Bipolar Disorder and Treatments

1
Bipolar Disorder and Treatments

• Kristina Macdonald, Amy MacHarg,
  Tabitha Mason, Angela Mcfalls,
  Jessica McMichael

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Bipolar Disorders Criteria

• According to the American Psychiatric
  Associations Diagnostic and Statistical Manual
  of Mental Disorders, fourth edition (DSM-IV)
  Bipolar Disorder is characterized by the
  occurrence of one or more Major Depressive
  Episodes accompanied by at least one Manic
  Episode.

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What Is Bipolar Disorder?

• A mood disorder that alters
• Feelings
• Thoughts
• Behaviors
• Perceptions
• (Within episodes of mania and depression)
• Bipolar Disorder is previously known as Manic
  Depression

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Clinical Presentations

• Most commonly diagnosed between ages of 18 and 24
• Mania, Hypomania, Psychosis, depression

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Characteristics of Mania

• Feeling of being able to do anything
• Little sleep is needed
• Feeling filled with energy
• Not caring about financial situations
• Delusions
• Substance abuse
• The DSM-IV has a list of symptoms and three or
  more must be present.

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Characteristics of Hypomania

• Feeling of creativity
• Dont worry about problems seriously
• Feeling as if nothing can bring you down
• Have confidence in yourself
• Similar to Mania except Hypomania is of lesser
  intensity

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Characteristics of Psychosis

• Poor attention and concentration
• Suspiciousness
• Social withdrawal
• Feeling that things around you have changed
• Describing the diagnosis with psychosis is
  usually used to clarify the severity of the state
  of the disorder

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Characteristics of Depression

• Sleep more than you normally would
• Feeling of tiredness
• Crying uncontrollably
• Withdrawing from activities you once enjoyed
• Staying in bed for days
• Weight Loss/Weight Gain
• The DSM-IV has a list of symptoms and five or
  more must be present during the same two week
  period.

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The Two Sides of Bipolar Disorder

• Bipolar I
• Episodes of full mania alternating with episodes
  of major depression
• Diagnosed in patients typically in early 20s

• Bipolar II
• Episodes of major depression and hypomania

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Evaluation of Patient

• Make sure no other medical condition is causing
  mood or thought disturbance
• Perform a physical examination
• Look for possibility of substance abuse
• Trauma to brain
• Seizure disorders
• Perform mental health evaluation
• Mental status examination (MSE)
• Assesses mood and cognitive abilities
• Safety of individual
• Examines forms of psychosis

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Evaluation of Patient Cont

• Subjective experience of patient
• Familys psychiatric history

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Prevalence

• Lifetime 1
• Males and Females no difference
• Age all ages
• Highest prevalence is in the 18 to 24 year age
  group
• First degree relatives incidence of BP
  increases
• Affects roughly 1/100 adults
• Very little data about kids and teenagers
• Linked to disturbed electrical activity in the
  brain
• (Griswold, 2000)

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Bipolar Disorder
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What Causes Bipolar?

• No single cause may ever be found for bipolar
  disorder. Among the biological factors observed
  in bipolar disorder, as detected by using imaging
  cans and other tests, are the following
• Over secretion of cortisol, a stress hormone.
• Excessive influx of calcium into brain cells.
• Abnormal hyperactivity in parts of the brain
  associated with emotion and movement coordination
  and low activity in parts of the brain associated
  with concentration, attention, inhibition, and
  judgment. (Well Connected, 2002)

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How Serious is Bipolar Disorder?

• According to Well-Connected, 2002
• Risk for Suicide
• An estimated 15-20 of patients who suffer from
  bipolar disorder and do not receive medical
  attention commit suicide.
• In a 2001 study of Bipolar I disorder, more than
  50 of patients attempted suicide the risk was
  highest during depressive episodes.
• Patients with mixed mania, and possible when it
  is marked by irritability and paranoia, are also
  at particular risk.
• Many young children with bipolar disorder are
  more severely ill than are adults with the
  disorder. According to a study in 2001, 25 of
  children with the disorder are seriously
  suicidal.

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Seriousness of Disorder Cont.

• Thinking and Memory Problems
• In a 2000 study, it was reported that bipolar
  disorder patients had varying degrees of problems
  with short- and long-term memory, speed of
  information processing, and mental flexibility.
• (Medications used for bipolar disorder, however,
  could have been responsible for some of these
  abnormalities and more research is needed to
  confirm or refute these findings)

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Seriousness of Disorder Cont.

• Substance Abuse
• Cigarette smoking is prevalent among bipolar
  patients, particularly those who have frequent or
  severe psychotic symptoms. Some experts speculate
  that, as in schizophrenia, nicotine use may be a
  form of self-medication because of its specific
  effects on the brain.
• Up to 60 of patients with bipolar disorder abuse
  other substances (most commonly alcohol, followed
  by marijuana or cocaine) at some point in the
  course of their illness.

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Seriousness of Disorder Cont.

• Effect on Loved Ones
• It is very difficult for even the most loving
  families and caregivers to be objective and
  consistently sympathetic with an individual who
  periodically and unexpectedly creates chaos
  around them.
• Often family members feel socially alienated by
  the fact of having a relative with mental
  illness, and they conceal this information from
  acquaintances.

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Seriousness of Disorder Cont.

• Economic Burden
• In 1991, the National Institute of Mental Health
  estimated that the disorder cost the country 45
  billion, including direct costs (patient care,
  suicides, and institutionalization) and indirect
  costs (lost productivity, and involvement of the
  criminal justice system.)
• In one major survey, 13 of patients had no
  insurance and 15 were unable to afford medical
  treatment.

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Treatment of Bipolar Disorder
(a four phase process)

• Evaluation and diagnosis of presenting symptoms
• Acute care and crisis stabilization for psychosis
  or suicidal or homicidal ideas or acts
• Movement toward full recovery from a depressed or
  manic state
• Attainment and maintenance of euthymia
• This four phase process was according to
  (Himanshu P. Upadhyaya, MBBS, MS.,2002)

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Treatments

• Inpatient Care
• Assess the patient
• Diagnose the condition
• Ensure safety of patient and others
• This care is necessary for
• Psychotic features
• Suicidal or homicidal ideations

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Treatments

• Antidepressant therapy
• Mood stabilizer
• Lithium carbonate
• Sodium divalproex
• Carbamazepine
• Antipsychotic Agents
• Risperidone
• Haloperidol

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Treatments

• Electroconvulsive therapy (ECT)
• Inpatient basis
• Severe cases
• Patient requires hospitalization often
• Faster than medications for therapeutic responses
• Memory loss before and after treatments
• 3-8 sessions
• Medications are still required in maintenance
  phase of treatment

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Mood Stabilizers (Upadhyaya,2002
)
Mood Stabilizer Common Adverse Effects Doses Special Concerns
Lithium carbonate (Eskalith CR, Lithobid) Lethargy or sedation, tremor, enuresis, weight gain, overt hypothroidism occurs in 5-10 of patients 300-600 PO tid/qid Must be adjusted by monitoring serum level and patient response Hypothyroidism, diabetes insipidus, polyuria, polydipsia
Sodium divalproex/ valproic acid (Depakote, Depakene) Sedation, platelet dysfunction, liver disease, weight gain 10-20 mg/kg/d Must be adjusted by monitoring serum levels Elevated liver enzymes or liver disease, bone marrow suppression
Carbamazepine (Tegretol) Suppressed WBS, dizziness, drowsiness, rashes, liver toxicity(rarely) 200 mg PO bid Must be adjusted by monitoring serum blood levels Drug-Drug interactions, bone marrow suppression
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Mood Stabilizers Cont
Gabapentin (Neurontin) Headache, fatigue, ataxia, dizziness, sedation, weight gain Not established Withdrawal seizures
Lamotrigine (Lamictal) Sedation, dizziness, nausea or emesis, diplopia, ataxia, headache, sleep disruption, benign rash Not established Stevens-Johnson syndrome
Topiramate (Topamax) Nephrolithiasis, psychomotor slowing, somnolence Not established Decrease doses in liver or renal impairment
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Mood Stabilizers Cont
Felbamate (Felbatol) Liver Disease, photosensitivity, headache, somnolence Not Established Aplastic anemia
Vigabatrin (Sabril) Investigational drug Weight gain, agitation, insomnia Not Established Unknown
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Psychotherapy

• Is not an effective treatment by itself, but can
  be used in addition to medication
• Types of therapy include
• -cognitive behavior therapy
• -psychoeducation
• -interpersonal therapy
• -multifamily support groups

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Cognitive Behavior Therapy

• More effective with the depressive part of
  bipolar disorder
• Involves identifying irrational thought
  patterns and altering them to better reflect
  reality Activities such as daily mood logs
  can help (Wilkinson 2002)

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Psychoeducation

• Learning signs and symptoms of his/her disorder
  what triggers mood alteration
• More useful for mania
• ---Being able to identify signs and symptoms of
  mania is helpful in the prevention of a full
  blown manic episode (Wilkinson 2002).

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Interpersonal Therapy

• Helps to improve social skills and thereby
  provides patients with more stability in
  interacting with others
• Activities include
• - role playing
• - modeling
• - guided in vivo practice (Wilkinson 2002)

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Multi-family Therapy

• Parent involvement in a child with BD by teaching
  the child
• -relaxation techniques
• -anger management
• -decision-making skills
• -communication/listening skills
• -seeing that children dont become victims of
  their illnesses (Wilkinson 2002)

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An Alternative Combination

• A combination of lithium and valproate can be
  effective in treatment if monotherapy fails.

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Treatment for Children and Adolescents

• Lithium is one of the original treatments for
  bipolar states in youth
• In a study in which chlorpramzine (thorazine) was
  used, approximately 30 to 50 of youths had an
  improvement with mood stabilizing
• In Frazier et als 2001 experiment, an eight week
  study of using olanzapine monotherapy in 23
  children and adolescents shown that there were
  significant improvements of mania and depression
  on doses ranging from 2.5 mg/day to 20 mg/day

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Treatment Trends in the Elderly

• The number of new lithium users per year fell
  from 653 to 281 in 2001 for older patients
• The number of divalproex users rose from 183 in
  1993 to 1090 in 2001
• Though there has been a decline in elderly
  lithium patients using lithium, lithium will
  continue to be a mainstay until other mood
  stabilizers are researched more extensively

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Choosing the site of Treatment

• According to the American Psychiatric
  Association, 2000
• One of the first decisions the psychiatrist must
  make is the overall level of care that the
  patient requires.
• Acute episodes of bipolar disorder are frequently
  of such severity that patients require treatment
  in either a full or partial hospital setting.
  (The least restrictive setting that is likely to
  allow for safe and effective treatment should be
  chosen.)
• If the patient is lacking the capacity to
  cooperate with treatment.
• Patients who are unable to care for themselves
  adequately, cooperate with outpatient treatment
  of their mood disorder, or provide reliable
  feedback to their psychiatrist regarding their
  clinical status are candidates for full or
  partial hospitalization, even in the absence of a
  tendency toward intentional self-harm.

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Site of Treatment Cont.

• If the patient is at risk for suicide or homicide
• Patients with suicidal or homicidal ideation
  require close monitoring. Patients at high risk
  may benefit from hospitalization, during with
  close observation, restricted access to violent
  means and more intensive treatment are possible.
• If the patient lacks psychosocial supports
• Recovery from acute bipolar episodes is aided by
  an environment that encourages safety,
  constructive activity, positive interpersonal
  interactions, and compliance with treatment. If
  the home environment lacks these features or
  exposes the patient to undesirable or dangerous
  activities, such as alcohol or drug abuse,
  admission to a hospital or an intensive day
  program may be necessary.

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Works Cited

• Bipolar Disorder. (2002). Well Connected A.D.A.M.
  Inc. Retrieved from www.well-connected.com .
• Dinan, Timothy G. (2002, April 27). Lithium in
  bipolar mood disorder. British
• Medical Journal, 324 (7344), 898-991.
• Griswold, Kim S. (2000, September). Management of
  Bipolar Disorder. American Family Physician.
  www.findarticles.com/cf_0/m3225/6_62/65286755/prin
  t.jhtml
• Hirshfeld, R., Clayton, P.J., Cohen, I., Fawcett,
  J., Keck, P., McClellan, J., et al. (2000). 
  Practice Guidelines for the Treatment of Patients
  With Bipolar Disorder. American Psychiatric
  Association Practice Guidelines for the Treatment
  of Psychiatric Disorders, Compendium 2000,
  503-562.
• Nathan, Peter F., Gorman, Jack M. (1998). A guide
  to treatments that work.
• New York Oxford University Press.
• Schlozman, Steven C. (2002, November). The Shrink
  in the Classroom. An Explosive Debate The
  Bipolar Child. Association for Supervision and
  Curriculum Development. (89-90).
• Shulman, Kenneth I. (2003, May 3). Changing
  prescription patters for lithium
• and valproic acid in old age Shifting practice
  without evidence. British Medical Journal, 326
• (7396), 960-962.

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Works Cited Cont.

• Srinath, Rajeev J. et al. (2003, February). The
  Index Manic Episode in Juvenile-Onset Bipolar
  Disorder The Pattern of Recovery. Canadian
  Journal of Psychiatry. Vol. 48 (1). Retrieved
  Oct. 22, 2003, from EBSCO Academic Search Elite
  Database.
• Sternstein, Aliya Gross, Neil. (2002, August
  12). Some uplifting news about depression.
• Business Week, (3795), 69.
• Treatment. Journal of Mental Health Counseling,
  (24) 348. Retrieved Oct 21, 2003, from EBSCO
  Academic Search Elite database.
• Upadhyaya, Himanshu P. et al. (2002, October).
  Mood Disorder Bipolar Disorder. eMedicine.
  www.emedicine.com/ped/topic240.htm.
• Wilkinson, Greta et al. (2002). Bipolar
  Disorder in Adolescence Diagnosis and