Diagnosing Bipolar Disorder

1. Diagnosing Bipolar Disorder “We’re all a little that way”

2. MH Disorders in OP Psychiatry • 25% “Other” = Schiz, Anx, ADHD, PD • 25% Depression -(often treatment resistant) • 25% Bipolar disorder • 25% “Bipolar Spectrum” • Complicated, confusing, comorbid, poor treatment outcome

3. Diagnosis of Mood Disorders • The possibilities: • Bipolar I = Mania with or w/o depression • Bipolar II = Hypomania with depression • Cyclothymia = hypomania with “minor” depression • Major Depression = depression • “Bipolar spectrum” = Depression + other complexities • Bipolar NOS or Mood DO NOS

4. Always consider these: • Significant medical condition • Depression due to general med condition • History of many physical symptoms • Secondary depression • Significant recent substance use • Meth and cocaine and pot = mania/psychosis • Alcohol and cocaine withdrawal = depression

5. Diagnosis of BPAD • Assessment of cross sectional symptoms inadequate for dx • One session = “One cut of an MRI” • Assessment of longitudinal course essential • Collateral info = other providers, admits, family history and input, follow-up visits • “The whole MRI” • “Biography”

6. Diagnosis • DSM IV TR criteria for mania • Distinct period of abnormally and persistently elevated or irritable mood lasting a week or requiring hospitalization, or with psychosis • Three or more of: grandiosity, decreased need for sleep; talkative; flight of ideas; distractibility; increase in goal directed activity; excessive involvement in pleasurable activities = buying sprees, sexual indiscretions, foolish business investments

7. DSM 4TR criteria for depression(MDD) • Depressed mood most of the day almost every day • Diminished interest or pleasure • Appetite and wt changes • Sleep changes • Agitation or slowness of movement • Fatigue • Guilt or “worthlessness” • Poor concentration • Thoughts of death or suicide

8. Other features of Depression • Psychosis--paranoia or hallucinations • Seasonal component = SAD • Postpartum onset • Catatonic features=marked psychomotor disturbance, immobility or stupor • Melancholic features = worse in a.m., anorexia or wt loss, marked guilt

9. Mixed Bipolar Episode • Meet criteria for both mania and depression • Often most severely ill • High suicide rate • Looks like agitated depression

10. Depression: Bipolar vs MDD • More common in Bipolar • Early age of onset • Recurrence • Postpartum • Rapid cycling • Brief duration • Baseline hyperthymic personality • Bubbly,outgoing, extroverted, etc

11. Symptoms: Bipolar vs Unipolar • More common in Bipolar • “Atypical” sx • Increased sleep & appetite, rejection sensitivity, mood reactivity, leaden paralysis • Psychotic depression • Anxious/agitated depression • Irritability and anger

12. Treatment response: BPAD vs MDD • More common in BPD • Antidepressant induced mania • Antidepressant induced psychosis, mixed states or suicidality,dysphoria (ACID syndrome) • Nonresponse to good med trial • Tolerance to medication = poop out effect • Rapid cycling, including only w/in depressed range

13. Differences between BPAD I & II BP-I BP-II Atypical features + +++ Mixed state/agitation + +++ Anxiety disorder ++ +++ Mood lability ++ +++++ Social anxiety + +++ Female/Male ratio 1:1 2/1

14. The Galaxy of Possibilities Single MDE *Atyp MDD *(PD) *Chronic MDD *Recurrent MDD *Psychotic MDD ** *Dysthymia **“Bipolar Spectrum DO” *Bipolar NOS *Bipolar II *Bipolar I *(Psychosis) *(ANXIETY) *(Psychosocial Stress) (ADHD)

15. Comorbid Illness • Substance dependence • ETOH, etc. = 45% lifetime • Anxiety DO • GAD, PD, PTSD = 45% lifetime • ADHD • Shared cognitive deficits when euthymic • Personality Disorders • Cluster B = BP, NPD, ASPD

16. Bipolar Spectrum Disorder, proposed for DSM V • At least one MDE • No spontaneous hypomania or mania • Family Hx of BPD in 1st degree relative or AD induced hypomania/mania • Ancillary criteria: • Hyperthymic personality • Recurrent MDE • Brief MDEs (< 3 mos) • Atypical depressive sx • Psychotic MDEs

17. Proposed definition cont. • Ancillary criteria cont: • Early age at onset • Postpartum depression • Antidepressant wear-off (acute but not prophylactic response) • Lack of response to 3 AD trials • Ghaemi and Goodwin

18. Bipolarity Index: 0 - 100 MGH Bipolar Program • Episode Characteristics • Age of Onset • Course of Illness • Comorbidities, jobs, education, marriage, law • Response to Treatment • Positive or negative or worsening (ACID) • Family History • Scientific basis for BPD/UPD distinction • manicdepressive.org

19. Misdiagnosis of BPAD I & II • “50% or higher rate (? > 80%) of misdx” • 50% of BPAD I present with depression • >>50% of BPAD II present with depression • Up to 10 years of rx for MDD prior to dx of BPAD • ? Bipolar Spectrum • Ill defined intermittent sx, etc

20. Misdx: patient factors • Lack of insight with regard to mania • Impaired memory for past depression • Failure to report manic sx or behavior • Experiencing hypomania as “normal good times” • Cultural positive feedback for hypomanic/manic sx

21. Misdx: clinician factors • Failure to include family in eval • Structure of DSM = “begins by separating bipolar from all depressions” • Inadequate knowledge of mania criteria • Intuitive “prototype” approach to dx • Practical desire to make dx which is more palatable and more treatable STIGMA • Lack of awareness of prevalence of bipolar

22. Misdx: Illness factors • First episode of illness often depression • May be recurrent for many years • Dysphoric depression is not conceptualized as a mixed state • Depressive episodes last longer than often fleeting hypomanic states

23. “There is no such thing as unipolar depresion” How much bipolarity?

24. BPD: Treated vs UntreatedMortality ratios p<.001

25. Treatment of Mania and Maintenance • Lithium • Valproate • Carbamazepine • Atypical Antipsychotics • Olanzapine, risperidone, ziprasidone, quetiapine, aripiprazole • Others = Oxcarb, Topirimate, Clonaz, Gabapentin

26. Treatment of Bipolar DepressionReplicated RCT n>100 • Quetiapine • 300mg - 600mg • Olanzapine • 5mg - 20mg • Olanzapine/fluoxetine (Symbiax) • Lamotrigine • 50mg - 200 mg • Lithium*

27. Antidepressants and BPDep --No Prospective DB RCT adequately powered study in BP I or II (Olanzapine/fluoxetine combo) --Recent NEJM article (NIMH Sept 07) = depressive sx improve at same rate with and without AD --Treatment emergent affective switch (TEAS) -TCA>Ven>SSRI>Bup --Treatment emergent rapid cycling --AD associated chronic irritable dysphoria

28. “ACID” (STEP-BD study) • Unrelenting dysphoria • Severe agitation • Refractory anxiety • Unendurable sexual excitement • Intractable insomnia • Suicidal obsessions and impulses • “histrionic demeanor” • Social, occupational, marital dysfunction • Improvement with stopping ADs

29. Antidepressants in BPD • Bipolar Treatment Centers • 30% of patients on AD • Community psychiatrists • 50-60% of patients on AD • Primary care providers • 70-80% of patients on AD

30. Treatment of BP Spectrum Agitated Depression • Add mood stabilizer • Lamotrigine - Oxcarb • Lithium • Depakote • Taper and DC antidepressants if poss. • Atypical antipsychotic Seroquel >Abilify>Zyprexa = Risp = Geodon • Sleep agents

31. Novel Treatments: not EBM • Pramipexole • 2 RCTs small numbers positive • Omega 3 • 4 small studies positive as add-on Rx • <1gm • Inositol • 6-20 gm/day, small studies, “suggestive”

32. BP Disorder Psycho-social treatments • Psychoeducation • CBT • Family Focused Therapy • IPSRT (Interpersonal social rhythm therapy) **Psychosocial or physical stressors are the most robust predictors of relapse

33. Long term outcome • BPAD I & II • 1/3 complete remission & funct. • 2/3 fail to achieve pre-morbid function • Chronic persistent sx in 20% • Social incapacity in 30% • “Bipolar Spectrum” • Who knows?