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Ask-the-Doctor Bipolar Disorder NAMI 2009. Descartes Li, M.D. Associate Clinical Professor University of California, San Francisco Chief, UCSF Bipolar Program http://psych.ucsf.edu/Patients/Bipolar_Program.asp. Questions. What questions that you would like reviewed?. The Limbic System.

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Ask-the-DoctorBipolar DisorderNAMI 2009

Descartes Li, M.D.

Associate Clinical Professor

University of California, San Francisco

Chief, UCSF Bipolar Program

http://psych.ucsf.edu/Patients/Bipolar_Program.asp


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Questions

What questions that you would like reviewed?



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What are theSubtypes of Bipolar Disorder?

Bipolar I: Depression with Classic Mania

Bipolar II: Depression with Hypomania

Bipolar III: Antidepressant Associated Hypomania


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Major Depressive Disorder

Cyclothymic Disorder

Dysthymic Disorder

Bipolar I Disorder

Bipolar II Disorder


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Major Depressive Disorder—Diagnostic Criteria

Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks

At least 1 of these 2 symptoms:

  • Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

DSM-IV-TR™ 2000.


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Major Depressive Disorder—Diagnostic Criteria

Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks

DSM-IV-TR™ 2000.


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DSM-IV Diagnostic CriteriaHypomanic Episode:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 4 days.

B. During the period of the mood disturbance, three or more of the following symptoms (four if the mood is only irritable):

APA Diagnostic and Statistical Manual. 1994


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DSM-IV Diagnostic CriteriaHypomanic Episode:

  • 1) inflated self-esteem or grandiosity

  • 2) decreased need for sleep (eg, feels rested after only 3 hours of sleep)

  • 3) more talkative than usual or pressure to keep talking

APA Diagnostic and Statistical Manual. 1994


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DSM-IV Diagnostic CriteriaHypomanic Episode: (continued)

  • 4) flight of ideas or subjective experience that thoughts are racing

  • 5) distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)

  • 6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

APA Diagnostic and Statistical Manual. 1994


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DSM-IV Diagnostic CriteriaHypomanic Episode: (continued)

  • 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

APA Diagnostic and Statistical Manual. 1994


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DSM-IV Diagnostic CriteriaHypomanic Episode: (continued)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

APA Diagnostic and Statistical Manual. 1994


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DSM-IV Diagnostic CriteriaHypomanic Episode: (continued)

E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)

APA Diagnostic and Statistical Manual. 1994


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DSM-IV Diagnostic CriteriaManic Episode:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. Same as for hypomanic episode


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DSM-IV Diagnostic CriteriaManic Episode: (continued)

C. The symptoms do not meet criteria for a Mixed Episode.

D.The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.


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DSM-IV Diagnostic CriteriaManic Episode: (continued)

E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).


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Bipolar Disorder: DIG FAST Mnemonic

D – Distractibility

I – Insomnia

G – Grandiosity (or inflated self esteem)

F – Flight of Ideas (or racing/crowded thoughts)

A – Activities (increased goal directed activities)

S- Speech (pressured)

T- Thoughtlessness (impulsivity, ie, increased pleasurable activities with potential for negative consequences: sex, money, traveling, driving)


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What is Rapid Cycling?

  • Four or more mood episodes per year.

  • Considered more treatment-refractory.

  • Individuals with bipolar disorder may go through periods of rapid-cycling that may last years.

  • Associated with antidepressant monotherapy.


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What is a Mixed Episode?

Rapidly alternating moods (sadness, irritability, euphoria) accompanied by criteria for both a Manic Episode and a Major Depressive Episode.

Duration of 1 week.

Frequently includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking.


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Controversy about antidepressants in bipolar disorder

  • They can cause hypomania where there was none.

  • They can induce cycling, or make it worse.

  • They may keep a person from becoming truly stable.

  • And they might, just might, cause some long-term harm, perhaps even irreversible harm.


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Step #1: Stop Cycling

  • Interventions:

    • Stop antidepressants

    • Prevent mania or hypomania

From http://www.psycheducation.org/depression/ADwithoutAD.htm#stop


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Summary Recommendations

1. Do not use antidepressants if rapid cycling or severe insomnia/agitation (suggesting bipolar mixed state) is already present.

2. Do not use antidepressant if there is a history of mania or hypomania on an antidepressant, use a mood stabilizer.

3. If you are on an antidepressant and are not doing well, try stopping that antidepressant to see if things are more stable (or at least, no worse).


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Treatment options for bipolar depression

What are they?

  • Optimize mood stabilizer or AAP

  • Lamotrigine

  • Psychotherapy

  • Dark therapy

  • Exercise

  • Electroconvulsive Therapy (ECT)

  • Antidepressants?!?

    Remember prevention!


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(Atypical) Antipsychotics: Don’t be afraid of the word “antipsychotic”


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Atypical Antipsychotics (AAPs)

Olanzapine (Zyprexa) 2.5mg-20mg/day

Quetiapine (Seroquel) 12.5-600mg/day

Risperidone (Risperdal) 0.25mg-6mg/d [also, Invega (paliperidone)]

Ziprasidone (Geodon) 20-160mg a day

Aripiprazole (Abilify) 5-30mg a day

listed in order of rate of weight gain/sedation (greatest to lowest)


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Psychotic Disorders:Atypical Antipsychotics

  • Multiple receptor effects: serotonin and dopamine receptor subtypes

  • Lower rates of side effects (compared with older antipsychotics), including tardive dyskinesia

  • Neuroleptic malignant syndrome rare

  • High rate of “metabolic syndrome”: weight gain, dyslipidemia, hyper-cholesterolemia, hyperglycemia (diabetes)


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How to manage weight gain

Initial target should be weight stabilization, then weight loss

  • Exercise and diet (for some people depression itself causes weight gain)

  • Avoid (if possible) medications that cause significant weight gain

  • Lower the dosage of medications

  • Antidote medications are only marginally helpful: amantadine, metformin, topiramate, H-2 blockers


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Evidence-based, psychosocial treatmentsfor bipolar disorder

  • Cognitive-behavioral therapy (CBT)

  • Interpersonal and Social rhythm psychotherapy (IPSRT)

  • Family-focussed therapy (FFT)

  • Psychoeducation


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Cognitive Behavioral Therapyof bipolar disorder

  • Recognition and Diagnosis of Bipolar Disorder

  • Medication Treatments for Bipolar Disorder

  • Symptom Monitoring: An Early Warning System

  • Cognitive Changes in Depressive Episodes and Mania

  • Behavioral Changes and Problems in Depressive Episodes and Mania

  • Psychosocial and Interpersonal Problems: Communication

Cognitive-Behavioral Therapy for Bipolar Disorder,by Monica Ramirez Basco, A. John Rush, The Guilford Press 1996,


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CBT techniques for bipolar disorder

  • a diary of significant events and associated feelings, thoughts and behaviors

  • questioning and testing assumptions or habits of thoughts that might be unhelpful and unrealistic

  • gradually facing activities which may have been avoided

  • trying out new ways of behaving and reacting.


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Evidence-based, psychosocial treatmentsfor bipolar disorder

  • Cognitive-behavioral therapy (CBT)

  • Interpersonal and Social rhythm psychotherapy (IPSRT)

  • Family-focussed therapy (FFT)

  • Psychoeducation


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Interpersonal and Social Rhythm Therapy

  • Interpersonal Therapy

  • Social Rhythms and The Social Rhythm Metric

    • “Zietgebers”

    • Find the right balance: how much rest, activity, stimulation is ideal?

    • Maintaining the balance

    • Adapting to changes in routine (planned and unplanned)



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Evidence-based, psychosocial treatmentsfor bipolar disorder

  • Cognitive-behavioral therapy (CBT)

  • Interpersonal and Social rhythm psychotherapy (IPSRT)

  • Family-focussed therapy (FFT)

  • Psychoeducation


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Expressed Emotion and Bipolar Disorder

Intensity of negative interactions in close personal relationships (e.g., family, living situation)

  • Criticism – predicts mania and depression

  • Hostility – predicts mania and depression

  • Over-involvement – predicts depression


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Family-Focused Treatment (FFT) of Bipolar Disorder

  • 21 outpatient sessions over 9 months

  • Assessment of patient and family

  • Psychoeducation about bipolar disorder (symptoms, early recognition, etiology, treatment adherence, self-management)

  • Communication enhancement training (behavioral rehearsal of effective speaking and listening strategies)

  • Problem-solving skills training

Miklowitz DJ & Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press, 1997.


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Family-Focused Treatment (FFT) and Medication Delays Relapses More Than Crisis Management (CM)+Medication

Cumulative Survival Rates Over 2-Year Follow-Up (N=101)

FFT+Medications

Cumulative Survival Rate

CM+Medications

Weeks of Follow-Up

CM vs. FFT 2(1)=8.71, p=.003; FFT, mean survival=73.5 weeks; CM, 53.2 weeks.

Miklowitz DJ, et al. Arch Gen Psychiatry 2003;60(9):904-912.


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Family-Focused Treatment Enhances Drug Adherence More Than Relapses More Than Crisis Management: Rates Over a 2-Year Follow-Up

16%

44%

39%

% of Patients

34%

45%

21%

2 (2)=9.1, p=.01.

Miklowitz DJ, et al. Arch Gen Psychiatry 2003;60(9):904-912.


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6 Relapses More Than

IPSRT (n=18)

ICM (n=20)

5

Social RhythmMetric Score

4

3

2

0

10

20

30

40

50

60

70

80

Weeks of Treatment

Change in Stability of Social Rhythmsas a Function of Time in Treatment

p=.006

ICM=Intensive clinical management. IPSRT=Interpersonal social rhythm therapy.

Frank E, et al. Biol Psychiatry 1997;41(12):1165-1173.


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Probability of Hospitalization if a Relapse Occurred: 2-Year Study

  • FFT: 55%

  • IFT: 88%

    Conclusion: Family intervention can help patients and families to avoid the need for rehospitalization during a period of symptom deterioration

Rea MM, et al. J Consult Clin Psychol 2003;71(3):482-492.


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Evidence-based, psychosocial treatments Studyfor bipolar disorder

  • Cognitive-behavioral therapy (CBT)

  • Interpersonal and Social rhythm psychotherapy (IPSRT)

  • Family-focussed therapy (FFT)

  • Psychoeducation


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What is psychoeducation? Study

A course in which you will learn:

  • What bipolar disorder is

  • Techniques and tips to better manage the disorder


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Psychoeducation Study

21 groups sessions of 90 minutes each

Topics include:

  • Awareness of the disorder (6 sessions)

    • Symptoms, etiology, triggers, course

  • Drug Adherence (7 sessions)

    • Review of medications, blood tests, alternative therapies

  • Avoiding substance abuse (1 session)

  • Early Detection of New Episodes (3 sessions)

  • Regular habits and stress management (4 sessions)

    • Includes problem-solving strategies

Psychoeducation Manual for Bipolar Disorder, by F. Colom and E. Vieta, Cambridge University Press, 2006.


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Overview of Bipolar Disorder Group Sessions UCSF Study

Introduction (Li)

Self Awareness (Donovan)

Medications (Li)

Sleep and Substances (Li)

Living a Healthy Lifestyle (Lehr)

Coping with Depression (Lehr)

Communication Skills (Thomas)

The Future: A Review (Li)



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Hormones and Mood Study

  • The basis of estrogen effects on mood is likely to be extremely complex, not simple

  • Too much estrogen may also be bad, perhaps associated with anxiety/agitation

  • High levels of estrogen can act to enhance the stress response, at least in rats

    Molecular Psychiatry (2004) 9, 531–538

  • Antidepressants can improve hormone-related hot flashes and mood problems, with or without supplemental estrogen

    Brizendine Current Psychiatry; October 2003

  • Use of hormone replacement is controversial because of risks (breast and endometrial cancer)

    Check out http://www.project-aware.org/index.shtml


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Hormones and Mood Study

More suicidal events (attempts, completed suicides) occur in the first week of the cycle. ?Low levels of estrogen in that phase, perhaps leading to low levels of serotonin

Saunders and Hawton Psychol Med. 2006 Jul;36(7):901-12

What is Premenstrual Dysphoric Disorder (PMDD)?

A more severe form of PMS.

symptoms can only occur in the second half of the cycle


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Bipolar disorder and pregnancy Study

  • 89 pregnant women with bipolar disorder (69% type I, 31% type II) followed prospectively across pregnancy.

  • 70.8% of the participants experienced at least one mood episode. Most of these episodes were either depressive or mixed (74%), and 47% occurred during the first trimester.

  • The risk of recurrence in women who discontinued treatment with mood stabilizers (85.5%) than those who maintained treatment (37.0%).

  • In addition, the women who discontinued mood stabilizer spent over 40% of their pregnancy in an illness episode, versus only 8.8% among subjects who maintained treatment with a mood stabilizer.

  • factors associated with increased relapse rates:

    • polytherapy with more than two psychotropic agents (RR=2.3),

    • use of antidepressants (RR=2.0),

    • primary mood stabilizer other than lithium (RR=1.6), abrupt discontinuation (less than two weeks) of mood stabilizer (RR=1.4).

      Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, et al. Risk of Recurrence in Women With Bipolar Disorder During Pregnancy: Prospective Study of Mood Stabilizer Discontinuation. Am J Psychiatry 2007; 164:1817-1824.


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Summary Study

  • Antidepressants are not helpful

  • Psychotherapy is helpful/critical

  • Weight gain is a common problem

  • Hormones have a great influence on mood, but HRT is controversial

  • Doing what works for you is most important (try something, record the results)


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Resources for Bipolar Disorder Study

Miklowitz, D. (2002). The Bipolar Disorder Survival Guide: What you and your family need to know. New York: Guilford Press.

Mondimore, F. M. (1999). Bipolar disorder: A guide for patients and families. Baltimore: Johns Hopkins University Press.

Jamison, K. R. (1995). An Unquiet Mind. New York: Knopf.

Website: http://www.psycheducation.org/

(Dr. Phelp’s website)


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