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 ObjectivesTo appreciate diagnostic challenges and consider repercussions of misdiagnosisTo implement appropriate use of clinical screeners and mood chartsTo 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%OCD3-39%ADHD20%Phobias10-26%GAD11-43%
4 BD comorbidity: the rule not the exception Diabetes-226-50%Alcohol abuse 56.3%Alcohol depend.38%Drug depend30.4%Drug abuse48.3%
5 Irritability Across Disease States (Partial list) Depressive disorderADHDCNS injuries/infectionsDementiaEndocrine disordersImpulse control disordersPTSDGADSubstance useSleep disordersPMDDPersonality Disorders
6 Dorothy ID: 44 y.o. female employed married with twin sons CC: depressed mood“lost zest for life”“Can’t concentrate”Insomnia/ hypersomniaIrritabilityHPI: Longsanding mild depression with 3 months worseningPPH: 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 affectPassive suicidal ideationsInterested in a/depr-s optimizationFHx:Mother side: depression, BD, alcohol abuseFather 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 BDEpisode in 20s could be interpreted as manic/hypomanicRecall bias, no collateral.Related to a/depress ?FHx of bipolar disorderPostpartum depressionAgainst 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 EpisodesPsychotic EpisodesAntidepressants Side EffectsNon adherence to treatmentAny diagnosis of MDD has to be provisional given high prevalence of switch to mania.
14 Mixed EpisodeThe criteria are met both for a Manic Episode and for a Major Depressive Episode for at least 1 weekSevere 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 asWorthlessnessSuicidal thoughtsWeight lossDifficulties focusingCC: Irritability w violent outbursts - longstandingImpulsivityHyperactivityDisturbed night sleep -3h
16 Kelly PPH: Poor historian Longstanding mood fluctuations Cannabis daily to calm selfAlcohol, cocaine periodicallyMethadone programAssault and threat charges up to 4/yearPH:Depression, BD, SA , suicides in the familyFarther jailed for murder when patient was 2 y.o.Raised by abusive motherSeveral abusive relationships as a young adult
17 Kelly MSE: Rapid speech Fast thought process Impulsive in verbal responsesHypersexualFidgety, restlessFair 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 overlappingconditions.Focus - vegetative symptoms:SleepWeightHypersexualityEgodystonic longstanding mood disturbancesNot directly associated with substances, life events
20 Kelly: Treatment and Outcomes Mood chartingMood stabilizers Epival, with Ziprasidone add on.DBTEuthymic moodNormalized sleep and weightNo s/h ideationsJust minor anger outbursts1 minor altercation episode with police in 2,5 yearsas compared up to 4/ year prior to treatment
21 Leanna 38 y.o. divorced female, 3 children Cc: depressive sxSelf harm, passive s.i.HPI:Mood fluctuationsDepr. Days to weeksHypomania. Day to weeksSubstance abuse Cocaine-3 yearsAbusive relationshipFlashbacks of childhood sex abuse
22 LeannaPH: 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
25 ComplexityPTSDc 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 anxietyself esteem social rhythmselements of DBTTopomax 100mg bid Quetiapine 400mg hs CBT group anxiety module Quality of Life OT group Seeking safety group Referral to individual trauma counselling ANA meeings
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?
32 MDQ: scoring and interpretation Answering “Yes” to 7 or more of the events in question #1,answering “Yes” to question #2, andanswering “Moderate problem” or “Serious problem” to question #3is considered a positive screen for BDPsychiatric Patient sample:Sensitivity: 73%Specificity: 90%Community Sample:Sensitivity 28%Specificity 97%(Zimmerman,et al, 2004)
33 Bipolar Spectrum Diagnostic Scale Total scoreLikelihood of BD<6Very unlikely6-10Low probability11-18Moderate probability19 or higherHighly likelyBSDS is a descriptive story- subtle features of bipolar illnessAddresses the concept of BDEach 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)
37 Acute management of Bipolar Depression 1st line : Lithium, lamotrigine, quetiapine, quetiapine XR, lithium or divalproex+SSRI, olanzapine+ SSRI, lithium or divalproex + bupropion2-nd line: Quetiapine + SSRI , adjunctive modafinil.Not recommended: Gabapentin , aripiprazole monotherapyEfficacy 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 ApproachesHPI axis dysregulation- rationale for antiglucocorticoid treatmentGlucocorticoid receptor antagonist- mifepristone-1 week improved:spatial memoryverbal fluencydepressive symptoms (MADRS) (Gallagher et al, 2009)
39 Ketamine in Treatment Resistant Bipolar Depression Novel mechanism of action- antagonist of NMDA receptorsTargerts glutamate, major excitatory neurotransmitter in the brain163 patients with TRD studied25-85% response rate 24 hrs post infusion14-70% 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 371% of subject responded to ketamine and 6% to placebo during the trial(Diazgranados et al 2010)
42 Asenapine Preclinicaly: Involves wide spectrum of receptors Improves hedonia, sleep architecture in animal model (Blier, 2012)3 week random. mania trial – significant-day2Comparable 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 AsenapineAsenapine in combination with Lithium or divalproex –superior efficacy over mood stabilizers aloneSide effects:Anxiety, somnolence (dose related?)well tolerated in patients with BD-INo 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, ziprazidoneAsenapine (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 factorDefining levelAbdominal obesityMenWomenWaist circumference>102 cm>88 cmFasting Plasma glucose (FPG)> 6.1 mmol/LBlood Pressure>130/85 mm HgTriglyceride> 1.7 mmol/LHDL-C<1.0 mmol/L<1.3 mmol/L
47 Monitoring patients on second generations antipsychotics Base4 W8 W12 wQuartAnnQ5yPersonal/familyhistoryXWeight (BMI)Waist circumfer.Blood PressureFasting Plasma GlucoseFast. lipid profile
48 MAPS programCombined Psychoeducation, CBT and Social Rhythms approaches including:M- monitoring mood and activitiesA- assessing prodromesP- preventing relapseS- SMART goal setting(specific-measurable-actionable-realistic-time bound)
49 Circadian rhythm (CR) instability Multiple competing inputs for CR advance/delaytiming of work/choresmealssocial contactsIn 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 sleepManaging sleep is fundamental priority in BD because:Sleep deprivation may trigger maniaPersistent sleep disturbance is commonAltered sleep may be a predictor of relapseAlteration 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 depressionprolong remission of an affective episodereduce suicide attemptsimprove 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 attentionLT 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 BDEducation:initial stage, engagement, most of pts know very littleBehavioral interventions:taking actions to control sx - monitoringavoid exacerbating stimuliCognitive component:twisted thinkingChain 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 maniaInteractive CBT program:
56 Popular books on BD An Unquient Mind by Kay Redfield Jamison Touched With Fire by Kay Redfield JamisonMadness: A Bipolar Life by Marya HornbacherManic: A Memoir by Terri CheneyThe Bipolar Disorder Survival Giude by David MilkowitzWalk on Eggshells by Jean Johnson