Bipolar Disorder: Journey Through Mania and Depression

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Bipolar DisorderJourney Through Mania and
Depression

• H.E. Logue, M.D.

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Bias Disclaimer

• There is no pharmaceutical support for this
  program.
• I am active in the research field and involved in
  clinical trials for most of the major
  pharmaceutical companies.

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Goals and Objectives

• Promote better understanding of the following
  aspects of Bipolar Disorder
• Prevalence
• Recognition and Diagnosis
• Understanding Risk Factors
• Genetic Predisposition
• Treatment Considerations
• Co-morbid Conditions
• Referral Consideration

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• Richard Dreyfuss
• Kitty Dukakis
• Liza Minnelli
• Carman Miranda
• Marilyn Monroe
• J.P. Morgan
• Ralph Nader
• Sir Isaac Newton
• Florence Nightingale
• Ozzy Osbourne
• Dolly Parton
• Boris Pasternak
• George Patton
• Jane Pauley
• Pablo Picasso
• Cole Porter
• Abraham Lincoln
• Joshua Logan

• Drew Carey
• Dick Cavett
• Ray Charles
• Frederick Chopin
• Winston Churchill
• Dick Clark
• Rosemary Clooney
• Kurt Cobain
• Natalie Cole
• Samuel Coleridge
• Sheryl Crow
• Irving Berlin
• Steven Foster
• Lord Byron (George Gordon)
• Noel Coward
• Alexander the Great
• Edwin Buzz Aldrin
• Hans Christian Anderson

• Victor Hugo
• Edgar Allen Poe
• Leo Tolstoy
• Michelangelo
• Ezra Pound
• Charlie Pride
• Sergey Rachmaninoff
• Patty Duke
• Thomas Eagleton
• Thomas Edison
• T.S. Eliot
• Ralph Waldo Emerson
• William Faulkner
• Eddie Fisher
• F. Scott Fitzgerald
• Betty Ford
• Harrison Ford
• Stephen Foster
• Sigmund Freud

• Charles Schultz
• King Saul
• William Tecumseh Sherman
• Neil Simon
• Rod Steiger
• William Styron
• Alfred, Lord Tennyson
• King Herod
• Nathaniel Hawthorne
• Ernest Hemingway
• Audrey Hepburn
• Howard Hughes
• Thomas Jefferson
• Joan of Arc
• Lyndon Baines Johnson
• Danny Kaye
• Ted Turner
• Mozart
• Larry King

• Mike Wallace
• George Washington
• Robin Williams
• Tennessee Williams
• Thomas Wolfe
• Virginia Woolf
• Lord Tennyson
• Vincent van Gogh
• Peter Tchaikovsky
• F. Scott Fitzgerald
• Charles Dickens
• Robert Louis Stevenson
• Walt Whitman
• Sylvia Plath
• Marlon Brando
• Art Buckwald
• John Bunyan
• Rodney Dangerfield
• Charles Darwin

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Prevalence

• Bipolar Disorder affects approximately
  5.7 million adult Americans
• The median age of onset for Bipolar Disorder is
  25 years.
• An equal number of men and women develop Bipolar
  Disorder and it is found in all ages, races,
  ethnic groups and social classes.
• Bipolar Disorder is the sixth leading cause of
  disability in the world.
• Bipolar Disorder results in 9.2 years reduction
  in expected life span, and as many as one in five
  patients with bipolar disorder completes suicide.

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Bipolar Disorder Subtypes

• Classic Bipolar Disorder
• Bipolar I
• Bipolar II
• Subtypes
• Cyclothymia
• Major Depression Unipolar/Recurrent
• Dysthymic Disorder
• Bipolar NOS (Not Otherwise Specified)
• Other Considerations
• Rapid Cycling (part of Bipolar I)
• Post-partum Onset
• Seasonal Pattern Mood Disorders

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DSM-IV Criteria - Depression

• Five or more of the following
• Depressed mood
• Diminished interest or pleasure in activities
• Significant weight loss/gain or decrease/increase
  in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or
  inappropriate guilt
• Diminished ability to think or concentrate, or
  indecisiveness
• Recurrent thoughts of death, recurrent suicidal
  ideation without a specific plan, or a suicide
  attempt or a specific plan for committing
  suicide.

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Diagnostic Dilemmas

• Secondary Depression

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Depression with

• Other psychiatric illnesses
• Schizophrenia
• Anxiety
• Panic disorder
• Obsessive-compulsive disorder
• Personality Disorders
• Borderline
• Compulsive
• Post-traumatic stress disorder
• Post-partum depression
• Grief/depression
• Practically any psychiatric disorder

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Depression with

• Organic/Medical Illnesses
• Hypothyroidism
• B-12 deficiency
• Folate deficiency
• Tuberculosis
• Myasthenia gravis
• Diabetes mellitus
• Hepatitis C
• Cushings disease
• Mononucleosis
• Parkinsons disease
• CHRONIC FATIGUE SYNDROME

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DSM-IV Criteria - Mania

• Three or more of the following
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep
  talking
• Flight of ideas or subjective experience that
  thoughts are racing
• Distractibility
• Increase in goal-directed activity or psychomotor
  agitation
• Excessive involvement in pleasurable activities
  that have a high potential for painful
  consequences

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Mood Symptoms

• Euphoria/Mania
• Depression (in mixed state)
• Anxiety
• Anger
• Hostility
• Irritability

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Behavioral Symptoms

• Energized Activity
• Diminished Need to/for Sleep
• Impulsivity
• Anger with Violence
• Elevated Libido
• Diminished Inhibitions
• Reckless Behavior

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Cognitive Symptoms

• Racing Rapid Thoughts
• Diminished Insight/Invincibility
• Sensory Hyperacuity
• Hallucinations
• Delusions
• Perceptual Distortions
• Distractible Disorganized Thoughts

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S-H-O-T

• S Symptomatology
• Do the symptoms appear to be manic or depressed
  or repeated episodes of depression or mania or
  continuing mood swings?
• H History
• What is the history of the person? The history of
  the family? Is there a family history of mood
  swings, mood disorders, substance abuse in
  persons with mood disorders or Bipolar diagnosis?
• O Ongoing illness
• What is the progression of the illness? What is
  the course of the disease? Does it continue to go
  on in a progression appearing as a Bipolar
  disease course?
• T Treatment response
• If one looks at the response of the treatment one
  should get a good deduction as to the nature of
  the illness.

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Understanding Risk Factors

• Stress (major or prolonged)
• Sleep Deprivation/Disruption
• Alcohol (major problem)
• Recreational Drug Use
• Discontinuation of Medications
• Loss or Perceived Loss (job, family, friends,
  finances, health, etc.)
• Interpersonal Conflict
• Travel Across Time Zones
• Mood-Altering Medications (benzodiazepines,
  antidepressants, antipsychotics)
• Death of Loved One or Friend
• Inadequate Coping Skills
• Early Dementia or Minimal Brain Damage

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Treatment

• Depression vs. Bipolar Depression

• Depression Pre-Modern Era
• Tincture of Time
• Prescribed trip to Europe
• Activity
• Physical
• Social
• Mental
• Somatic
• Insulin shock
• Electric shock
• Spiritual

• Depression Modern Era
• Education and Psychotherapy
• Pharmacotherapy
• 1950s Tricyclics
• 1960s Tetracyclics, etc.
• 1990s SSRIs (Prozac, Paxil, Zoloft)
• SNRI (Wellbutrin)
• SSNRIs (Effexor, Remeron, Cymbalta)
• Spiritual

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Treatment Statistics

• Patients with Bipolar Disorder face up to ten
  years of coping with symptoms before receiving an
  accurate diagnosis.
• Nearly 9 out of 10 patients with bipolar disorder
  are satisfied with their current medication(s),
  although side effects remain a problem.
• Participation in a Depression and Bipolar Support
  Alliance patient-to-patient support group
  improved treatment compliance by almost 86 and
  reduced in-patient hospitalization.
• Consumers who report high levels of satisfaction
  with their treatment and treatment provider have
  a much more positive outlook about their illness
  and their ability to cope with it.

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Bipolar Disorder Type II (Depressed Type)

• Incorporate all of the previous slide
• Recent studies suggest antidepressants cause a
  sooner relapse or conversion to mania
• Treating the Bipolar component is equivalent to
  casting both broken legs.
• Mood stabilizers
• Lithium only drug proven to reduce suicide rate
• Antidepressants
• 1950s Richard Dreyfuss
• 1990s Depakote, Tegratol, Trileptal, Lamictal
• Atypicals?

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Bipolar Disorder Type I (Manic and Depressive)

• Mania
• Antipsychotics
• 1953 Thorazine/chlorpromazine
• Worlds first psychotropic medication
• Could treat psychosis and mania
• Other conventional antipsychotics followed
• Risk and Benefits
• Atypical Antipsychotics
• Zyprexa, Seroquel, Abilify, Risperdal, Geodon
• Risk and Benefits
• Anticonvulsants
• Depakote, Tegratol, Trileptal, Lamictal
• Risk and Benefits
• Electroconvulsive Therapy

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Genetics

• Like the illness, a complicated topic
• Confounding issues
• Hypersexuality
• Family disintegration
• Separation of siblings
• Twins

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Genetic Models

• Mendelian vs. Polygenic Models
• 1 affected parents 1 in 4 affected offspring
• 2 affected parents 2 in 3 affected offspring
• 1 dizygotic/fraternal twin 1 in 6 affected twin
• 1 monozygotoc/identical twin 2 in 3 affected
  twin
• Epistatic Model
• Number 22 is prominently mentioned (same gene as
  schizophrenia
• Gene 21q is also involved
• Genes 18p and 18q also are involved