Perspectives on Bipolar Disorder and Psychosis

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Perspectives on Bipolar Disorder and
Psychosis 9th November 2010 Dr Tim
Sales Consultant Psychiatrist Honorary Senior
Clinical Lecturer

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• Structure of talk
• Overview of Bipolar Disorder
• Overview of Schizophrenia and Psychosis
• Question time

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• Bipolar Disorder need to know
• What do you already know?
• Where do you get new information from?
• Map of Medicine

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• Bipolar Affective Disorder
• Common life time prevalence 1.3
• Peak of onset mid teens to mid twenties
• 50 of patients non-adherent to treatment
• as with other long term conditions
• 10 - 20 suicide rate
• 46 co-morbid alcohol misuse
• 41 co-morbid drug misuse

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Bipolar affective disorder is multi-dimensional
Hypomania
Mania
Mania
Maintenance
Mild depressive episode
Severe depressive episode
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Ongoing symptoms in Bipolar Disorder
n146 12.8 year follow up
Judd et al 2002
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• Goals in Maintenance Treatment
• Symptom control
• Prevention of new episodes
• Prevention of sub-syndromal episodes
• Prevent suicide
• Enhance functioning

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• When to start Maintenance Treatment
• Consider long term treatment earlier
• 1 severe episode of mania
• 2 less severe episodes of illness
• At least 2 years of treatment to maintain
  progress

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• Which Maintenance Treatment?
• 5 drugs are effective as monotherapy in trials gt
  1year
• Lithium
• Olanzapine
• Aripiprazole
• Lamotrigine
• Quetiapine
• 1 year data for Sodium Valproate
• Avoid routine use of long term anti-depressants

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• Schizophrenia need to know
• What do you already know?
• Where do you get new information from?
• Map of Medicine

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• Schizophrenia
• Common life time risk 0.5 1.0
• Peak of onset mid teens to mid twenties
• 50 of patients non-adherent to treatment
• as with other long term conditions
• 10 - 20 suicide rate
• Higher risk of cardiovascular disease

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• NICE Guidelines (2009 update)
• Recommends anti-psychotics for schizophrenia
• non-adherence, troublesome side effects
• No specific anti-psychotics are recommended
• both 1st and 2nd generation anti-psychotics
  recommended

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CATIE results of Phase I discontinuationLieber
man JA, et al. N Engl J Med 2005353120923
ITT population Any cause Any cause Lack of efficacy Intolerability
Median time (months) Lack of efficacy Intolerability
Olanzapine 64 9.2 15 19
Quetiapine 82 4.6 28 15
Risperidone? 74 4.8 27 10
Perphenazine 75 5.6 25 16
Ziprasidone 79 3.5 24 15
Significantly longer for olanzapine than
quetiapine and risperidone, but not
perphenazine or ziprasidone
Significantly lower for olanzapine vs. all
except ziprasidone
No significant difference
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CUtLASS 1 SGAs vs. FGAsJones PB, et al. Arch
Gen Psychiatry 200663107987

• No advantage of SGAs over FGAs in terms of
  quality of life or symptoms over 1 year
• There were no significant differences in
  symptoms, global functioning, or in rates of
  objectively assessed EPS
• Total healthcare and social costs (52 weeks) not
  significantly different FGAs 18,800, SGAs
  20,100
• Drug costs were twice as much on SGAs than FGAs
  (3.8 vs. 2.1)
• No patient preference for any particular drug or
  drug group at any stage.

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Weighing it up SGAs vs. FGAs
Efficacy Safety
Pragmatic studies show no clinically important differences between FGAs and SGAs regarding efficacy and quality of life. All are associated with troublesome side-effects and are poorly tolerated. Side-effect profiles vary with individual agents and doses. In general FGAs more EPS SGAs more weight gain and metabolic effects.
Cost Patient factors
Acquisition costs of FGAs lower than SGAs. No significant difference in cost of care. Side-effects of individual agents may be more acceptable and tolerated by individual patients than others.
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• The role of Primary Care
• Early identification of symptoms and relapse
• Monitoring and re-referral if problems with
  treatment
• non-adherence, troublesome side effects
• Regular review for physical health problems
• focussing on cardiovascular disease

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• The wisest mind has something yet to learn
• George Santayana (1863 1952)
• Any questions?
• Thank you for your time