Depression in Bipolar Affective

DisorderDiagnosis and Treatment

Dr Scott Eaton MBChB, MRCPsych, FRANZCP@drscotteaton

•Disclosure

Goals:•Understand the complexities of

diagnosis of Depression in Bipolar Affective Disorder. Differentiate from depression in Bipolar, unipolar depression and borderline personality disorder.

•Introduction to the CANMET guidelines for treatment of bipolar depression. Review the debate regarding the use of antidepressants.

DSM IV/V• The diagnosis of BP I requires the following:

• A manic episode of at least 1 week’s duration that leads to hospitalization or other significant impairment in occupational or social functioning

• The episode cannot be caused by another medical illness or by substance abuse

• Manic episodes also must include at least 3 of the following symptoms:

• Grandiosity

• Diminished need for sleep

• Excessive talking or pressured speech

• Racing thoughts or flight of ideas

• Clear evidence of distractibility

• Increased level of goal-focused activity at home, at work, or sexually

• Excessive pleasurable activities, often with painful consequences

• Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 days’ duration, along with at least 3 of the following symptoms:

• Grandiosity or inflated self-esteem

• Diminished need for sleep

• Pressured speech

• Racing thoughts or flight of ideas

• Clear evidence of distractibility

• Psychomotor agitation at home, at work, or sexually

• Engaging in activities with a high potential for painful consequences

• DSMV - “other specified”

• For major depressive episodes, the person experiences 5 or more of the following symptoms for the same 2 weeks, with at least 1 of the symptoms being either of the first 2 listed:

• Depressed mood

• Markedly diminished pleasure or interest in nearly all activities

• Significant weight loss or gain or significant loss or increase in appetite

• Hypersomnia or insomnia

• Psychomotor retardation or agitation

• Loss of energy or fatigue

• Decreased concentration ability or marked indecisiveness

• Preoccupation with death or suicide; patient has a plan or has attempted suicide

• The symptoms cause significant impairment and distress

• The mood is not the result of substance abuse or a medical condition

• Mixed episodes are characterized by the following:

• Persons must meet the criteria for both mania and major depression; the depressive event is required to be present for 1 week only (DSMV only 3 features required)

• The mood disturbance results in marked disruption in social or vocation function

• The mood is not the result of substance abuse or a medical condition

Cases

•Typical presentations

•Small groups

•Formulate questions to help identify bipolar depression or the primary differentials.

Unipolar vs Bipolar

•Why bother?

•Conundrum of over and underdiagnosis.

•Early intervention of the right sort.

•Forty et al - 2008 British Journal Psychiatry

•593 UPD vs 443 BPD

•Lifetime psychopathology screening

•no UPD had bipolar/schizophrenia rel

•reviewed GP and psych case notes

Bipolarity Symptoms

•Psychosis 11vs30% p<.001

•Diurnal Mood variation 50vs60% p.003

•Hypersomnia 21vs43% p<.001

•More episodes of depression 4vs5 p.006

•Shorter episodes 26vs69weeks p<.001

Unipolar symptoms

•excessive self-reproach 96vs87% p<.000

•loss of energy p.05

•loss of libido 63vs35% p<.001

Personality Disorder

•Bassett 2012 ANZJP

•Review

•features of Borderline PD

•fear of abandonment

•impulsivity

•recurrent self-injurious behaviour

•affective instability

•episodic explosive rage/psychosis

•Disturbed Relatedness - identity disturbance, emptiness, unstable relationships.

•Behavioural Dysregulation

•Affective Dysregulation

Differences•Family Hx of mood disorder - bipolar

•life trajectories - greater impact - bipolar

•Childhood Trauma

•Self-mutilation

•“Rapid” cycle vs Prolonged

•deficiency in mindfulness - borderline

•reduced self-control - borderline

•Depression - anger vs Depression - elation

Depressed Borderline

•Earlier age of onset

•greater frequency of depressive episodes

•greater “atypical features”

•comorbid anxiety

•substance abuse

•suicide attempts

•no bipolar family history

Text

Comorbidity

•Borderline - incidence 9% BPD I, 11% BPDII

•Bipolar 1 - Borderline 11%

•BipolarII - Borderline 16%

•Borderline better prognosis!!

•Guidelines first published in 2005

•updated in 07 and 09

•Multinational specialists with interest in Bipolar Disorder

Facts:

•prevalence BP1 0.4%, BP11 1.4%

•lifetime suicide attempts - 1/3

•completed suicide 0.014 per 100person years

•high work impairment

Chronic disease management

•Educated clinicians = later relapse time

•frequent monitoring = better social/occupational function

•symptom checklist = earlier recognition of EWS

Psychosocial• Group psychoeducation

• Interpersonal Psychotherapy

• CBT

• Internet Based Therapy

• improvements in acute depression, long term maintenance, hospitalization, function, adherence.

• Family Focused Therapy improved well being in carers

Bipolar Depression:Pharmcology• First Line Treatments: (dose increase/change

treatment 2-3/52)

• Lithium

• Lamotrigine

• Quetiapine , XR

• Combinations:

• Lithium/Valproate + SSRI (Not Paroxetine)

• Olanzapine + SSRI (not P)

• Lithium + Valproate

• Lithium/Valproate + buproprion

•Second Line Treatments

•Valproate

•Combination Therapy

•Quetiapine + SSRI

•+ modafinil

•Lithium/valproate + lamotrigine

• Third Line Treatments

• Carbamazepine

• ECT

• Olanzapine

• Combination Therapy

• Lithium + Carbamazepine

• Lithium/valproate + Venlafaxine

• Lithium + MAOI/TCA

• Lithium + Pramipexole

• Lithium/CBZ/Valp + SSRI +Lamotrigine

• Quetiapine + SSRI

Not Recommended

•Gabapentin

•Aripiprazole

•Ziprasidone

•Combination:

•+ ziprasidone

•+ levetiracetam

•“Novel Therapies”

•EPA

•NAC

•Pramipexole

Bipolar II Depression

• First:

• Quetiapine, XR

• Second:

• Lithium, Lamotrigine, Valproate

• Lithium/Valproate + antidepressant

• Lithium+Valpraote

• Atypical + antidepressant

• Third:

• antidepressant

• quetiapine + lamotrigine

• + ECT, +NAC, +T3

Antidepressants!!

• Most often used

• Some circumstances - good evidence for worse outcomes (paroxetine/buproprion)

• Strong evidence better than placebo and low rate of SWITCH

• Mood stabilizer reduce risk of switch

• Beware “mild switch”

•suggest:

•SSRI can be used first line WITH a mood stabilizer

•Taper after 6-8/52 remission

•avoid TCA or SNRI

•Not in Mixed state or Rapid cyclers or monotherapy

• The ISBD recommendations for acute treatment of a depressive episode in bipolar disorder include the following:

• Adjunctive antidepressants may be used for an acute bipolar I or II depressive episode when there is a history of previous positive response to antidepressants.

• Adjunctive antidepressants should be avoided for an acute bipolar I or II depressive episode with 2 or more concomitant core manic symptoms, in the presence of psychomotor agitation or rapid cycling.

• For maintenance treatment, the following is recommended:

• Maintenance treatment with adjunctive antidepressants may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy.

• The recommendations for antidepressant monotherapy includes the following:

• Antidepressant monotherapy should be avoided in bipolar I disorder.Antidepressant monotherapy should be avoided in bipolar I and II depression with 2 or more concomitant core manic symptoms.

• The recommendations for antidepressant use in mixed states include the following:

• Antidepressants should be avoided during manic and depressive episodes with mixed features. Antidepressants should be avoided in bipolar patients with predominantly mixed states. Previously prescribed antidepressants should be discontinued in patients experiencing current mixed states.