Bipolar disorders 2007
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Bipolar Disorders - 2007. Ronald A. Remick, MD, FRCP(C) Consultant Psychiatrist Member, Board of Directors, MDA Phone : 604-682-2344 ext 62121 Email : [email protected] Epidemiology. 1. Lifetime prevalence : bipolar I : 0.8% bipolar II : 0.6% (Murphy, 2000)

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Bipolar Disorders - 2007

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Bipolar disorders 2007

Bipolar Disorders - 2007

Ronald A. Remick, MD, FRCP(C)

Consultant Psychiatrist

Member, Board of Directors, MDA

Phone : 604-682-2344 ext 62121

Email : [email protected]


Epidemiology

Epidemiology

1. Lifetime prevalence :

bipolar I : 0.8%

bipolar II : 0.6% (Murphy, 2000)

2. Bipolar disorder is the 6th leading cause of

disability, ages 15-44, worldwide…

depression is 2nd!

3. At any given point in time, 60% of

bipolars are not in treatment


Mood disorders and the workplace new data

Mood Disorders and the Workplace (new data)

30% of disability claims in Canada ($15-30 billion annually) due to mood disorders (second only to cardiovascular disease)…and increasing!


Mood disorders and the workplace new data1

Mood Disorders and the Workplace (new data)

Absenteeism vs Presenteeism

Presenteeism (lost productivity while at work) – likely a more significant problem with mood disorders than previously recognized in Canada

Productivity loss from presenteeism due to depression is 4 hours/week while loss from absenteeism is but 1 hour/week (between $6-60 billion loss per annum)!


Epidemiology1

Epidemiology

1. Course of bipolar I is 9-10 cycles during a lifetime – often stabilizing after 4-5 cycles

2. Without treatment – average depressive episode is 10 weeks, average manic episode is 5 weeks

3. Sixty percent of patients have an increase in episode intensity/duration with age


Bipolar disorders 2007

What about the role of ‘stress’ in bipolar illness?

1. Disruption in sleep, but not ‘stress’ per se can lead to a bipolar relapse.

2. Early childhood ‘trauma’ is NOT causative in bipolar illness. However,

a. sexual abuse – may increase risk of suicide attempts

b. physical abuse – may increase risk of manic relapses

c. sexual/physical abuse – may lead to earlier illness onset


Genetics of bipolar illness

Genetics of Bipolar Illness

1. Polygenic inheritance. Fifty percent of bipolar patients have a family history of bipolar illness.

2. Linkage studies (in several studies) have identified markers on chromosome 18 &22.

3. Near future is identifying individuals at risk; long term future – superior treatments.


Evolving genetic concepts new data

Evolving genetic concepts(new data)

1. endophenotypes are gene intermediaries that turn on or turn off a specific gene

2. “Stress/adversity’ can influence endophenotypes. That is, stress or adversity can turn on or turn off certain genes that can either trigger depression (vulnerability) or protect from depression (resiliency)


Stress and the brain new data

STRESS and the BRAIN(new data)

CRF

ACTH

adrenaline

cAMP

BDNF

brain cell growth


Stress and the brain

STRESS and the BRAIN

(new data)CRF

ACTH

adrenalineSTRESS

cAMP

BDNF

brain cell growth


Bipolar disorders 2007

Limbic System

Hypothalamus

STRESS

CRF

Mood dysregulation

HippocampalShrinkage

Memory impairment

Pituitary

Apoptosis/neuron death

ACTH

Adrenal Cortex

Cortisol + Adrenaline


Diagnosing bipolar disorders

DIAGNOSING BIPOLAR DISORDERS


Diagnosis of depression

Diagnosis of depression

1.A distinct mood change (depressed, irritable, anxious, etc) for at least two weeks

2. Four or more SIGECAPS :

S leep C oncentration

I nterest A ppetite

G uilt P sychomotor activity

E nergy S uicide


Diagnosis of mania hypomania

Diagnosis of mania/hypomania

1. A distinct mood change (elated, irritable, expansive, etc) for > one week (four days for hypomania)

2. Three or more GST RAID :

G randiosity R apid thoughts

S leep(decreased) A gitation

T alkative I mpaired judgement

D istractible


Diagnosing bipolar illness

Diagnosing bipolar illness

1. Distinguish bipolar I (mania) from bipolar

II (hypomania)

2. ***Bipolar II is among the most frequently

missed diagnoses in psychiatry***

3. The diagnosis of bipolar II disorder is

risky, at best, without collateral

information.


Diagnosis of hypomania

Diagnosis of hypomania

Doctors often fail to ask key questions (*of afamily member and the patient) that assist in the diagnosis of bipolar II disorder :

“ Has there been a period of time when you were feeling so good or hyper that other people thought you were not your normal self, or were so hyper you got into trouble?”

“ What about a period of time when you were so irritable that you would shout at people or start fights or arguments?”


Treatment of bipolar disorders

Treatment of Bipolar Disorders


Treatment of bipolar disorders1

Treatment of Bipolar Disorders

1. Bipolar disorder is a chronic illness:

a) Expect exacerbations and remissions

b) Long term chemotherapy is the rule not the exception

2. It is risky, at best, to treat bipolar patients in a vacuum i.e. without the involvement of family/significant others


Treatment of bipolar illness

Treatment of bipolar illness

1. PSYCHOLOGICAL INTERVENTIONS

2. BIOLOGICAL INTERVENTIONS


Treatment of bipolar illness1

Treatment of bipolar illness

PSYCHOLOGICAL TREATMENTS

1. Psycho education :

a. Mood Disorders Assoc of British Columbia

b. internet/ readings, etc

2. Psychotherapy :

a. Cognitive Behavioral Therapy (CBT) for the depressive phase of illness

b. Cognitive Behavioral Therapy (CBT) to prevent manic relapses


Cognitive behavioral therapy cbt

Cognitive Behavioral Therapy (CBT)

1. The evidence based psychotherapies (CBT – cognitive behavioral therapy) are AS EFFECTIVE as antidepressants in mild/moderate MDD.

2. Cognitive therapy (CBT) is accessible in British Columbia.


Cognitive behavioral therapy

Cognitive Behavioral Therapy

CBT response rate(8-12 weekly sessions) – 65%

Core features:

a. identify automatic maladaptive thoughts and distorted beliefs that lead to depressive moods

b. learn strategies to modify these beliefs and practice adaptive thinking patterns

c. use a systematic approach to reinforce positive coping behaviors


Cognitive behavioral therapy1

Cognitive Behavioral Therapy

CBT is accessible:

a. private psychologist (not covered by medical

insurance)

b. Changeways (www.changeways.com) - a

group based CBT program offered at many

hospitals/mental health centers throughout

BC (free – covered by medical insurance)

c. www.carmha.ca/publications - ‘anti-

depressant skills workbook’ (free download)-

an outstanding self directed CBT workbook


Biological treatments for bipolar disorders

Biological Treatments for bipolar disorders

1. LITHIUM

2. VALPROIC ACID

3. CARBAMAZEPINE

4. LAMOTROGINE

5. ATYPICAL ANTIPSYCHOTICS

6. ANTIDEPRESSANTS

7. OTHER ANTICONVULSANTS


Lithium wherefore art thou old old data

Lithium* – wherefore art thou?*old, old data!


Lithium

Lithium

1. Expect “two thirds” response to lithium:

33% - complete response

33% - significant mood

attenuation

33% - no response/intolerance

2. “anti-suicide” effect of lithium

3. lithium remains the ‘gold standard’ in treating bipolar illness and is among the most effective and underutilized treatments in all of psychiatry!


Suicide attempts before during one year and two years post lithium treatment

Suicide attempts before, during, one year, and two years post lithium treatment


Valproic acid

Valproic Acid

1. Valproic acid (divalproex; Depokoate; Epival) is an effective antimanic agent

2. The evidence for the prophylactic efficacy of valproic is still not clear (one short RCT, pharmaceutical company sponsored)

3. Valproic is far superior as an anti manic rather than an antidepressant preventative agent

4. Serum levels appropriate (versus no defined therapeutic range with carbamazepine)


Carbamazepine

Carbamazepine

1. Carbamazepine (Tegretol) is an effective antimanic agent (19 studies)

2. Carbamazepine is an effective prophylactic agent (10 RCTs), but likely less effective than lithium (Davis et al, 1999)

3. Carbamazepine appears to be a forgotten (yet very effective) treatment in bipolar illness

4. Oxcarbazepine (Trileptil) is being touted as a ‘similar’ but ‘superior’ medication to carbamazepine, but recent studies shed some doubt


Lamotrogine lamictal

Lamotrogine (Lamictal)

1. There is increasing evidence that lamotrogine is an effective agent in treating both bipolar I and II depression.

2. There is very limited (but some) evidence that lamotrogine is an effective anti-manic or prophylactic agent.

3. Lamotrogine has a relatively benign (e.g. non sedative, weight neutral) side effect profile. Dose range not determined but likely 100-300mg/day


Other anticonvulsants in bipolar disorder

Other anticonvulsants in bipolar disorder

There is NO evidence that gabapentin (Neurontin) or topiramate (Topramax) has any benefit at all in the treatment of bipolar depression, bipolar mania, and/or the preventative/prophylactic treatment of bipolar illness


Typical atypical antipsychotics

Typical/Atypical Antipsychotics

1. All are effective in mania. Limited evidence for effectiveness in prophylaxis or in depressive episodes.

2. All atypical antipsychotic research is pharmaceutical industry sponsored .

3. Significant concerns about weight gain, dyslipidemia, & diabetes with atypicals; especially olanzapine(Zyprexa) and clozapine(Clozaril) but alsorisperidone(Risperdol) and quetiapine (Seroquel)


Medical co morbidity and life expectancy

Medical Co-Morbidity and Life Expectancy

1.Individuals with schizophrenia and affective disorders have increased risk of death from medical causes and a shorter lifespan

2.Comparing mortality in public mental health clinics in the USA with the general population (1997-2000), patients lost decades of potential years of life (average 25 years)


Medical co morbidity and life expectancy cont

Medical Co-Morbidity and Life Expectancy(cont)

3. As in the general population the main cause of death is coronary heart disease (CHD), but to an even greater extent

4. Cardiovascular standardized mortality rate in schizophrenia is approximately 2X the general population (2.3 in males and 2.1 in females) Patients with both unipolar and bipolar disorder also have increased mortality from CHD


Cardiac metabolic co morbidity health determinants

Medication

Weight gain

Diabetes/lipids

Metabolic syndrome

Cardiac effects

Patient Factors

Failure to recognize illness

Refusal of treatment

Non-adherence with treatment

Cardiac/Metabolic Co-morbidityHealth Determinants

Lifestyle

Smoking

Substance abuse

Diet, exercise

Poverty

Systemic Factors

Limited attention to medical care

Separation of psychiatric and mental health care

“Falling between the cracks”


Lifestyle

Lifestyle

The diet of individuals with SMI(Serious Mental Illness) has been characterized as high fat,high in calories and high in simple carbohydrates

Patients with SMI are less active then those in the general population and are more likely to walk as their sole form of physical activity

Smoking rates are elevated in the SMI and range between 32% and 92% in schizophrenia samples


Metabolic abnormalities with atypical antipsychotics

Metabolic Abnormalities with Atypical Antipsychotics


Typical atypical antipsychotics1

Typical/Atypical Antipsychotics

1. All are effective in mania. Limited evidence for effectiveness in prophylaxis or in depressive episodes.

2. All atypical antipsychotic research is pharmaceutical industry sponsored .

3. Significant concerns about weight gain, dyslipidemia, & diabetes with atypicals; especially olanzapine(Zyprexa) and clozapine(Clozaril) but alsorisperidone(Risperdol) and quetiapine (Seroquel)


Bipolar disorders 2007

Do not rashly use every new product of which the peripatetic siren sings. Consider what surprising reactions may occur in the laboratory from the careless mixing of unknown substances. Be as considerate of your patient and yourself as you are of the test tube.

- Sir William Osler


Managing depressive and manic relapses

Managing depressive and manic relapses


Managing depressive and manic relapses1

Managing depressive and manic relapses

“don’t throw out the baby with the bathwater”


Managing depressive relapse

Managing Depressive Relapse

1. Don’t throw out the baby with the bathwater!

2. The risk of an antidepressant induced manic

switch in both bipolar I/II is < 10%

3. Treatment options:

a. second mood stabilizer (I), especially lamotrogine

b. antidepressant (II,I)/lamotrogine

c. CBT(I,II)

d. ECT(I,II)


Managing manic hypomanic relapse

Managing Manic/Hypomanic Relapse

1. Don’t throw out the baby with the bath water.

2. Other treatment options :

a. hospital care (I)

b. no treatment intervention (II)

c. second mood stabilizer (I/II)

d. atypical /typical antipsychotic (I/II)

e. benzodiazepine (II)

f. ECT (I)


Prevention of future manic relapses ulysses agreement

Prevention of future manic relapses – Ulysses Agreement

1. Set it up BEFORE manic relapse with doctors, family, employers, etc.

2. Put it in writing…outline the type of treatment e.g. hospitalization, antipsychotic medication, etc.


Grey zones in bipolar illness or topics for future presentations

“Grey zones” in bipolar illness…or topics for future presentations

1.“Stressful life problems” versus mild depressive relapse

2. The role of psychological “adversity” in bipolar illness

3.. To treat or not treat hypomania

4. Social/family/vocational stigma

5. “ Doctor should we have children?”

6. Bipolar illness and creativity


What s the deal with childhood bipolar illness new data

What’s the deal with childhood bipolar illness?(*new data)

1. The onset in bipolar illness can be in late adolescence, particularly in children of bipolar parents.

2. The diagnosis of childhood bipolar illness (i.e. ages 5-15)is very different in USA compared to Canada, where childhood bipolar illness is virtually nonexistent.


What s the deal with childhood bipolar illness

What’s the deal with childhood bipolar illness?

3. In Canada, the onset of bipolar illness typically begins with a lengthy depressive episode.

4. In the USA, children with mood lability/irritability, anxiety and insomnia are often given a diagnosis of childhood bipolar illness.

5. The USA position is not consistent with decades of age of onset research, genetic studies, or current diagnostic criteria for bipolar disorders.


Doctor should we have children

“Doctor, should we have children?”

1. The risks are real, but small (2% versus 15%).

2. Illness severity is not related to the severity of the illness in the family.

3. Illness onset is at least twenty years in the future with extensive new develop- ments and treatments on the way.

4. Bipolar illness, without any other risk factors, in a parent is certainly not an exclusion to having and effectively parenting children.


The relationship between creativity and bipolar illness

The relationship between creativity and bipolar illness

1. Many studies have shown that between 20 and 35% of artists (musicians, painters, writers, poets, etc) develop bipolar illness where the rate of bipolar illness in the population is about 2%.

2. The higher rate of bipolar illness cannot be explained by ‘stressful’ life style, poverty, etc.


The relationship between creativity and bipolar illness1

The relationship between creativity and bipolar illness

3. Severe manic and depressive episodes impair creative output.

4. Creativity and bipolar illness have a familial (i.e. genetic) link.

5. Touched with Fire : Manic Depressive Illness and the Artistic Temperment. by Kay Redfield Jamieson (1993)


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