Bipolar Disorder Discovery Series

Facts, Insights & Perspectives Dr. Andrea J. Levinson, MD MSc FRCPC

Head: Early Intervention Clinic CAMH

Acknowledgements

The Mood Disorders Association of Ontario thanks Lundbeck Canada for the educational grant that

made this program possible. ----------------------

We also thank our distinguished speakers for donating their time to this project

Llll Bipolar Disorder Discovery Series

What is Bipolar Disorder?

• Everyone has ups and downs in mood.

• Bipolar disorder, also known as manic-depressive illness, features unusual shifts in:

• Mood

• Energy

• Activity levels

….in the way that affects carrying out day-to-day tasks.

• When many symptoms happen during the same week or two, it is usually an “episode” of illness

What is Bipolar Disorder?

• A highly recurrent, often disabling mood disorder

• The most lethal of the major psychiatric disorders

• The most grandiose of all psychiatric disorders—mimics all other disorders!

Bipolar disorder can be treated.

People with bipolar disorder can lead full and productive lives.

Risk Factors

• There is NO single cause of Bipolar Disorder.

• Many factors act together to increase the risk of illness:

Genetics: Having a parent or sibling with bipolar disorder increases the risk of bipolar disorder 4 - 6 times.

Changes in neurotransmitter and hormonal balance

Major life changes, particularly those disrupting sleep

How common is Bipolar Disorder?

Bipolar I affects of the population.

Bipolar I & II together affect of the population.

• Bipolar Disorder affects men and women equally.

• Bipolar Disorder usually starts in the teenage years (age 15-19).

What Defines DSM-IV Bipolar Disorder?

• The occurrence of one or more Manic Episodes, or Mixed Episodes

• Depressive episodes are frequent but not always necessary for diagnosis

• Main subtypes: I and II

Bipolar I versus Bipolar II

Bipolar I versus Bipolar II

• Bipolar I Disorder

– Requires a Manic Episode (or Mixed) episode

– May also have experienced a Major Depression

– Often includes psychotic symptoms

• Bipolar II Disorder

– Requires a Hypomanic Episode

– AND a Major Depression

– No psychotic symptoms or severe impairment in hypomania

– No mixed episodes

Phases of Bipolar Disorder

• Well state

• Depression

• Mania

• Mixed Episode

• Residual symptoms or ‘Subsyndromal’ State

6%9%

32% 53%

Weeks asymptomatic

Weeks depressed

Weeks manic/hypomanic

Weeks cycling/mixed

BD Patients Are Symptomatic Almost Half Their Lives

Judd et al. Arch Gen Psychiatry 2002;59:530-537

N=146; 13 year Follow up

The Manic Episode

• A distinct period of abnormal and persistently elevated, expansive, or irritable mood (at least 1 week of daily symptoms for mania, and 4 days for hypomania)

• With abnormal mood, at least 3 of the following 7 symptoms exist:

Key Symptoms

• Increased self-esteem/grandiosity

• Decreased need for sleep

• Increased talking/pressured speech

• Flight of ideas/racing thoughts

• Distractibility

• Increase in activity or agitation

• Excessive pursuit of risky pleasurable activities

Manic Episode Continued...

• Not superimposed on other psychotic illness nor a mixed episode

• No organic factor (e.g. drugs, trauma)

• Marked impairment in social/occupational functioning

• No delusions/hallucinations for at least 2 weeks in the absence of mood symptoms

Hypomanic Episode

• ? The ideal human condition

• Same symptoms of mania, but very mild

• Never have psychotic symptoms; if present, call it a manic episode

• Minimum of 4 days

Hypomania Versus Mania

Hypomania

• Mild, less severe

• Little to mild dysfunction

• Little to mild lapses of judgment

• Commonly responds to outpatient management

• Sleep regulation and or benzos can sometimes terminate episode

Mania

• Severe

• Severe dysfunction

• Major lapses of judgment

• Psychotic symptoms

• Often requires inpatient treatment

• Need for acute mood stabilizer and or antipsychotic treatment

Major Depression

• Depressed mood or irritable mood most of the day, nearly every day

• Lasting at least 2 weeks

• Diminished interest or pleasure in daily activities

• Significant weight loss when not dieting or weight gain

• Insomnia or hypersomnia

Major Depression Continued…

• Psychomotor agitation or retardation nearly every day

• 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

Tips to Diagnose Bipolar Disorder

• Family history

• Follow-up or Observation by the same treatment provider over a long time (months to years)

• Starting a diary of energy, drive, sleep and mood (from personal and family report)

• Identifying what “normal happiness” looks like

• Recognizing that extreme irritability may actually be a sign of mania

Missing the Diagnosis – Patient Survey

• Misdiagnosis occurred in 69%

• Most frequent misdiagnoses

– Depression (60%)

– Anxiety disorders (26%)

– Schizophrenia (18%)

– Borderline or antisocial personality disorder (17%)

– Alcohol/substance abuse (14%)

• 35% of patients waited 10 years or more for a correct diagnosis of Bipolar Disorder.

Data on file National DMDA

Differentiating Bipolar Disorder from other conditions

• Depending on the severity and frequency of symptoms, it is easy to misdiagnose:

– Acute depression diagnosed as unipolar depression

– Acute psychosis diagnosed as schizophrenia

– Mild symptoms diagnosed as ‘personality problems’

– Co-existing alcohol or substance misuse causes the bipolar disorder to be hidden

Possible Barriers to Diagnosis

• People don’t go to see a doctor if feeling too happy! (usually when depressed…)

• Often, people don’t remember hypomania or even mania

• Insufficient training in Bipolar Disorder for doctors

And that’s not all…

Bipolar disorder often co-exists with other illnesses:

• Psychiatric problems • Drug and alcohol problem

• Anxiety disorders

• Attention deficit hyperactivity disorder (ADHD)

• Other medical problems • Thyroid disease

• Migraine headaches

• Heart disease

• Diabetes

• Obesity

Key Goals in Treating Bipolar

• Educate not just the person but also family and friends about symptoms of BD

• Aim to improve functioning and symptoms

• Find a medication or combination of medication that works, and find a way to make easy to continue taking

• Identify new episodes early and treat

• Promote routine activity and sleep patterns

• Be aware of stressors and how to handle them

Probable Bipolar Triggers

• Sleep Deprivation

• Highly stressful events

• Certain substances including excessive alcohol, steroids, and some medications including antidepressants

Treating Any Phase of BD

• Supportive therapy and crisis management

• Acute phase—medicines are key to symptom

control

• Maintenance phase

– Minimize residual symptoms

– Maximize functioning

– Minimize medication side effects

– Provide support and psychotherapy as necessary

Pharmacotherapy

• Lithium

• Anticonvulsants

– Divalproex

– Carbamazepine

• Antidepressants

– Bupropion, SSRIs, venlafaxine, etc

• Antipsychotics

– Typical - haloperidol, perphenazine…

– Atypicals – olanzapine (Zyprexa), quetiapine (Seroquel), etc

• Others

– Benzodiazepines

– ECT www.psychguides.com

Traditional mood stabilizers

Treatments for Bipolar Disorder

An effective maintenance treatment plan usually includes

medication and often includes

psychotherapy

Medication

• What is medication used for? – To treat acute episodes such as severe depression or

mania

– To prevent flare-ups of new episodes

• What kind of medications are used? – There are many categories of medicines, including

mood stabilizers, antidepressants and antipsychotics.

Medication

1. Mood stabilizing medications Mood stabilizers are often used long-term to help

maintain a stable mood and prevent new mood episodes.

2. Atypical antipsychotic medications Atypical antipsychotics are often used to treat acute

symptoms, especially mania. Some can also treat depressive symptoms and maintain mood stability.

3. Antidepressant medications Antidepressants sometimes are used to treat acute symptoms of depression.

1. Mood stabilizing medications – Lithium

– Valproic acid or divalproex sodium (Depakene/Depakote)

– Anticonvulsants • Lamotrigine (Lamictal), Carbamazepine (Tegretol)

2. Atypical antipsychotic medications – Quetiapine (Seroquel), Olanzapine (Zyprexa), Risperidone

(Risperdal), Aripiprazole (Abilify)

3. Antidepressant medications – Fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox),

citalopram (Celexa), escitalopram (Cipralex), sertraline (Zoloft)

Examples of Medications

Psychotherapy

• Psychoeducation

• Cognitive behavioral therapy (CBT)

• Family-focused therapy

• Interpersonal and social rhythm therapy

• Peer-support and self-help strategies

Bipolar Disorder & The Brain

fMRI Scans During An Emotional Task Show Distinct BD Pattern Compared to Controls

Medial prefrontal cortex (red area) • less active

The hippocampus (blue/green region) • more active

Lagopoulos J et al, Neuroreport. 2007

Differences in brain function

Blue areas: the least active Red areas: the most active

Brain Chemistry

Different types of neurotransmitters release from neural ending and control the mood: • Dopamine • Serotonin • Norepinephrine

00

Neurotransmitters

Mood Disorders Association Programs for BD

Our understanding of depression, anxiety and bipolar disorder is shaped by the lived experience. We serve individuals and families across Ontario, providing:

• awareness, education and training

• family and youth clinical support

• recovery programs, and

• peer support

Individuals and families impacted by mood disorders recover and heal

Team of 8 staff & 170 volunteers

Our unique value proposition: “Talk to someone who’s been there”

Mission

Vision

Mental Health M.A.P. (My Action Plan)

On-line resource - empower individuals affected by depression, anxiety and bipolar disorders (and family members) to take control of recovery:

Inspired, designed, developed and guided by individuals affected by mental illness

Takes holistic approach to helping individuals take control of their recovery and continue on road to wellness, borrowing from medical and recovery models

Entries & plans are entirely confidential

Useful Websites

• http://mooddisorderscanada.ca/ • http://www.psycheducation.org/ • http://camh.net/ • http://cmha.ca/bins/index.asp • http://www.health.com/health/bipolar-disorder/ • https://www.facingus.org/ • http://mymoodmonitor.com/ • http://www.nimh.nih.gov/health/topics/bipolar-

disorder/index.shtml • http://livingmanicdepressive.com/ • http://www.bipolaraware.co.uk/

A Few Good Books

• The Bipolar Disorder Survival Guide • Take Charge of Bipolar Disorder • The Bipolar Workbook: Tools for Controlling Your Mood

Swings • Bipolar Disorder For Dummies • What Goes Up: Surviving the Manic Episode of a Loved

One

Fact or Fiction?

• People with bipolar disorder never get better or get back to a normal life.

• Living with bipolar disorder is challenging, but with appropriate treatment and good support it can be effectively managed and patients can have their normal personal and social life.

Fact or Fiction?

• People with bipolar disorder have frequent mood changes from mania to depression, and vice versa.

• Both extremes of mood episodes aren’t necessary for a diagnosis of bipolar disorder. Most patents spend more time in depressive episodes. Sometimes, manic episodes are not very severe.

Fact or Fiction?

• Bipolar disorder only affects mood.

• In addition to mood, energy level, memory , judgment, concentration, appetite, sleep and sex drive are affected.

Fact or Fiction?

• The only treatment for bipolar disorder is the medication.

• Medication is the foundation of treatment, but other therapies and self-help strategies also play an important role.

Questions?