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Ask-the-Doctor Bipolar Disorder NAMI 2009 Descartes Li, M.D. Associate Clinical Professor University of California, San Francisco Chief, UCSF Bipolar Program /Patients/Bipolar_Program.as p 2018/10/24 Questions What questions that you would like reviewed? The Limbic System What are the Subtypes of Bipolar Disorder? Bipolar I: Depression with Classic Mania Bipolar II: Depression with Hypomania Bipolar III: Antidepressant Associated Hypomania Dysthymic Disorder Major Depressive Disorder Cyclothymic Disorder Bipolar I Disorder Bipolar II Disorder Major Depressive Disorder Diagnostic Criteria 1. Depressed mood 2. Loss of interest or pleasure in all, or almost all, usual activities DSM-IV-TR 2000. Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks At least 1 of these 2 symptoms: Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Major Depressive Disorder Diagnostic Criteria DSM-IV-TR 2000. Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks 3. Significant weight loss or weight gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate or indecisiveness 9. Recurrent thoughts of death or suicide DSM-IV Diagnostic Criteria Hypomanic Episode: A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 4 days. B. During the period of the mood disturbance, three or more of the following symptoms (four if the mood is only irritable): APA Diagnostic and Statistical Manual. 1994 DSM-IV Diagnostic Criteria Hypomanic Episode: 1) inflated self-esteem or grandiosity 2) decreased need for sleep (eg, feels rested after only 3 hours of sleep) 3) more talkative than usual or pressure to keep talking APA Diagnostic and Statistical Manual. 1994 DSM-IV Diagnostic Criteria Hypomanic Episode: (continued) 4) flight of ideas or subjective experience that thoughts are racing 5) distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) 6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation APA Diagnostic and Statistical Manual. 1994 DSM-IV Diagnostic Criteria Hypomanic Episode: (continued) 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) APA Diagnostic and Statistical Manual. 1994 DSM-IV Diagnostic Criteria Hypomanic Episode: (continued) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. APA Diagnostic and Statistical Manual. 1994 DSM-IV Diagnostic Criteria Hypomanic Episode: (continued) E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism) APA Diagnostic and Statistical Manual. 1994 DSM-IV Diagnostic Criteria Manic Episode: A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. Same as for hypomanic episode DSM-IV Diagnostic Criteria Manic Episode: (continued) C. The symptoms do not meet criteria for a Mixed Episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. DSM-IV Diagnostic Criteria Manic Episode: (continued) E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism). Bipolar Disorder: DIG FAST Mnemonic D Distractibility I Insomnia G Grandiosity (or inflated self esteem) F Flight of Ideas (or racing/crowded thoughts) A Activities (increased goal directed activities) S- Speech (pressured) T- Thoughtlessness (impulsivity, ie, increased pleasurable activities with potential for negative consequences: sex, money, traveling, driving) What is Rapid Cycling? Four or more mood episodes per year. Considered more treatment- refractory. Individuals with bipolar disorder may go through periods of rapid- cycling that may last years. Associated with antidepressant monotherapy. What is a Mixed Episode? Rapidly alternating moods (sadness, irritability, euphoria) accompanied by criteria for both a Manic Episode and a Major Depressive Episode. Duration of 1 week. Frequently includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking. Controversy about antidepressants in bipolar disorder They can cause hypomania where there was none. They can induce cycling, or make it worse. They may keep a person from becoming truly stable. And they might, just might, cause some long-term harm, perhaps even irreversible harm. Step #1: Stop Cycling Interventions: Stop antidepressants Prevent mania or hypomania From From http://depression/ADwithoutAD.htm#/depression/ADwithoutAD.htm#stop Summary Recommendations 1. Do not use antidepressants if rapid cycling or severe insomnia/agitation (suggesting bipolar mixed state) is already present. 2. Do not use antidepressant if there is a history of mania or hypomania on an antidepressant, use a mood stabilizer. 3. If you are on an antidepressant and are not doing well, try stopping that antidepressant to see if things are more stable (or at least, no worse). Treatment options for bipolar depression What are they? Optimize mood stabilizer or AAP Lamotrigine Psychotherapy Dark therapy Exercise Electroconvulsive Therapy (ECT) Antidepressants?!? Remember prevention! (Atypical) Antipsychotics: Dont be afraid of the word “antipsychotic” Atypical Antipsychotics (AAPs) Olanzapine (Zyprexa) 2.5mg-20mg/day Quetiapine (Seroquel)12.5-600mg/day Risperidone (Risperdal)0.25mg-6mg/dalso, Invega (paliperidone) Ziprasidone (Geodon)20-160mg a day Aripiprazole (Abilify) 5-30mg a day listed in order of rate of weight gain/sedation (greatest to lowest) Psychotic Disorders: Atypical Antipsychotics Multiple receptor effects: serotonin and dopamine receptor subtypes Lower rates of side effects (compared with older antipsychotics), including tardive dyskinesia Neuroleptic malignant syndrome rare High rate of “metabolic syndrome”: weight gain, dyslipidemia, hyper- cholesterolemia, hyperglycemia (diabetes) How to manage weight gain Initial target should be weight stabilization, then weight loss Exercise and diet (for some people depression itself causes weight gain) Avoid (if possible) medications that cause significant weight gain Lower the dosage of medications Antidote medications are only marginally helpful: amantadine, metformin, topiramate, H-2 blockers Evidence-based, psychosocial treatments for bipolar disorder Cognitive-behavioral therapy (CBT) Interpersonal and Social rhythm psychotherapy (IPSRT) Family-focussed therapy (FFT) Psychoeducation Cognitive Behavioral Therapy of bipolar disorder Recognition and Diagnosis of Bipolar Disorder Medication Treatments for Bipolar Disorder Symptom Monitoring: An Early Warning System Cognitive Changes in Depressive Episodes and Mania Behavioral Changes and Problems in Depressive Episodes and Mania Psychosocial and Interpersonal Problems: Communication Cognitive-Behavioral Therapy for Bipolar Disorder, by Monica Ramirez Basco, A. John Rush, The Guilford Press 1996, CBT techniques for bipolar disorder a diary of significant events and associated feelings, thoughts and behaviors questioning and testing assumptions or habits of thoughts that might be unhelpful and unrealistic gradually facing activities which may have been avoided trying out new ways of behaving and reacting. Evidence-based, psychosocial treatments for bipolar disorder Cognitive-behavioral therapy (CBT) Interpersonal and Social rhythm psychotherapy (IPSRT) Family-focussed therapy (FFT) Psychoeducation Interpersonal and Social Rhythm Therapy Interpersonal Therapy Social Rhythms and The Social Rhythm Metric “Zietgebers” Find the right balance: how much rest, activity, stimulation is ideal? Maintaining the balance Adapting to changes in routine (planned and unplanned) The Social Rhythm Metric Evidence-based, psychosocial treatments for bipolar disorder Cognitive-behavioral therapy (CBT) Interpersonal and Social rhythm psychotherapy (IPSRT) Family-focussed therapy (FFT) Psychoeducation Expressed Emotion and Bipolar Disorder Intensity of negative interactions in close personal relationships (e.g., family, living situation) Criticism predicts mania and depression Hostility predicts mania and depression Over-involvement predicts depression Family-Focused Treatment (FFT) of Bipolar Disorder 21 outpatient sessions over 9 months Assessment of patient and family Psychoeducation about bipolar disorder (symptoms, early recognition, etiology, treatment adherence, self-management) Communication enhancement training (behavioral rehearsal of effective speaking and listening strategies) Problem-solving skills training Miklowitz DJ FFT, mean survival=73.5 weeks; CM, 53.2 weeks.(1)=8.71, p=.003; FFT, mean survival=73.5 weeks; CM, 53.2 weeks. Miklowitz DJ, et al. Miklowitz DJ, et al. Arch Gen PsychiatryArch Gen Psychiatry 2003;60(9):904-912. 2003;60(9):904-912. Family-Focused Treatment Enhances Drug Adherence More Than Crisis Management: Rates Over a 2-Year Follow-Up 21%21% 34%34% 44%44% 45%45% 16%16% 39%39% % of Patients% of Patients 2 (2)=9.1, p=.01.2 (2)=9.1, p=.01. Miklowitz DJ, et al. Miklowitz DJ, et al. Arch Gen PsychiatryArch Gen Psychiatry 2003;60(9):904-912. 2003;60(9):904-912. Change in Stability of Social Rhythms as a Function of Time in Treatment Weeks of TreatmentWeeks of Treatment 0 0 70708080303050504040606010102020 2 2 3 3 4 4 5 5 6 6 IPSRT (n=18)IPSRT (n=18) ICM (n=20)ICM (n=20) Social RhythmSocial Rhythm Metric ScoreMetric Score p=.006p=.006 ICM=Intensive clinical management. IPSRT=Interpersonal social rhythm therapy.ICM=Intensive clinical management. IPSRT=Interpersonal social rhythm therapy. Frank E, et al. Frank E, et al. BiolBiol Psychiatry Psychiatry 1997;41(12):1165-1173. 1997;41(12):1165-1173. Probability of Hospitalization if a Relapse Occurred: 2-Year Study FFT: 55% IFT: 88% Conclusion: Family intervention can help patients and families to avoid the need for rehospitalization during a period of symptom deterioration Rea MM, et al. Rea MM, et al. J Consult J Consult ClinClin PsycholPsychol 2003;71(3):482-492. 2003;71(3):482-492. Evidence-based, psychosocial treatments for bipolar disorder Cognitive-behavioral therapy (CBT) Interpersonal and Social rhythm psychotherapy (IPSRT) Family-focussed therapy (FFT) Psychoeducation What is psychoeducation? A course in which you will learn: What bipolar disorder is Techniques and tips to better manage the disorder Psychoeducation 21 groups sessions of 90 minutes each Topics include: Awareness of the disorder (6 sessions) Symptoms, etiology, triggers, course Drug Adherence (7 sessions) Review of medications, blood tests, alternative therapies Avoiding substance abuse (1 session) Early Detection of New Episodes (3 sessions) Regular habits and stress management (4 sessions) Includes problem-solving strategies Psychoeducation Manual for Bipolar Disorder, by F. Colom and E. Vieta, Cambridge University Press, 2006. Overview of Bipolar Disorder Group Sessions UCSF Introduction (Li) Self Awareness (Donovan) Medications (Li) Sleep and Substances (Li) Living a Healthy Lifestyle (Lehr) Coping with Depression (Lehr) Communication Skills (Thomas) The Future: A Review (Li) Hormones and Mood Hormones and Mood The basis of estrogen effects on mood is likely to be extremely complex, not simple Too much estrogen may also be bad, perhaps associated with anxiety/agitation High levels of estrogen can act to enhance the stress response, at least in rats Molecular Psychiatry (2004) 9, 531538 Antidepressants can improve hormone-related hot flashes and mood problems, with or without supplemental estrogen Brizendine Current Psychiatry; October 2003 Use of hormone replacement is controversial because of risks (breast and endometrial cancer) Check out /index.shtml Hormones and Mood More suicidal events (attempts, completed suicides) occur in the first week of the cycle. ?Low levels of estrogen in that phase, perhaps leading to low levels of serotonin Saunders and Hawton Psychol Med. 2006 Jul;36(7):901-12 What is Premenstrual Dysphoric Disorder (PMDD)? A more severe form of PMS. symptoms can only occur in the second half of the cycle Bipolar disorder and pregnancy 89 pregnant women with bipolar disorder (69% type I, 31% type II) followed prospectively across pregnancy. 70.8% of the participants experienced at least one mood episode. Most of these episodes were either depressive or mi