

    • Monitor Adherence versus Cost Effectiveness on an ongoing basis


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    Take Home Points: Bipolar Depression Disorders

    • Bipolar disorder is common and patients tend to present with depression

    • Antidepressant monotherapy should be avoided

    • Screening for bipolar disorder in clinics recommended

    • When detected treat bipolar disorder

    • Bipolar depression has limited FDA approved TX

    • Mood stabilizers and SGAs have some risks but may be helpful and improve the course of the illness


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    Perils and Pitfalls: Bipolar Disorder Disorders

    • Major Depression is more common and the diagnosis is more reliable (MDD>BPAD>BP II> BPNOS>Cycl)

    • Denying antidepressants can increase morbidity

    • When bipolar disorders are favored psychotherapy may be overlooked

    • New FDA approved TX: EMSAM (transdermal selegiline), Vagus Nerve Stimulation, the STAR*D study

    • Bipolar/ADD pts will not get stimulants


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    Pitfalls of Bipolar Disorder Screening Disorders

    • Mood Swings are reported by lots of patients for lots of reasons

    • Mood Swings are a reason for referral from various sources

    • Bipolar disorders - easily considered, rarely eliminated

    • The FDA approved TXs: Quetiapine, lithium and lamotrigine may be a bitter pill to swallow

    • Bipolar disorders are less reliable & TX is with up to 10 medications


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