Perils and Pitfalls of the Diagnosis of The Bipolar Disorders Discuss the recognition of bipolar disorder in the clinic setting Discuss the treatment options for bipolar depression Describe the efficacy and safety of treatment options for bipolar depression Q: Is this episode of depression really due to Major Depression or due to Bipolar Disorder?

Bipolar Disorders are Diagnoses of Inclusion According to DSM-IV-TR: Major Depression should only be DX’d after a H/O of mania/hypomania has been excluded and the bipolar disorders have been ruled out Screening for H/O mania/hypomania is essential in order to differentiate the bipolar disorders from the depressive disorders

Bipolar Disorders are Diagnoses of Inclusion According to DSM-IV-TR : Bipolar Disorder – manic, mixed, depressed Bipolar Disorder – type II Bipolar Disorder NOS, & Cyclothymia There is no exclusion other than the ascription of a General Medical Condition or Drug Intoxication or Withdrawal Syndrome.

Why is Screening Necessary? 1. Patients don’t report manic symptoms 2. Evaluation may not use outside sources 3. The Antidepressant Problem: Patients often request antidepressants Antidepressants worsen the course and may lead to more depressive episodes

Screening for Mania and Mixed States The Mood Disorder Questionnaire (MDQ) is a validated screening instrument for bipolar I and II disorders Hirschfeld RM, et al. Am J Psychiatry. 157:1873, 2000

DIGFAST: Symptoms of Hypomania and Mania D Distractibility: poorly focused I Insomnia: decreased need for sleep G Grandiosity: inflated self-esteem F Flight of ideas: c/o racing thoughts A Activities: increased activities S Speech: pressured or more talkative T Thoughtlessness: “risk-taking” behaviors sexual, financial, travel, driving Ghaemi et al, World J Biol Psych 2: 65, 2000

The Unmistakable Triad George Winokur, Classification of Mania & Depression, 1991 Euphoria Pressured Speech Hyperactivity 3 Signs in 3 Days in 3 Settings

The Questionable Quad –the 4 I’s George Winokur, Classification of Mania & Depression, 1991 Irritability Insomnia Impulsivity Impaired Social/Vocational Life >4 Days – Hypomania <4 Days – Bipolar NOS

Longitudinal Assessment of the Course of Bipolar Disorders Mania Hypomania Euthymia Polarity of Symptoms Subsyndromal Depression Depression Depression

Medications for Bipolar Disorder Mood Stabilizers Divalproex DR Divalproex ER Carbamazepine ER Lamotrigine - M Lithium - M Depakote Depakote ER Equetro Lamictal Eskalith, Lithobid FDA Approvals – Depression or Maintenance

Mood Stabilizers Lamotrigine - increase slowly may increase Divalproex levels & vice versa, Watch out for Rashes Carbamazepine – Monitor levels, autoinduces itself & reduces APs, Dizzy, Double Vision, Dropping, Decreased Sodium, Agran. Lithium – Monitor levels, Chem 7, drug-drug interactions, Tremor, Thirst, Thyroid, Toxicity Divalproex – Monitor levels, LFTs, Tremor, GI side effects, Alopecia, Pancreatitis

Medications for Bipolar Disorder Second Generation Antipsychotics Aripiprazole - M Olanzapine - M Quetiapine - Depr Risperidone Ziprasidone Abilify Zyprexa Seroquel Risperidal Geodon Olanzapine/Fluoxetine – Depr Symbyax

SGAs Guidelines Baseline: Weight (BMI) – monthly for the first 3 months Waist circumference Blood pressure Fasting plasma glucose (and Hemoglobin A1c if hyperglycemia is detected) Fasting lipid profile AIMS (Abnormal Involuntary Movement Scale) or other screening tool for tardive dyskinesia Opthalmologic screening should be obtained for those on Quetiapine and those with diabetes mellitus

SGA Guidelines Q3months: Weight (BMI) Blood pressure Fasting plasma glucose (and Hemoglobin A1c if hyperglycemia is detected) Fasting lipid profile Q6 months: AIMS (Abnormal Involuntary Movement Scale) or other screening tool for tardive dyskinesia Opthalmologic screening should be obtained for those on Quetiapine and those with diabetes mellitus.

Optimal TX of Bipolar Depression Clear Rationale for MS vs AP Balance Efficacy versus Tolerability Screen for Manic Sx, Non-Response Psychosocial Therapies Monitor Adherence versus Cost Effectiveness on an ongoing basis

Take Home Points: Bipolar Depression Bipolar disorder is common and patients tend to present with depression Antidepressant monotherapy should be avoided Screening for bipolar disorder in clinics recommended When detected treat bipolar disorder Bipolar depression has limited FDA approved TX Mood stabilizers and SGAs have some risks but may be helpful and improve the course of the illness

Perils and Pitfalls: Bipolar Disorder Major Depression is more common and the diagnosis is more reliable (MDD>BPAD>BP II> BPNOS>Cycl) Denying antidepressants can increase morbidity When bipolar disorders are favored psychotherapy may be overlooked New FDA approved TX: EMSAM (transdermal selegiline), Vagus Nerve Stimulation, the STAR*D study Bipolar/ADD pts will not get stimulants

Pitfalls of Bipolar Disorder Screening Mood Swings are reported by lots of patients for lots of reasons Mood Swings are a reason for referral from various sources Bipolar disorders - easily considered, rarely eliminated The FDA approved TXs: Quetiapine, lithium and lamotrigine may be a bitter pill to swallow Bipolar disorders are less reliable & TX is with up to 10 medications