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Bright Nights Community Forum

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Bright Nights Community Forum

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    1. Bright Nights Community Forum Bipolar Disorders University of Michigan Depression Center Ann Arbor Public Library

    2. Bright Nights Forums U-M Depression Center and Ann Arbor Public Library Presentation on topics of interest relevant to mental health in community Panel of experts from U-M Depression Center and Professionals in community Q/A format Improve community awareness of resources available.

    3. Bright Nights Forums Bipolar Disorder: March 29th Suicide: May 24th Sleep and Depression: October 2006

    4. Aretaeus of Cappadocia Melancholia & mania 2 forms of the same disease Mania manifests as euphoria, but others display furious rages Melancholics – possible for them to fly into rage..

    5. Understanding Affective Disorders Kraepelin proposed affect to consist of 3 components Volition Energy & Drive Emotion Happy / Sad Intellect Rate of thoughts Content of thoughts

    6. Celebrities with Bipolar Disorder

    12. Wilhelm Greisinger Mittelformen In which a change from depression to manic exaltation occurs. “Melancholia with destructive drives” “Melancholia with long lasting exaltation of volition” In their mild forms, mittleformen are indistinguishable from personality deviations.

    13. Epidemiology of Bipolar Disorder ECA study lifetime prevalence 1.3% Bipolar I 0.8% Bipolar II 0.5% Including “bipolar spectrum” disorders BP Not otherwise specified ~3% No male or female predominance Females with more depression Despite the infrequency of bipolar disorder and the difficulties inherent in diagnosis, prevalence values are fairly consistent across survey sites. The mean lifetime prevalence of bipolar I and II disorders in the Epidemiologic Catchment Area surveys is 1.3%, with a standard deviation of 1.2%. Notably, however, the prevalence is likely higher than reported. When biopolar spectrum disorders are taken into account, the rate may approach 5%. No male or female predominance is apparent, although females are more apt to have depression. References Bebbington P, Ramana R. The epidemiology of bipolar affective disorder. Soc Psychiatry Psychiatr Epidemiol. 1995;30:279-292. Dunner DL. Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disord. 2003;5:456-463 Lish JD, Dime-Meenan S, Whybrow PC, Price RA, Hirschfeld RM. The National Depressive and Manic- Depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281-29 Despite the infrequency of bipolar disorder and the difficulties inherent in diagnosis, prevalence values are fairly consistent across survey sites. The mean lifetime prevalence of bipolar I and II disorders in the Epidemiologic Catchment Area surveys is 1.3%, with a standard deviation of 1.2%. Notably, however, the prevalence is likely higher than reported. When biopolar spectrum disorders are taken into account, the rate may approach 5%. No male or female predominance is apparent, although females are more apt to have depression. References Bebbington P, Ramana R. The epidemiology of bipolar affective disorder. Soc Psychiatry Psychiatr Epidemiol. 1995;30:279-292. Dunner DL. Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disord. 2003;5:456-463 Lish JD, Dime-Meenan S, Whybrow PC, Price RA, Hirschfeld RM. The National Depressive and Manic- Depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281-29

    14. BP Disorder & Genetics BP disorder is 80% genetics - And 100% environmental! Having a BP sibling or parent increases likelihood of developing BP fivefold compared to general population. Risk increases with increasing number of affected in family. Overlap with genetic risk for other mood, anxiety, and psychotic disorders.

    15. Spectrum of Bipolar Disorders Bipolar I Bipolar II Major depression with a strong family history of bipolar disorder Hypomania Antidepressant-induced mania and hypomania Cyclothymia Rapidly changing mood swings NOS Secondary mania, due to other illnesses or drugs Spectrum of Bipolar Disorders Since 1921 when Emil Kraepelin delineated manic depression (bipolar disorder) as a psychiatric illness from schizophrenia, the definition of bipolar disorder has been expanding. We realize today that bipolar disorder is not a single, definable psychiatric illness, but rather a spectrum of disorders, which are listed on this slide. Bipolar I—one or more manic episodes or mixed episodes and often one or more major depressive episodes Bipolar II—one or more major depressive episodes accompanied by at least one hypomanic episode Major depression with family history of bipolar disorder Hypomania Antidepressant-induced mania/hypomania Cyclothymia—milder form of bipolar disorder Rapidly changing mood swings (ie, rapid cycler) NOS Secondary mania (illness or drug-induced) American Psychiatric Association. Practice Guideline for the Treatment of Patients with Bipolar Disorder. 2nd ed. Washington, DC; 2002. Spectrum of Bipolar Disorders Since 1921 when Emil Kraepelin delineated manic depression (bipolar disorder) as a psychiatric illness from schizophrenia, the definition of bipolar disorder has been expanding. We realize today that bipolar disorder is not a single, definable psychiatric illness, but rather a spectrum of disorders, which are listed on this slide. Bipolar I—one or more manic episodes or mixed episodes and often one or more major depressive episodes Bipolar II—one or more major depressive episodes accompanied by at least one hypomanic episode Major depression with family history of bipolar disorder Hypomania Antidepressant-induced mania/hypomania Cyclothymia—milder form of bipolar disorder Rapidly changing mood swings (ie, rapid cycler) NOS Secondary mania (illness or drug-induced) American Psychiatric Association. Practice Guideline for the Treatment of Patients with Bipolar Disorder. 2nd ed. Washington, DC; 2002.

    16. Bipolar Disorders Bipolar Disorder: The Ingredients Bipolar disorder is characterized by significant and often abrupt shifts in mood and energy. This schematic illustrates the multidimensionality of the disease and indicates that the first presentation is usually depression rather than mania. This is one of the reasons for misdiagnosis or lack of diagnosis of bipolar depression—a physician may not recognize bipolar disorder unless questions regarding a previous history of mania have been asked. Between full-blown manic and depressive episodes, patients may also experience subsyndromal depression or hypomania. The resolution of an episode, on its own or with treatment, may be a normal mood state (euthymia), or a switch from depression to mania or vice versa. Not every patient will experience all these episodes. The timeline for mood changes can be days, weeks, or months. Original schematic based on MEASURE™ Educational Review Board discussions. Alternative representations of the episodes of bipolar disorder are published: eg, see Stahl SM. Essential Psychopharmacology. New York, NY: Cambridge University Press; 2000.Bipolar Disorder: The Ingredients Bipolar disorder is characterized by significant and often abrupt shifts in mood and energy. This schematic illustrates the multidimensionality of the disease and indicates that the first presentation is usually depression rather than mania. This is one of the reasons for misdiagnosis or lack of diagnosis of bipolar depression—a physician may not recognize bipolar disorder unless questions regarding a previous history of mania have been asked. Between full-blown manic and depressive episodes, patients may also experience subsyndromal depression or hypomania. The resolution of an episode, on its own or with treatment, may be a normal mood state (euthymia), or a switch from depression to mania or vice versa. Not every patient will experience all these episodes. The timeline for mood changes can be days, weeks, or months. Original schematic based on MEASURE™ Educational Review Board discussions. Alternative representations of the episodes of bipolar disorder are published: eg, see Stahl SM. Essential Psychopharmacology. New York, NY: Cambridge University Press; 2000.

    17. Misdiagnosis of Bipolar Disorder Often mistaken for depression (40%–70% initially misdiagnosed)1-3 Often see several clinicians without accurate diagnosis2 Mean time to diagnosis long (8 years in 1 study)3,4 Rate of misdiagnosis worse with comorbidity2 Optimal management of bipolar disorder depends on timely diagnosis and the initiation of effective treatment.1-4 An accurate, early diagnosis is sometimes difficult, however, especially as patients often present in the depressive phase, which can be mistaken for unipolar depression.2 Tondo and colleagues studied the time to lithium treatment in 345 bipolar I and II patients. They found that the mean time from illness onset to maintenance treatment averaged 8.38 years.4 This is alarming because it has been estimated that almost 75% of first life-threatening suicide attempts occurred within that 8-year latency.3 Other factors contributing to misdiagnosis include the presence of mixed mania, rapid cycling, and psychiatric comorbidities such as panic disorder and social phobia. Misdiagnosis is a major factor leading to poor outcomes.1,2 References 1. Bowden CL. A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord. 2005:84:117-125; 2. Thomas P. The many forms of bipolar disorder: a modern look at an old illness. J Affect Disord. 2004;79(Suppl 1):S3-S8; 3. Baldessarini R et al. Am J Psychiatry. 1999;156:811-812; 4. Tondo L, Baldessarini RJ, Hennen J, Floris G. Lithium maintenance treatment of depression and mania in bipolar I and bipolar II disorders. Am J Psychiatry. 1998;155:638-645. Optimal management of bipolar disorder depends on timely diagnosis and the initiation of effective treatment.1-4 An accurate, early diagnosis is sometimes difficult, however, especially as patients often present in the depressive phase, which can be mistaken for unipolar depression.2 Tondo and colleagues studied the time to lithium treatment in 345 bipolar I and II patients. They found that the mean time from illness onset to maintenance treatment averaged 8.38 years.4 This is alarming because it has been estimated that almost 75% of first life-threatening suicide attempts occurred within that 8-year latency.3 Other factors contributing to misdiagnosis include the presence of mixed mania, rapid cycling, and psychiatric comorbidities such as panic disorder and social phobia. Misdiagnosis is a major factor leading to poor outcomes.1,2 References 1. Bowden CL. A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord. 2005:84:117-125; 2. Thomas P. The many forms of bipolar disorder: a modern look at an old illness. J Affect Disord. 2004;79(Suppl 1):S3-S8; 3. Baldessarini R et al. Am J Psychiatry. 1999;156:811-812; 4. Tondo L, Baldessarini RJ, Hennen J, Floris G. Lithium maintenance treatment of depression and mania in bipolar I and bipolar II disorders. Am J Psychiatry. 1998;155:638-645.

    18. Misdiagnosis of Bipolar Disorder 2000 NDMDA initial diagnosis (69%) Misdiagnosis of Bipolar Disorder This slide shows data from a study conducted by the National Depressive and Manic-Depressive Association (NDMDA) that found an initial diagnosis of bipolar disorder was often inaccurate. This study demonstrated that the most common misdiagnoses for patients with bipolar disorder include depression, anxiety, schizophrenia, cluster B, and alcohol abuse Hirschfeld et al show that 40% of patients with bipolar disorder are misdiagnosed as having unipolar depression Hirschfeld data also confirm the NDMDA data, showing a delay in proper diagnosis In 35% of patients who were symptomatic for bipolar disorder, more than 10 years passed before a correct diagnosis was made Hirschfeld RM, Vornik LA. Recognition and diagnosis of bipolar disorder. J Clin Psychiatry. 2004;65(suppl 15):5-9.Misdiagnosis of Bipolar Disorder This slide shows data from a study conducted by the National Depressive and Manic-Depressive Association (NDMDA) that found an initial diagnosis of bipolar disorder was often inaccurate. This study demonstrated that the most common misdiagnoses for patients with bipolar disorder include depression, anxiety, schizophrenia, cluster B, and alcohol abuse Hirschfeld et al show that 40% of patients with bipolar disorder are misdiagnosed as having unipolar depression Hirschfeld data also confirm the NDMDA data, showing a delay in proper diagnosis In 35% of patients who were symptomatic for bipolar disorder, more than 10 years passed before a correct diagnosis was made Hirschfeld RM, Vornik LA. Recognition and diagnosis of bipolar disorder. J Clin Psychiatry. 2004;65(suppl 15):5-9.

    19. Onset of Bipolar Disorder Onset in teens for most patients (peak ages, 15–19 years) Late onset less rare than was thought (possibly 6% aged >60 years) Relapse frequent (75%–90%) The peak period of onset of bipolar disorder is late adolescence or early adulthood, with some cases of childhood onset reported. The lifetime prevalence of bipolar disorder decreases after the fourth decade of life, suggesting that onset in old age might be uncommon. However, in a large Veterans Affairs database, new-onset bipolar disorder was identified in 6% of more than 16,000 individuals 60 years of age or older. Despite continual maintenance treatment, the majority of patients with bipolar disorder suffer relapse. The 5-year risk of relapse into mania or depression is 73%, and two thirds of those are multiple relapses. References Bebbington P, Ramana R. The epidemiology of bipolar affective disorder. Soc Psychiatry Psychiatr Epidemiol. 1995;30:279-292. Sajatovic M, Blow F, Ignacio RV, Kales HC. New onset bipolar disorder in later life. Am J Geriatr Psychiatry. 2005;13:282-289; Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Am J Psychiatry. 1995;152:1635-1640. The peak period of onset of bipolar disorder is late adolescence or early adulthood, with some cases of childhood onset reported. The lifetime prevalence of bipolar disorder decreases after the fourth decade of life, suggesting that onset in old age might be uncommon. However, in a large Veterans Affairs database, new-onset bipolar disorder was identified in 6% of more than 16,000 individuals 60 years of age or older. Despite continual maintenance treatment, the majority of patients with bipolar disorder suffer relapse. The 5-year risk of relapse into mania or depression is 73%, and two thirds of those are multiple relapses. References Bebbington P, Ramana R. The epidemiology of bipolar affective disorder. Soc Psychiatry Psychiatr Epidemiol. 1995;30:279-292. Sajatovic M, Blow F, Ignacio RV, Kales HC. New onset bipolar disorder in later life. Am J Geriatr Psychiatry. 2005;13:282-289; Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Am J Psychiatry. 1995;152:1635-1640.

    20. McLean Harvard First-Episode Mania study 239 BP with first Manic/mixed episode 173 recruited for study 151 followed for an average of 4.86 years Recovery at 2 years Syndromal (DSMIV)98% Symptomatic (YM) 72% Functional (occupational) 43%

    21. Disability With Bipolar Disorder Bipolar disorder is the 6th leading cause of medical disability worldwide among people aged 15 to 44 years Bipolar disorder is associated with a greater degree of disability than osteoarthritis, human immunodeficiency virus infection, diabetes, and asthma

    22. Social Impact of Bipolar Disorder Unemployment rate 60%, includes college graduates 65% report impaired long-term relationships Bipolar disorder exacts a tremendous toll on daily function and quality of life. The disease has a markedly negative impact on employment and social relationships. References Hirschfeld MA, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 Survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64:161-17. Bipolar disorder exacts a tremendous toll on daily function and quality of life. The disease has a markedly negative impact on employment and social relationships. References Hirschfeld MA, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 Survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64:161-17.

    23. Economic Impact of Bipolar Disorder The estimated annual societal cost of bipolar disorder ranges from $10 billion to $45 billion Indirect costs 49.5 lost workdays/year/patient 180 million lost workdays/year $25.9 billion salary-equivalent lost/year Direct costs include expenditures related to inpatient and outpatient care, as well as nontreatment-related expenditures such as those incurred for the criminal justice system used by individuals with the illness. Indirect costs include the lost productivity of wage-earners, homemakers, individuals in institutions, those who have committed suicide, and caregivers. Bipolar disorder exacts a considerable socioeconomic toll in terms of indirect costs. The average patient loses nearly 50 workdays per year, equating to 180 million lost workdays per year overall. The salary-equivalent loss is nearly $30 billion per year. References Wyatt RJ, Henter I. An economic evaluation of manic-depressive illness—1991. Soc Psychiatry Psychiatr Epidemiol. 1995;30:213-219; Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405-418; Begley CE, Annegers JF, Swann AC, et al. The lifetime cost of bipolar disorder in the US. An estimate for new cases in 1998. Pharmacoeconomics. 2001;19:483-495. Direct costs include expenditures related to inpatient and outpatient care, as well as nontreatment-related expenditures such as those incurred for the criminal justice system used by individuals with the illness. Indirect costs include the lost productivity of wage-earners, homemakers, individuals in institutions, those who have committed suicide, and caregivers. Bipolar disorder exacts a considerable socioeconomic toll in terms of indirect costs. The average patient loses nearly 50 workdays per year, equating to 180 million lost workdays per year overall. The salary-equivalent loss is nearly $30 billion per year. References Wyatt RJ, Henter I. An economic evaluation of manic-depressive illness—1991. Soc Psychiatry Psychiatr Epidemiol. 1995;30:213-219; Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405-418; Begley CE, Annegers JF, Swann AC, et al. The lifetime cost of bipolar disorder in the US. An estimate for new cases in 1998. Pharmacoeconomics. 2001;19:483-495.

    24. Epidemiological Catchment Area Survey (ECA): Comorbidity and Bipolar Disorder The ECA survey demonstrated that other psychiatric and substance-use disorders are much more prevalent in patients with bipolar disorder than in the general population. They are 3 times more likely to abuse or be dependant on alcohol and 7 times more likely to abuse or be dependent on drugs. Panic disorder is 26 times more frequent in bipolar disorder patients than in the general population, and OCD is 8 times more frequent. References Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264:2511-8; Chen YW, Dilsaver SC. Comorbidity of panic disorder in bipolar illness: evidence from the Epidemiologic Catchment Area Survey. Am J Psychiatry. 1995;152:280-282. Chen YW, Dilsaver SC. Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders. Psychiatry Res. 1995;59:57-64. The ECA survey demonstrated that other psychiatric and substance-use disorders are much more prevalent in patients with bipolar disorder than in the general population. They are 3 times more likely to abuse or be dependant on alcohol and 7 times more likely to abuse or be dependent on drugs. Panic disorder is 26 times more frequent in bipolar disorder patients than in the general population, and OCD is 8 times more frequent. References Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264:2511-8; Chen YW, Dilsaver SC. Comorbidity of panic disorder in bipolar illness: evidence from the Epidemiologic Catchment Area Survey. Am J Psychiatry. 1995;152:280-282. Chen YW, Dilsaver SC. Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders. Psychiatry Res. 1995;59:57-64.

    25. Substance-Use Disorder & BPD Bipolar disorder with co-existing substance-use disorder is associated with an increase in Suicide attempts Suicidal ideas Seeking hospital admission Hospital admission Violence Aggressive behavior Doubled risk of suicide In patients with bipolar disorder, comorbid substance-use disorder doubles the risk of suicide. The presence of both current substance-use problems and substance-induced symptoms is associated with recent suicide crisis and a lifetime suicide attempt. Patients with both bipolar and substance-use disorders may be more likely to seek psychiatric treatment or hospitalization than those with only one of the two conditions. Co-occurring substance abuse also leads to more hospitalizations. Substance abuse in the severely mentally ill significantly increases the chances of committing an offense (whether or not resulting in arrest or conviction) or displaying hostile or aggressive behavior. References Potash JB, Kane HS and Chiu YF et al., Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships, Am J Psychiatry 157 (2000), pp. 2048–2050. Scott H, Johnson S and Menezes P et al., Substance misuse and risk of aggression and offending among the severely mentally ill, Br J Psychiatry 172 (1998), pp. 345–350. Comtois KA, Russo JE and Roy-Byrne P et al., Clinicians' assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients, Biol Psychiatry 56 (2004), pp. 757–763; Comtois KA, Russo JE, Roy-Byrne P, Ries RK. Clinicians' assessment of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients. Biol Psychiatry. 2004;56:757-763; Strakowski SM, DelBello MP. The co-occurrence of bipolar and substance use disorders. Clin Psychol Rev. 2000;20:191-206. Strakowski SM, DelBello MP, Fleck DE, et al. Effects of co-occurring alcohol abuse on the course of bipolar disorder following a first hospitalization for mania. Arch Gen Psychiatry. 2005;62:851-858.In patients with bipolar disorder, comorbid substance-use disorder doubles the risk of suicide. The presence of both current substance-use problems and substance-induced symptoms is associated with recent suicide crisis and a lifetime suicide attempt. Patients with both bipolar and substance-use disorders may be more likely to seek psychiatric treatment or hospitalization than those with only one of the two conditions. Co-occurring substance abuse also leads to more hospitalizations. Substance abuse in the severely mentally ill significantly increases the chances of committing an offense (whether or not resulting in arrest or conviction) or displaying hostile or aggressive behavior. References Potash JB, Kane HS and Chiu YF et al., Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships, Am J Psychiatry 157 (2000), pp. 2048–2050. Scott H, Johnson S and Menezes P et al., Substance misuse and risk of aggression and offending among the severely mentally ill, Br J Psychiatry 172 (1998), pp. 345–350. Comtois KA, Russo JE and Roy-Byrne P et al., Clinicians' assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients, Biol Psychiatry 56 (2004), pp. 757–763; Comtois KA, Russo JE, Roy-Byrne P, Ries RK. Clinicians' assessment of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients. Biol Psychiatry. 2004;56:757-763; Strakowski SM, DelBello MP. The co-occurrence of bipolar and substance use disorders. Clin Psychol Rev. 2000;20:191-206. Strakowski SM, DelBello MP, Fleck DE, et al. Effects of co-occurring alcohol abuse on the course of bipolar disorder following a first hospitalization for mania. Arch Gen Psychiatry. 2005;62:851-858.

    26. Substance-Use in BPD: Treatment Issues Less likely to respond to treatment1 Less likely to adhere to medications1,2 Less likely to adhere to lithium treatment Less likely to gain full remission and resolve symptoms Remission during hospitalization less likely to occur vs no substance-use disorder Bipolar patients with a history of substance abuse have poorer treatment outcomes. Nonadherence to treatment is more likely and can be predicted by both substance abuse and numerous previous hospital admissions. Substance abuse is also a predictor of nonadherence to medications, including prophylactic lithium. The likelihood of full remission and resolution of symptoms is significantly lower than in patients without substance-use disorder. Remission of bipolar disorder during hospitalization is significantly less likely than among patients without prior substance abuse. Eventual remission during hospitalization is significantly more likely for patients taking an anticonvulsant mood stabilizer, alone or in combination with lithium, as opposed to lithium without an anticonvulsant. References Goldberg JF, Garno JL, Leon AC, Kocsis JH, Portera L. A history of substance abuse complicates remission from acute mania in bipolar disorder. J Clin Psychiatry. 1999;60:733-740. Aagaard J, Vestergaard P. Predictors of outcome in a prophylactic lithium treatment: a 2-year prospective study. J Affect Dis. 1990;18:259-266. Strakowski SM, Keck PE Jr, McElroy SL, et al. Twelve-month outcome after a first hospitalization for affective psychosis. Arch Gen Psychiatry. 1998;55:49-55.Bipolar patients with a history of substance abuse have poorer treatment outcomes. Nonadherence to treatment is more likely and can be predicted by both substance abuse and numerous previous hospital admissions. Substance abuse is also a predictor of nonadherence to medications, including prophylactic lithium. The likelihood of full remission and resolution of symptoms is significantly lower than in patients without substance-use disorder. Remission of bipolar disorder during hospitalization is significantly less likely than among patients without prior substance abuse. Eventual remission during hospitalization is significantly more likely for patients taking an anticonvulsant mood stabilizer, alone or in combination with lithium, as opposed to lithium without an anticonvulsant.

    27. APA Treatment Guidelines for Comorbid BPD and Substance-Use Disorder Treatment should proceed concurrently, preferably in a dual-diagnosis program Alcohol abuse may affect bipolar pharmacotherapy Alcohol-related dehydration may raise serum lithium to toxic levels Hepatic dysfunction may alter plasma levels of valproate and carbamazepine According to the American Psychiatric Association Guidelines for treating bipolar disorder, comorbid substance-use disorder may contribute to violence and aggression in some patients, increase the risk of suicide or suicidal ideation, and may obscure or exacerbate endogenous mood swings, making diagnosis and treatment more complex. Further, they warn that patients may abuse alcohol or drugs to ameliorate the symptoms of bipolar disorder. The panel emphasizes that treatment should include therapy for both disorders concurrently, preferably in a dual-diagnosis program. Reference American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Available at: http://www.psych.org/psych_pract/treatg/pg/Practice%20Guidelines8904/BipolarDisorder_2e.pdf. Accessed January 24, 2006. According to the American Psychiatric Association Guidelines for treating bipolar disorder, comorbid substance-use disorder may contribute to violence and aggression in some patients, increase the risk of suicide or suicidal ideation, and may obscure or exacerbate endogenous mood swings, making diagnosis and treatment more complex. Further, they warn that patients may abuse alcohol or drugs to ameliorate the symptoms of bipolar disorder. The panel emphasizes that treatment should include therapy for both disorders concurrently, preferably in a dual-diagnosis program. Reference American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Available at: http://www.psych.org/psych_pract/treatg/pg/Practice%20Guidelines8904/BipolarDisorder_2e.pdf. Accessed January 24, 2006.

    28. Medical Conditions & BP Migraine Thyroid disease Lithium Type 2 diabetes Antipsychotics Obesity Mood stabilizers Antipsychotics Polycystic Ovarian Syndrome Valproate and other anticonvulsants Multiple sclerosis Multiple episodes may increase risk of dementia General medical disorders that frequently co-occur with bipolar disorder include migraine, thyroid disease, type 2 diabetes, and obesity. Community studies have shown significant associations between bipolar disorder and migraine, multiple sclerosis, and obesity. On average, the risk of dementia appears to increase with the number of affective episodes, according to a large-scale registry. The association between atypical antipsychotics, which have been shown to diminish depressive symptoms during the treatment of mania, has also shown to be associated with weight gain and obesity, as is valproate and other anticonvulsants. These drugs have also been linked to polycystic ovarian syndrome in women. References McElroy SL. Diagnosing and treating comorbid (complicated) bipolar disorder. J Clin Psychiatry. 2004;65(Suppl 15):35-44; Kessing LV, Anderson PK. Does the risk of developing dementia increase with the number of episodes in patients with depressive disorder and in patients with bipolar disorder? J Neurol Neurosurg Psychiatry. 2004;75:1662-1666; Joffe H, Taylor AE, Hall JE. Polycystic ovarian syndrome—relationship to epilepsy and antiepileptic drug therapy. J Neurol Neurosurg Psychiatry. 2001;86:2946-2949. General medical disorders that frequently co-occur with bipolar disorder include migraine, thyroid disease, type 2 diabetes, and obesity. Community studies have shown significant associations between bipolar disorder and migraine, multiple sclerosis, and obesity. On average, the risk of dementia appears to increase with the number of affective episodes, according to a large-scale registry. The association between atypical antipsychotics, which have been shown to diminish depressive symptoms during the treatment of mania, has also shown to be associated with weight gain and obesity, as is valproate and other anticonvulsants. These drugs have also been linked to polycystic ovarian syndrome in women. References McElroy SL. Diagnosing and treating comorbid (complicated) bipolar disorder. J Clin Psychiatry. 2004;65(Suppl 15):35-44; Kessing LV, Anderson PK. Does the risk of developing dementia increase with the number of episodes in patients with depressive disorder and in patients with bipolar disorder? J Neurol Neurosurg Psychiatry. 2004;75:1662-1666; Joffe H, Taylor AE, Hall JE. Polycystic ovarian syndrome—relationship to epilepsy and antiepileptic drug therapy. J Neurol Neurosurg Psychiatry. 2001;86:2946-2949.

    29. Causes of Medical Problems in Bipolar Disorder Poor diet Smoking1 Obesity (32%)2 Medications Inactivity Underutilization of medical resources Nonadherence (>50%)3 A variety of factors contribute to medical morbidity in the bipolar population. Examples include nutritional factors, smoking, obesity, and underutilization of medical resources. References Fagiolini A, Frank E, Houck PR et al. Prevalence of obesity and weight change during treatment in patients with bipolar I disorder. J Clin Psychiatry. 2002; 63:528-533; Breslau N, Novak P, Kessler RC. Daily smoking and the subsequent onset of psychiatric disorders. Psychological Medicine. 2004;34:323-333; Fleck DE, Keck PE Jr, Corey KB, Strakowski SM. Factors associated with medication adnerence in African American and white patients with bipolar disorder. J Clin Psychiatry. 2005;66:646-652. A variety of factors contribute to medical morbidity in the bipolar population. Examples include nutritional factors, smoking, obesity, and underutilization of medical resources. References Fagiolini A, Frank E, Houck PR et al. Prevalence of obesity and weight change during treatment in patients with bipolar I disorder. J Clin Psychiatry. 2002; 63:528-533; Breslau N, Novak P, Kessler RC. Daily smoking and the subsequent onset of psychiatric disorders. Psychological Medicine. 2004;34:323-333; Fleck DE, Keck PE Jr, Corey KB, Strakowski SM. Factors associated with medication adnerence in African American and white patients with bipolar disorder. J Clin Psychiatry. 2005;66:646-652.

    30. Obesity in Bipolar Disorder 35.4% of patients with bipolar disorder had BMI =30 mg/kg2 Decreased sense of well being and QOL2 Increased relapses of depressive episodes2,3 More likely to have made a suicide attempt4 Bipolar disorder treatments have been associated with weight gain and endocrine changes; new weight gain increases IR and may promote PCOS in predisposed women5 Individuals with bipolar disorder are more likely to be obese compared to the general population. In one study, 35.4% of patients with bipolar disorder met the criteria for obesity. In addition to a diminished overall quality of life, obesity is significantly associated with depressive recurrences and greater likelihood of suicide attempts. Treatment of bipolar disorder may exacerbate weight problems. Weight gain has been associated with the use of mood stabilizers and antipsychotics, especially atypical drugs. New weight gain increases insulin insensitivity and may raise the risk of polycystic ovarian syndrome in predisposed women with bipolar disorder who have no previous hormonal abnormalities. References Fagiolini A, Kupfer DJ, Houck PR, Novick EM, Frank E. Obesity as a correlate of outcome in patients with bipolar I disorder. Am J Psychiatry. 2003;160:112-117. McLaren KD, Marangell LB. Special considerations in the treatment of patients with bipolar disorder and medical co-morbidities. Ann Gen Hosp Psychiatry. 2004;3:7. Post RM. The impact of bipolar depression. J Clin Psychiatry. 2005;66(Suppl 5):5-10; Osby U et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:884-850; Rasgon NL, Altshuler LL, Fairbanks L, et al. Reproductive function and risk for PCOS in women treated for bipolar disorder. Bipolar Dis. 2005;7:246-259.Individuals with bipolar disorder are more likely to be obese compared to the general population. In one study, 35.4% of patients with bipolar disorder met the criteria for obesity. In addition to a diminished overall quality of life, obesity is significantly associated with depressive recurrences and greater likelihood of suicide attempts. Treatment of bipolar disorder may exacerbate weight problems. Weight gain has been associated with the use of mood stabilizers and antipsychotics, especially atypical drugs. New weight gain increases insulin insensitivity and may raise the risk of polycystic ovarian syndrome in predisposed women with bipolar disorder who have no previous hormonal abnormalities. References Fagiolini A, Kupfer DJ, Houck PR, Novick EM, Frank E. Obesity as a correlate of outcome in patients with bipolar I disorder. Am J Psychiatry. 2003;160:112-117. McLaren KD, Marangell LB. Special considerations in the treatment of patients with bipolar disorder and medical co-morbidities. Ann Gen Hosp Psychiatry. 2004;3:7. Post RM. The impact of bipolar depression. J Clin Psychiatry. 2005;66(Suppl 5):5-10; Osby U et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:884-850; Rasgon NL, Altshuler LL, Fairbanks L, et al. Reproductive function and risk for PCOS in women treated for bipolar disorder. Bipolar Dis. 2005;7:246-259.

    31. Treatment Decisions: Bipolar Disorder Collaborative care involves encouraging patients to participate in choosing their medications, whenever practical. This is done by sharing the profiles of drugs that are on a menu of reasonable choices. Several published guidelines provide direction for making such treatment decisions. The American Psychiatric Association and the Expert Consensus Panel for Bipolar Disorder each have published guidelines, and the STEP-BD guidelines provide practical tables that summarize the profiles of the most commonly used medications. The treating psychiatrist will determine what is reasonable for a given patient and help the patient select the most advantageous treatment. By enlisting the patient and his or her supports as collaborators in managing treatment, we expect to improve concordance between the treatment plan and patient practice. Reference Sachs GS. Managing Bipolar Affective Disorder. Science Press Ltd: London, UK; 2004.Collaborative care involves encouraging patients to participate in choosing their medications, whenever practical. This is done by sharing the profiles of drugs that are on a menu of reasonable choices. Several published guidelines provide direction for making such treatment decisions. The American Psychiatric Association and the Expert Consensus Panel for Bipolar Disorder each have published guidelines, and the STEP-BD guidelines provide practical tables that summarize the profiles of the most commonly used medications. The treating psychiatrist will determine what is reasonable for a given patient and help the patient select the most advantageous treatment. By enlisting the patient and his or her supports as collaborators in managing treatment, we expect to improve concordance between the treatment plan and patient practice. Reference Sachs GS. Managing Bipolar Affective Disorder. Science Press Ltd: London, UK; 2004.

    32. Guidelines for Acute Mania Guidelines for Acute Mania For a patient with mania or mixed episodes, APA 2002 guidelines recommend either lithium or divalproex plus an antipsychotic as first-line initial therapy. For less ill patients, monotherapy with lithium, divalproex, or an antipsychotic may be sufficient. When choosing an antipsychotic, atypical agents are preferred over typical agents because of their improved tolerability profile. APA Expert Consensus Guidelines. Am J Psychiatry. 2002;159(suppl 4):1-50. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Treatment guidelines for bipolar disorder: A critical review. J Affect Disord. 2005;86:1-10. Keck PE Jr, et al. Postgrad Med Special Report. 2004:1-120.Guidelines for Acute Mania For a patient with mania or mixed episodes, APA 2002 guidelines recommend either lithium or divalproex plus an antipsychotic as first-line initial therapy. For less ill patients, monotherapy with lithium, divalproex, or an antipsychotic may be sufficient. When choosing an antipsychotic, atypical agents are preferred over typical agents because of their improved tolerability profile. APA Expert Consensus Guidelines. Am J Psychiatry. 2002;159(suppl 4):1-50. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Treatment guidelines for bipolar disorder: A critical review. J Affect Disord. 2005;86:1-10. Keck PE Jr, et al. Postgrad Med Special Report. 2004:1-120.

    33. Guidelines for Acute Bipolar Depression Guidelines for Acute Bipolar Depression First line therapy for depressive episodes in patients with bipolar disorder is the initiation of either lithium or lamotrigine. Monotherapy with an antidepressant is not recommended. Simultaneous treatment with lithium and an antidepressant is an alternative for those who are more severely ill. ECT should be considered in patients with life-threatening inanition, suicidality, or psychosis. APA Expert Consensus Guidelines. Am J Psychiatry. 2002;159 (suppl 4):1-50. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Treatment guidelines for bipolar disorder: A critical review. J Affect Disord. 2005;86:1-10. Keck PE Jr, et al. Postgrad Med Special Report. 2004:1-120.Guidelines for Acute Bipolar Depression First line therapy for depressive episodes in patients with bipolar disorder is the initiation of either lithium or lamotrigine. Monotherapy with an antidepressant is not recommended. Simultaneous treatment with lithium and an antidepressant is an alternative for those who are more severely ill. ECT should be considered in patients with life-threatening inanition, suicidality, or psychosis. APA Expert Consensus Guidelines. Am J Psychiatry. 2002;159 (suppl 4):1-50. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Treatment guidelines for bipolar disorder: A critical review. J Affect Disord. 2005;86:1-10. Keck PE Jr, et al. Postgrad Med Special Report. 2004:1-120.

    34. Guidelines for Bipolar Maintenance Guidelines for Bipolar Maintenance Long-term maintenance treatment goals for patients with bipolar disorder can vary. A primary goal of therapy is to prevent relapse by averting the return of symptoms severe enough to meet the criteria for the disorder. A second goal is to expand the response into complete remission. However, realistic management goals may be limited to the ongoing, short-term endpoints of obtaining and maintaining acute symptom control and the prevention of suicide attempts. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Treatment guidelines for bipolar disorder: A critical review. J Affect Disord. 2005;86:1-10. Keck PE Jr, et al. Postgrad Med Special Report. 2004:1-120.Guidelines for Bipolar Maintenance Long-term maintenance treatment goals for patients with bipolar disorder can vary. A primary goal of therapy is to prevent relapse by averting the return of symptoms severe enough to meet the criteria for the disorder. A second goal is to expand the response into complete remission. However, realistic management goals may be limited to the ongoing, short-term endpoints of obtaining and maintaining acute symptom control and the prevention of suicide attempts. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Treatment guidelines for bipolar disorder: A critical review. J Affect Disord. 2005;86:1-10. Keck PE Jr, et al. Postgrad Med Special Report. 2004:1-120.

    35. Suicide Risk in Bipolar Disorder Patients with bipolar disorder have a higher risk of suicide than patients with any other psychiatric or medical illness Odds ratio for suicide attempts is 6.2, higher than any other disorder, including depression Bipolar disorder is a significant source of loss of life through suicide. The risk in patients with this disorder is greater than in those with other psychiatric or medical illnesses. References Woods SW. The economic burden of bipolar disease. J Clin Psychiatry. 2000;61(Suppl 13):38-41; Chen Y-W, Dilsaver CS. Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders. Biol Psyschiatry. 1996;39:896-899; Goldberg JJF, Harrow M. Consistency of remission and outcome in bipolar and unipolar mood disorders: a 10-year prospective follow-up. J Affect Dis. 2004;81:123-131. Bipolar disorder is a significant source of loss of life through suicide. The risk in patients with this disorder is greater than in those with other psychiatric or medical illnesses. References Woods SW. The economic burden of bipolar disease. J Clin Psychiatry. 2000;61(Suppl 13):38-41; Chen Y-W, Dilsaver CS. Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders. Biol Psyschiatry. 1996;39:896-899; Goldberg JJF, Harrow M. Consistency of remission and outcome in bipolar and unipolar mood disorders: a 10-year prospective follow-up. J Affect Dis. 2004;81:123-131.

    36. Increased Mortality in Patients With Bipolar Disorder Additionally, people with bipolar disorder were at increased risk for all-cause mortality. Not surprisingly, suicide (included in the “unnatural” SMR) was a highly prevalent cause; the SMR for suicide was highest for younger patients in the first year after they were first diagnosed. However CVD, cerbrovascular disease, gastrointestinal disease, and some cancers also were causes for the increased mortality rate of people with bipolar disorder. In fact, natural causes accounted for about half of the excess mortality in the bipolar population. Because of this, the investigators suggest that the somatic health of these patients is an important area that needs to be addressed and improved upon, independent of the risk of suicide. Reference Osby U, Brandt L, Correia N, Ekbom A, Sparén P. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:844-850.Additionally, people with bipolar disorder were at increased risk for all-cause mortality. Not surprisingly, suicide (included in the “unnatural” SMR) was a highly prevalent cause; the SMR for suicide was highest for younger patients in the first year after they were first diagnosed. However CVD, cerbrovascular disease, gastrointestinal disease, and some cancers also were causes for the increased mortality rate of people with bipolar disorder. In fact, natural causes accounted for about half of the excess mortality in the bipolar population. Because of this, the investigators suggest that the somatic health of these patients is an important area that needs to be addressed and improved upon, independent of the risk of suicide. Reference Osby U, Brandt L, Correia N, Ekbom A, Sparén P. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:844-850.

    37. Suicide prevention and Lithium

    38. BP Concluding statements.. Bipolar Disorders are a category of mood disorders - with a broad range of severity. BP is eminently treatable. But requires treatment to be ongoing Collaboration between Treatment team and patient BP is a serious illness. Lives, families, and careers affected People die from it

    39. Prechter Bipolar Genes Project Goals Determine what keeps BP patients well, and what causes problems Find the genes involved Study Track participants for 5 years through interview, questionnaires, cognitive testing Collect blood sample for DNA analysis

    40. Prechter Bipolar Genes Project For more information: www.hcpfmd.org www.depressioncenter.org New toll-free #: 1-877-UM GENES (1-877-864 3637) Email: BPresearch@umich.edu

    41. Panel Members Melvin McInnis, MD University of Michigan Cheryl King, PhD University of Michigan Juan Lopez, MD University of Michigan Shabnum H. Sheikh, MD St Joseph Mercy Hospital Jon-Kar Zubieta, MD University of Michigan Katharene Schoof, MSW, ACSW University of Michigan

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