Perils and Pitfalls of the Diagnosis of The Bipolar Disorders

1)1)Discuss the recognition of bipolar disorder Discuss the recognition of bipolar disorder in the clinic settingin the clinic setting

2)2)Discuss the treatment options for bipolar Discuss the treatment options for bipolar depressiondepression

3)3)Describe the efficacy and safety of treatment Describe the efficacy and safety of treatment options for bipolar depressionoptions for bipolar depression

Q: Is this episode of depression really due to Major Depression or due to Bipolar Disorder?

Bipolar Disorders are Diagnoses of Inclusion

According to DSM-IV-TR:Major Depression should only be DX’d after a H/O of mania/hypomania has been excluded and the bipolar disorders have been ruled out

Screening for H/O mania/hypomania is essential in order to differentiate the bipolar

disorders from the depressive disorders

Bipolar Disorders are Diagnoses of Inclusion

According to DSM-IV-TR :

Bipolar Disorder – manic, mixed, depressed

Bipolar Disorder – type II

Bipolar Disorder NOS, & Cyclothymia

There is no exclusion other than the ascription of a General Medical Condition or Drug Intoxication or Withdrawal Syndrome.

Why is Screening Necessary?

1. Patients don’t report manic symptoms

2. Evaluation may not use outside sources

3. The Antidepressant Problem:

a)Patients often request antidepressants

b)Antidepressants worsen the course and may lead to more depressive episodes

Screening for Mania and Mixed States

The Mood Disorder Questionnaire (MDQ) is a validated screening instrument for bipolar I and II disordersHirschfeld RM, et al. Am J Psychiatry. 157:1873, 2000

DIGFAST:Symptoms of Hypomania and Mania

D Distractibility: poorly focused I Insomnia: decreased need for sleepG Grandiosity: inflated self-esteemF Flight of ideas: c/o racing thoughtsA Activities: increased activitiesS Speech: pressured or more talkativeT Thoughtlessness: “risk-taking” behaviors

sexual, financial, travel, driving

Ghaemi et al, World J Biol Psych 2: 65, 2000

EuphoriaPressured Speech

Hyperactivity

3 Signs in 3 Days in 3 Settings

The Unmistakable Triad George Winokur, Classification of Mania & Depression, 1991

IrritabilityInsomnia

ImpulsivityImpaired Social/Vocational Life

>4 Days – Hypomania<4 Days – Bipolar NOS

The Questionable Quad –the 4 I’s George Winokur, Classification of Mania & Depression,

1991

Longitudinal Assessment of the Course of Bipolar Disorders

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Euthymia

Depression

Mania

SubsyndromalDepression

Depression

Hypomania

Medications for Bipolar Disorder Mood Stabilizers

Divalproex DR Divalproex ER

Carbamazepine ER

Lamotrigine - M

Lithium - M

Depakote Depakote ER

Equetro

Lamictal

Eskalith, Lithobid

FDA Approvals – Depression or Maintenance

Mood Stabilizers Lamotrigine - increase slowly may increase

Divalproex levels & vice versa, Watch out for Rashes

Carbamazepine – Monitor levels, autoinduces itself & reduces APs, Dizzy, Double Vision, Dropping, Decreased Sodium, Agran.

Lithium – Monitor levels, Chem 7, drug-drug interactions, Tremor, Thirst, Thyroid, Toxicity

Divalproex – Monitor levels, LFTs, Tremor, GI side effects, Alopecia, Pancreatitis

Medications for Bipolar Disorder Second Generation Antipsychotics

Aripiprazole - M

Olanzapine - M

Quetiapine - Depr

Risperidone

Ziprasidone

Abilify

Zyprexa

Seroquel

Risperidal

Geodon Olanzapine/Fluoxetine – Depr Symbyax

SGAs Guidelines

Baseline:Weight (BMI) – monthly for the first 3 monthsWaist circumferenceBlood pressure Fasting plasma glucose (and Hemoglobin A1c if hyperglycemia is detected)Fasting lipid profile AIMS (Abnormal Involuntary Movement Scale) or other screening tool for tardive dyskinesia

Opthalmologic screening should be obtained for those on Quetiapine and those with diabetes mellitus

SGA Guidelines

Q3months: Weight (BMI) Blood pressure Fasting plasma glucose (and Hemoglobin A1c if hyperglycemia is detected)Fasting lipid profile

Q6 months: AIMS (Abnormal Involuntary Movement Scale) or other screening tool for tardive dyskinesiaOpthalmologic screening should be obtained for those on Quetiapine and those with diabetes mellitus.

Optimal TX of Bipolar Depression

Clear Rationale for MS vs AP

Balance Efficacy versus Tolerability

Screen for Manic Sx, Non-Response

Psychosocial Therapies

Monitor Adherence versus Cost Effectiveness on an ongoing basis

Take Home Points: Bipolar Depression

Bipolar disorder is common and patients tend to present with depression

Antidepressant monotherapy should be avoided Screening for bipolar disorder in clinics recommended When detected treat bipolar disorder Bipolar depression has limited FDA approved TX Mood stabilizers and SGAs have some risks but may

be helpful and improve the course of the illness

Perils and Pitfalls: Bipolar Disorder

Major Depression is more common and the diagnosis is more reliable (MDD>BPAD>BP II> BPNOS>Cycl)

Denying antidepressants can increase morbidity When bipolar disorders are favored psychotherapy

may be overlooked New FDA approved TX: EMSAM (transdermal

selegiline), Vagus Nerve Stimulation, the STAR*D study

Bipolar/ADD pts will not get stimulants

Pitfalls of Bipolar Disorder Screening

Mood Swings are reported by lots of patients for lots of reasons

Mood Swings are a reason for referral from various sources

Bipolar disorders - easily considered, rarely eliminated The FDA approved TXs: Quetiapine, lithium and

lamotrigine may be a bitter pill to swallow Bipolar disorders are less reliable & TX is with up to

10 medications