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Bipolar Affective Disorder: practical aspects and update

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Presentation on theme: "Bipolar Affective Disorder: practical aspects and update"— Presentation transcript:

1 Bipolar Affective Disorder: practical aspects and update
Iouri Rybak, MD, FRCPC Assistant Professor, Dept. of Psychiatry Western University Mood and Anxiety Disorders Program Regional Mental Health Care

2 Objectives To appreciate diagnostic challenges and consider repercussions of misdiagnosis To implement appropriate use of clinical screeners and mood charts To utilize practical strategies to contribute to wellness as an optimal treatment outcome in patients with BD

3 BD comorbidity: the rule not the exception
Panic Disorder 7-33% OCD 3-39% ADHD 20% Phobias 10-26% GAD 11-43%

4 BD comorbidity: the rule not the exception
Diabetes-2 26-50% Alcohol abuse 56.3% Alcohol depend. 38% Drug depend 30.4% Drug abuse 48.3%

5 Irritability Across Disease States (Partial list)
Depressive disorder ADHD CNS injuries/infections Dementia Endocrine disorders Impulse control disorders PTSD GAD Substance use Sleep disorders PMDD Personality Disorders

6 Dorothy ID: 44 y.o. female employed married with twin sons
CC: depressed mood “lost zest for life” “Can’t concentrate” Insomnia/ hypersomnia Irritability HPI: Longsanding mild depression with 3 months worsening PPH: 8 y.o. suic. thoughts 23 y.o.-1-st depress. episode Mid 20s- alcohol abuse, shoplifting, sex promiscuity Denied somatovegetative sx 35 y.o. - postpartum depress. ED - binges and excess exercising MH: thyroid, hysterectomy

7 Dorothy MSE: Increased latency of speech Moderately depressed mood
Sad and anxious affect Passive suicidal ideations Interested in a/depr-s optimization FHx: Mother side: depression, BD, alcohol abuse Father side: abuse family, brother –suicide.

8 Mania: Differential Diagnosis
Mania Due to General Medical Condition Substance Induced Mood Disorder Hypomanic Episode Mood Disorder with Prominent Irritable Mood AD/HD

9 The Most Reasonable Diagnostic Impression
Dysthymic Disorder Major Depressive Disorder Bipolar Disorder II Depression plus Alcohol Abuse in Remission

10 Dorothy: diagnostic challenges
For BD Episode in 20s could be interpreted as manic/hypomanic Recall bias, no collateral. Related to a/depress ? FHx of bipolar disorder Postpartum depression Against BD Thyroid disorder: diagn. and treatment ( s/e)challenges ED: diagn. and treat.(weight) challenges Pt’s preference for a/depr.

11 Dorothy: diagnosis and follow up
Dysthymic disorder with superimposed MDE Cipralex 20mg-40mg Wellbutrin SR 150mg-300mg 1-st y.: improvement with mood fluctuations’ range moderate depr. to euthymia 2-nd y.: episodes of hyperactivity, decreased need for sleep, overly talkative. Started on Epival- blood – dyscrasia - Lamotrigine.

12 Danger of missing BD Unopposed Antidepressant therapy:
Rapid Cycling - 23 % (Ghaemi et al, 2000) Manic episode- 55% (Ghaemi et al, 2000) Mixed Episodes Psychotic Episodes Antidepressants Side Effects Non adherence to treatment Any diagnosis of MDD has to be provisional given high prevalence of switch to mania.

13 Danger of Overdiagnosing BD
Inappropriate treatment with mood stabilizers and a/psychotics: Excessive sedation Metabolic syndrome Reproductive function Thyroid , kidney dysfunction (lithium) Liver dysf-n, blood dyscrasias ( a/convulsants)

14 Mixed Episode The criteria are met both for a Manic Episode and for a Major Depressive Episode for at least 1 week Severe enough to cause marked impairment in occupational functioning or in usual social activities.

15 Kelly: ID: 43 yo unemployed female, c-l marriage, 4 children, no custody
…as well as Worthlessness Suicidal thoughts Weight loss Difficulties focusing CC: Irritability w violent outbursts - longstanding Impulsivity Hyperactivity Disturbed night sleep -3h

16 Kelly PPH: Poor historian Longstanding mood fluctuations
Cannabis daily to calm self Alcohol, cocaine periodically Methadone program Assault and threat charges up to 4/year PH: Depression, BD, SA , suicides in the family Farther jailed for murder when patient was 2 y.o. Raised by abusive mother Several abusive relationships as a young adult

17 Kelly MSE: Rapid speech Fast thought process
Impulsive in verbal responses Hypersexual Fidgety, restless Fair insight – asks for help

18 Kelly: Diff. Diagnosis? Substance Dependence Substance related mood disorder Adult ADHD BD PTSD Personality disorder with mixed features, predominantly a/social

19 Kelly: Diagnostic challenge
Easy to miss BD in the complexity of overlapping conditions. Focus - vegetative symptoms: Sleep Weight Hypersexuality Egodystonic longstanding mood disturbances Not directly associated with substances, life events

20 Kelly: Treatment and Outcomes
Mood charting Mood stabilizers Epival, with Ziprasidone add on. DBT Euthymic mood Normalized sleep and weight No s/h ideations Just minor anger outbursts 1 minor altercation episode with police in 2,5 years as compared up to 4/ year prior to treatment

21 Leanna 38 y.o. divorced female, 3 children
Cc: depressive sx Self harm, passive s.i. HPI: Mood fluctuations Depr. Days to weeks Hypomania. Day to weeks Substance abuse Cocaine-3 years Abusive relationship Flashbacks of childhood sex abuse

22 Leanna PH: Sex abuse 8-15 y.o. family members No acceptance or support Individ. trauma counselling –26 y.o. Sex abuse survivors group FH: Extensive hx of mood, substance and personality disorders

23 Leanna: Mood Fluctuations
Apathetic Hypersomnic Overeating Social Isolation Elevated mood Erratic sleep pattern Increased goal directed activity Risky involvement in pleasurable activities Hyperactivity

24 BD-II / BPD

25 Complexity PTSDc BPD - BD-II - Substance Abuse Typical presentation Dimentions versus categories PTSDc and BPD-more similarities that differences BD-II and BPD – 31.5% overlap (Gunderson) Diagnostical Accent?- The most beneficial for treatment. Pharmacotherapy in BPD. What is adherence? Focus on BAD-II often distracts from compexity Focus on BD-II often distracts from complexity

26 Leanna: Treatment -for substance cravings and anxiety
for anxiety self esteem social rhythms elements of DBT Topomax 100mg bid Quetiapine 400mg hs CBT group anxiety module Quality of Life OT group Seeking safety group Referral to individual trauma counselling ANA meeings

27 Scales Screeners Mood Charts

28 “Accurate diagnosis has enormous implications for short- and long-term treatment planning, and it is essential to note that diagnosis is a process rather than a one thing event” APA Practice Guidelines, 2011

29 The Mood Disorder Questionnaire (MDQ)
This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor. However, a positive screen here may suggest that you might benefit from seeking such an evaluation from your doctor. Regardless of the questionnaire results, if you or someone you know has concerns about your mental health, please contact your physician or another healthcare professional.

30 INSTRUCTIONS: Please answer each question as best you can. YES / NO
1.Has there ever been a period of time when you were not your usual self and you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? ... you were so irritable that you shouted at people or started fights or arguments? ... you felt much more self-confident than usual? ... you got much less sleep than usual and found that you didn’t really miss it? ... you were more talkative or spoke much faster than usual? ... thoughts raced through your head or you couldn’t slow your mind down? ... you were so easily distracted by things around you that you had trouble concentrating or staying on track? ... you had much more energy than usual? ... you were much more active or did many more things than usual? ... you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? ... you were much more interested in sex than usual? ... you did things that were unusual for you or that other people might have thought were excessive, foolish or risky? ... spending money got you or your family in trouble?

31 MDQ (Cont) 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? 3. How much of a problem did any of these cause you - like being able to work; having family, money or legal troubles; getting into arguments or fights?O No problem O Minor problem O Moderate problem O Serious problem 4.* Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic- depressive illness or bipolar disorder? 5.* Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *Derived from Hirschfeld RM. Am J Psychiatry. 2000:157(11): 60-OL25821 PRINTED IN USA © 2003, ELI LILLY AND COMPANY. ALL RIGHTS RESERVED.

32 MDQ: scoring and interpretation
Answering “Yes” to 7 or more of the events in question #1, answering “Yes” to question #2, and answering “Moderate problem” or “Serious problem” to question #3 is considered a positive screen for BD Psychiatric Patient sample: Sensitivity: 73% Specificity: 90% Community Sample: Sensitivity 28% Specificity 97% (Zimmerman,et al, 2004)

33 Bipolar Spectrum Diagnostic Scale
Total score Likelihood of BD <6 Very unlikely 6-10 Low probability 11-18 Moderate probability 19 or higher Highly likely BSDS is a descriptive story- subtle features of bipolar illness Addresses the concept of BD Each sentence is worth 1 point, to that total add the number below for the item selected. Add 6 points for “fits me very well”, 4 points for “ fits me fairly well”, 2 points for “fits me to some degree”.

34 Bipolar Spectrum Diagnostic Scale (BSDS)
Sensitivity bipolar I : 75% Sensitivity bipolar II / NOS : 79% Overall Specificity : 85% (Ghaemi et al, 2005)


36 Some treatment aspects

37 Acute management of Bipolar Depression
1st line : Lithium, lamotrigine, quetiapine, quetiapine XR, lithium or divalproex+SSRI, olanzapine+ SSRI, lithium or divalproex + bupropion 2-nd line: Quetiapine + SSRI , adjunctive modafinil. Not recommended: Gabapentin , aripiprazole monotherapy Efficacy of pharmacotherapy in Bipolar Depression remains uncertain recent reviews and meta-analysis reinforce doubts (STEP-BD, Sidor, Mac Queen, 2011) Lamotrigine, divalproex- some benefits (Geddes et al 2009,Smith et al 2010)

38 New Approaches HPI axis dysregulation- rationale for antiglucocorticoid treatment Glucocorticoid receptor antagonist- mifepristone-1 week improved: spatial memory verbal fluency depressive symptoms (MADRS) (Gallagher et al, 2009)

39 Ketamine in Treatment Resistant Bipolar Depression
Novel mechanism of action- antagonist of NMDA receptors Targerts glutamate, major excitatory neurotransmitter in the brain 163 patients with TRD studied 25-85% response rate 24 hrs post infusion 14-70% response rate 72 hrs post infusion (Rot et al 2012)

40 Ketamine in Treatment Resistant Bipolar Depression
Within 40 minutes, depressive symptoms significantly improved in subjects receiving ketamine versus placebo, the improvement remained significant through day 3 71% of subject responded to ketamine and 6% to placebo during the trial (Diazgranados et al 2010)

41 Mixed episode: treatment options
Lithium Anticonvulsants divalproex Carbamazepine Lamotrigine A/depressants ECT Antipsychotics 1st generation 2nd generation Risperidone Olanzapine Ziprasidone Aripiprazole Quetiapine Asenapine

42 Asenapine Preclinicaly: Involves wide spectrum of receptors
Improves hedonia, sleep architecture in animal model (Blier, 2012) 3 week random. mania trial – significant-day2 Comparable to olanzapine, early response predicts remission better than olanzapine. 12 weeks mixed episodes trial: manic + depress. sx improvement by 3 weeks olanzapine - didn’t differ. from placebo

43 Asenapine Asenapine in combination with Lithium or divalproex –superior efficacy over mood stabilizers alone Side effects: Anxiety, somnolence (dose related?) well tolerated in patients with BD-I No change in prolactine level (Citrome et al, 2009)

44 Difference in acute treatment of depressive, manic and mixed episodes requires accuracy in diagnostic impression.

45 Maintenance pharmacotherapy of BD
1-st line: Lithium, lamotrigine (depression only?), divalproex, olanzapine, quetiapine, lithium or divalproex +quetiapine, risperidone, aripiprazole, ziprazidone Asenapine (Sycrest) In 40 weeks trial asenapine >olanzapine (Grunze, 2012) Not recommended: Adjunctive flupenhtixol, monotherapy with gabapentin, topiramate and a/depressants

46 Metabolic s-m (at least 3 of the following)
Risk factor Defining level Abdominal obesity Men Women Waist circumference >102 cm >88 cm Fasting Plasma glucose (FPG) > 6.1 mmol/L Blood Pressure >130/85 mm Hg Triglyceride > 1.7 mmol/L HDL-C <1.0 mmol/L <1.3 mmol/L

47 Monitoring patients on second generations antipsychotics
Base 4 W 8 W 12 w Quart Ann Q5y Personal/family history X Weight (BMI) Waist circumfer. Blood Pressure Fasting Plasma Glucose Fast. lipid profile

48 MAPS program Combined Psychoeducation, CBT and Social Rhythms approaches including: M- monitoring mood and activities A- assessing prodromes P- preventing relapse S- SMART goal setting (specific-measurable-actionable-realistic-time bound)

49 Circadian rhythm (CR) instability
Multiple competing inputs for CR advance/delay timing of work/chores meals social contacts In vulnerable individuals, changes in social time cues could lead to disruption in CR and ultimately to relapse

50 Sleep disturbance in BD
The most evident “symptom” of CR disruption is the disturbance of sleep Managing sleep is fundamental priority in BD because: Sleep deprivation may trigger mania Persistent sleep disturbance is common Altered sleep may be a predictor of relapse Alteration in sleep-wake cycle may have harmful effects on general health, incl. weight gain and insulin resistance

51 Interpersonal and Social Rhythm Therapy (IPSRT)
IPSRT has been shown to: speed time to remission of bipolar depression prolong remission of an affective episode reduce suicide attempts improve occupational functioning (Mildowitz et al, 2007)

52 Bright Light Therapy (LT) for CR disturbance
LT open trial in mood and cognitive sx (ADHD) LT significantly improved mood, core ADHD symptoms, and objective measures of attention LT may corect circadian phase disturbance contributing to both subjective and objective dysfunction in adult ADHD independently of mood improvement ( Rybak et al, 2006)

53 CBT for BD Education: initial stage, engagement, most of pts know very little Behavioral interventions: taking actions to control sx - monitoring avoid exacerbating stimuli Cognitive component: twisted thinking Chain analysis

54 CBT for BD Examples of Socratic questions re: the presence of mania:
Do you think you are manic? Have you ever felt this way before? If not, what do you think is happening to you? If not, why do other people seem to think you are manic? How is mania different from how you feel now? Is it possible that you are getting manic and just don’t want to see it?

55 CBT for BD Examples of Socratic questions re: the presence of mania:
How do you explain your change in mood. How could you tell if this was mania or something else? What would have to happen to convince you that this is mania Interactive CBT program:

56 Popular books on BD An Unquient Mind by Kay Redfield Jamison
Touched With Fire by Kay Redfield Jamison Madness: A Bipolar Life by Marya Hornbacher Manic: A Memoir by Terri Cheney The Bipolar Disorder Survival Giude by David Milkowitz Walk on Eggshells by Jean Johnson

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