MEASURE Resource Module

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MEASURE Resource Module
 
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Approved/Unapproved Use

• The following presentation may contain
  information concerning a use that has not been
  approved by the US Food and Drug Administration.
  Any unlabeled/investigational discussion of drugs
  will be disclosed during the presentation.

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The Phenomenology and Epidemiology of Bipolar
Disorder
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Bipolar Disorder Spectrum of Mood Variation
Total Mood Variations
Rapid Cycling 1520
Mania
Classic Bipolar 40
Depression
Mixed Mania 4050
Hypomania 5
Cyclothymia 5
M
D
D
m
M
d
M
D
d
m
d
m
Normal
M Full mania m Hypomania D Severe
depression d Mild depression
Goodwin FK et al. In Goodwin FK, Jamison KR,
eds. Manic-Depressive Illness. New York,
NY Oxford University Press 199074-84.
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Symptom Domains of Bipolar Disorder
Dysphoric or Negative Mood and Behavior
Manic Mood and Behavior

• Euphoria
• Grandiosity
• Pressured speech
• Impulsivity
• Excessive libido
• Recklessness
• Social intrusiveness
• Diminished need for sleep

• Depression
• Anxiety
• Irritability
• Hostility
• Violence or suicide

BIPOLARDISORDER
Cognitive Symptoms
Psychotic Symptoms

• Racing thoughts
• Distractibility
• Disorganization
• Inattentiveness

• Delusions
• Hallucinations

Slide courtesy of Keck PE Jr. adapted from
Goodwin FK, Jamison KR. Manic-Depressive Illness.
Oxford University Press New York, NY 1990.
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Assessment of Patients With Mood Symptoms

• Obtain symptoms and duration of current manic or
  depressive episode
• Inquire about past manic, hypomanic, or
  depressive episodes
• Assess for substance abuse
• Determine if there is a family history of mood
  disorders
• Ask about past treatment with psychiatric
  medications and response
• Information from collateral resources
• Evaluate risk of harm to self or others

Marchand WR. Hosp Physician. 20033921-30. Bowden
CL. Psychiatr Serv. 20015251-55.
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Presentation of Depressed Patients Who May Be
Bipolar

• Hyperphagia/weight gain
• Hypersomnia
• Melancholic features
• Severe anhedonia
• Seasonal mood changes
• Psychomotor slowing
• Psychotic features
• History of poor response to antidepressants

• History of recurrent but brief depressive
  episodes
• History of antidepressant-induced mania or
  hypomania
• Family history of bipolar illness in a
  first-degree relative
• Early age of onset
• Postpartum onset

Marchand WR. Hosp Physician. 20033921-30.
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Features That May Indicate a Mixed Episode

• Anxiety and panic
• Family history of bipolar illness in a
  first-degree relative
• Psychomotor agitation with extreme fatigue
• Racing thoughts
• Severe insomnia
• Severe irritability
• Suicidal ideation

Marchand WR. Hosp Physician. 20033921-30.
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Symptoms of Manic, Hypomanic, and Mixed States
Associated symptoms (3 required or 4 if the mood
is irritable but not elevated)
Grandiosity Decreased sleep
Increased speech Flight of ideas
Distractibility Increased activity
Excessive pleasure-seeking
Same as for manic episode
Same as for manic episode
Also meets criteria for a major depressive
episode
Duration of episode required for diagnosis
At least 4 days
At least 1 week
1 week or hospitalization
Marked impairment or hospitalization or psychosis
Does not cause marked impairment
Same as for manic episode
Impairment
Adapted from the American Psychiatric
Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC
2000345-428.
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Mood Disorder Episode Criteria
Hypomanic Episodes
Manic or Mixed Episodes
Depressive Episodes
Disorder
Common but not required
Common but not required
Bipolar I disorder
? 1 required
Bipolar II disorder
None allowed
? 1 required
? 1 required
Cyclothymic disorder
Required, but not major depression
Numerous periods over 2 years required
None allowed
Bipolar disorder NOS
None allowed
Required, but do not meet criteria for a
specific bipolar disorder
Required, but not major depression
Major depressive disorder
None allowed
? 1 required
None allowed
Dysthymic disorder
None allowed
? 2 years required but not major depression
None allowed
NOS not otherwise specified
Adapted from the American Psychiatric
Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC
2000345-428.
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Rapid Cycling

• Phenomenon that specifies the natural history or
  course of bipolar disorder
• Describes 1450 of bipolar patients
• Most commonly seen in women and BP II disorder
• Associated with prior antidepressant use
• Predictor of poor response to lithium and
  carbamazepine
• Possible predictor of response to divalproex

Calabrese JR et al. J Affect Disord.
200167241-255.
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Bipolar Disorder Challenges Misdiagnosis
NDMDA Survey of Its Bipolar Members Rate of
Misdiagnosis
1994 2000
73 69

• Most frequent misdiagnosis unipolar depression
• Treatment as unipolar depression can lead to
  worsening of symptoms by switching into mania or
  cycle acceleration

Goodwin FK et al. In Goodwin FK, Jamison KR,
eds. Manic-Depressive Illness. New York,
NY Oxford University Press 199074-84. Hirschfel
d RMA et al. J Clin Psychiatry.
200364161-174. Lish JD et al. J Affect Disord.
199431281-294.
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Epidemiology of Bipolar Disorder

• Estimates for lifetime prevalence of any type of
  bipolar disorder worldwide are
• 0.5 to over 5
• Diagnostic assessment methods and criteria
  varied broadly from study to study

Two Major US Epidemiological Surveys

• The Epidemiologic Catchment Area Study
• Bipolar I prevalence 0.8
• Bipolar II prevalence 0.5
• Any bipolar disorder 1.3
• Bipolar I age of onset 18 years
• Bipolar II age of onset 22 years
• Bipolar I male female
• Bipolar II male lt female

• NCS The US National Comorbidity Survey (only BP
  I examined)
• Bipolar I prevalence 0.45
• Manic episode prevalence 1.6
• Bipolar I age of onset 21 years
• Bipolar I male female

Kleinman LS et al. Pharmacoeconomics.
200321601-622.
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Bipolar Spectrum Disorders Prevalence and Impact
Project

• A recent nationwide study uncovered new data
  regarding prevalence of bipolar disorder using
  MDQ as screening tool
• Prevalence appears to be 3.7 and is highest in
  the 1824-year age range (compared with
  previously accepted 1)
• Only 1 in 5 patients with bipolar disorder is
  correctly diagnosed
• Those who are correctly diagnosed are likely to
  be more impaired, female, and poorer
• 1 in 3 is misdiagnosed as having unipolar major
  depression, perhaps due to the prevalence of the
  depressive phase of the illness

Hirschfeld RMA et al. J Clin Psychiatry.
20036453-59.
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Screening for Bipolar I and II Disorders
Hirschfeld RMA et al. J Clin Psychiatry.
20036453-59.
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Prevalence of Bipolar I and II Disorder Among
Racial Groups
Race 3.1 4.3 7.6 4.1 6.3 5.2
Race Caucasian African American Native
American Asian/Pacific Islander Other Unknown
Hirschfeld RMA et al. J Clin Psychiatry.
20036453-59.
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Physicians Diagnoses Among MDQ Positives in the
Community
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Dx with bipolar disorder Dx with depression but
not bipolar disorder Neither bipolar disorder
nor depression Dx
31
49
Hirschfeld RMA et al. J Clin Psychiatry.
20036453-59.
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Bipolar I and II Disorder in the Community
Conclusions

• Prevalence is 3.7 and is highest in the
  1824-year age group
• Prevalence is higher among Native and African
  Americans
• Only 1 in 5 with bipolar disorder is correctly
  diagnosed by doctors
• Those correctly diagnosed are likely to be more
  impaired, female, and poorer
• 1 in 3 is misdiagnosed as having unipolar
  depression
• Those diagnosed with unipolar depression are
  likely to be less impaired, female, with higher
  income and less substance abuse
• MDQ works well in the community as a screen for
  bipolar I and II disorder

Hirschfeld RMA et al. J Clin Psychiatry.
20036453-59.
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Predicting Type of Recurrent Episode Manic or
Depressive?

• Factors predicting next episode will be manic
• Initial mood-congruent psychotic feature
• Low prehospitalization occupational status
• Nonmixed initial mania
• Factors predicting next episode will be
  depressive
• High occupational achievement
• Initial dysphoric states
• Psychiatric or medical comorbidities

Tohen M et al. Am J Psychiatry.
20031602099-2107.