1. 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?

2. 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

3. 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.

4. 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

5. 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

6. 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

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

8. 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

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

10. 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

11. 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

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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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