part i -- bipolar basics kurt weber, phd kurt.weber@snc.edu mental health america – brown county...
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Part I -- Bipolar Part I -- Bipolar BasicsBasics
Kurt Weber, PhDKurt Weber, PhDkurt.weber@snc.edukurt.weber@snc.edu
Mental Health America – Brown CountyMental Health America – Brown CountyBemis International CenterBemis International Center
St Norbert CollegeSt Norbert CollegeMay 13, 2008May 13, 2008
“Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.
“I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do.”
Kay Redfield Jamison, PhD, An Unquiet Mind, 1995, p 6
Purpose of today…Purpose of today…
Some foundation information that Some foundation information that mental health professionals and mental health professionals and “consumers” should know…“consumers” should know…
Bipolar disorderBipolar disorder formerly known as manic-depressive disorder brain disorder
causes unusual shifts in a person’s mood, energy, and ability to function
Some people alternate mania and depression, others have episodes of mostly one kind
Episodes vary in duration from days to years the symptoms of bipolar disorder are severe
damaged relationships poor job or school performance suicide
good newsgood news
treatable bipolar disorder can be treated, and
people with this illness can lead full and productive lives
Types of Bipolar Types of Bipolar DisordersDisorders
The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder
Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder
When 4 or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder
Some people experience multiple episodes within a single week, or even within a single day
Rapid cycling tends to develop later in the course of illness and is more common among women than among men
demographicsdemographics Approximately 23 million Americans suffer
from bipolar disorder National Comorbidity Study-Replicated
(NCS-R) the lifetime prevalence of bipolar disorder is 51%
National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) lifetime prevalence of bipolar I disorder of 33% Native Americans have the highest incidence Asians and Hispanics have the lowest
World Health Organization (1990) bipolar disorder is the sixth leading cause of
disability worldwide among people 15-44 years old
Studies suggest that bipolar disorder clients will be fully symptomatic 8% of the time, and symptomatic 59% of the time
30% of bipolar clients have both manic and depressive episodes
32% have mixed manic and depression 22% have only manic episodes 10% have only mixed episodes
Depressive episodes in Depressive episodes in BDBD
Depression most frequent episode episodes last longer (254 weeks) than
manic episodes (55 weeks)
comorbiditycomorbidity
485% of bipolar clients will have an anxiety disorder
708% will have a personality disorder Suicidal ideation is also highly
associated with comorbid substance abuse
There is a strong association of suicide attempts and comorbid anxiety disorders
suicidesuicide
NIMH (2000) Suicide is a significant risk in bipolar
disorder, the highest of any psychiatric disorder at 20%
As many as 25-50% of clients will make a suicide attempt
Most suicidal ideation occurs during depressed or mixed episodes
features and subtypes features and subtypes (Mays)(Mays)
Bipolar I Bipolar II
Psychomotor retarded agitated or retarded
Sleep hypersomnia insomnia/hypersomnia
Suicide +++ ++++ Switching to mania hypomania Gender m = f f > m Prevalence 1% 1-2%
mixed episodesmixed episodes
50% of clients have mixed mania state of mind characterized by symptoms of
both mania and depression more common in bipolar children and
women may feel agitated, angry, irritable, and
depressed all at once combines a high activity level with
depression particular danger of suicide or self- injury
Rapid cyclingRapid cycling frequently recurring (4+ episodes/yr) treatment
resistant depression alternating with hypomanic/manic episodes
most commonly seen in female clients and with bipolar II disorder
15-25% of clients early onset common not known whether antidepressants can initiate
rapid cycling Variations include
ultra-rapid (1 day to 1 week) ultradian (<24 hours) continuous
gender issuesgender issues
no gender difference in the incidence of bipolar I
both have onset in puberty men may have a slightly earlier onset
Manic episodes equal frequencies among men and women
Women are more likely to be treated than men and receive treatment earlier in the illness (NESARC)
no evidence of difference in treatment responsiveness to mood stabilizers
Women…Women…
more frequent and more severe episodes of depression
more comorbidities anxiety, obesity, migraine, thyroid
greater relative increase in AODA and suicide
more rapid cycling and mixed states
Women with BD…Women with BD…
have a high risk of anovulatory disorders and polycystic ovary syndrome (PCOS)
metabolic condition that occurs in 7-15% of reproductive-aged women elevated androgens chronic anovulation insulin resistance elevated LDL with low HDL 3x risk of endometrial cancer
pregnancypregnancy 50% of women with bipolar disorder have the
onset of symptoms within 1 year of menarche (Mays)
however, most are not accurately diagnosed until they have had a child and developed postpartum depression 67% of bipolar women will have postpartum
depression 33-50% of postpartum depressions begin during
pregnancy and worsen postpartum Suicide risk for the new mother is 70x higher
during baby's first year of life if mother has postpartum depression
risk factors and risk factors and warning signs for PPDwarning signs for PPD
Previous postpartum depression (50-75%) Having a mood disorder - bipolar disorder
gives 25% risk Single motherhood Stressful events Substance abuse Mood disorder symptoms during
pregnancy
No psychotropic drugs are known to be safe for pregnancy or breastfeeding
however, bipolar disorder itself is also dangerous for pregnancy due to substance abuse poor self-care suicide
medication for bipolar reproductive-age females recall that 50% of pregnancies in the US are
unplanned
CausesCauses
“…has anyone found the true cause of bipolar disorder? It would be wonderful to say that X or Y was the cause, but the answer is not that simple”
biopsychosocial modelbiopsychosocial model
Most scientists believe that mental illnesses are caused by a combination of several factors working together
In bipolar disorder, these factors are usually divided into biological and psychological causes
In plain English, the main reasons mental illness develops are physical (biological) and environmental
genetic originsgenetic origins if one parent has bipolar illness, chances are 1:7
that their child will however, there are relatively few studies of the
heritability of bipolar disorder why?
numerous subtypes of the disorder categorical distinction between major depression and
bipolar disorder (the presence of one manic episode) that confounds all genetic studies of depression since the disorders seem to be clearly related at some level
so, what is inherited?so, what is inherited?
neurotransmitter functioning! neurotransmitter system has
received a great deal of attention as a possible cause of bipolar disorder
some studies suggest that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the cause
other studies indicate that an imbalance of these substances is the problem the specific level of a neurotransmitter is
not as important as its amount in relation to the other neurotransmitters
still other studies have found evidence that a change in the sensitivity of the receptors on nerve cells may be the issue
sounds like…sounds like…
researchers are quite certain that the neurotransmitter system is at least part of the cause of bipolar disorder
further research is still needed to define its exact role
Typical course of BD Typical course of BD (Mays)(Mays)
median age of onset is 19 median age of onset is 19 first episodefirst episode
most likely to be mania in males, depression in femalesmost likely to be mania in males, depression in females Severe psychosocial stressors appear more Severe psychosocial stressors appear more
important in the first episode than latter important in the first episode than latter episodes, i.e. there is “kindling” to stress – each episodes, i.e. there is “kindling” to stress – each episode requires less stress to occurepisode requires less stress to occur
90% of clients who have one manic 90% of clients who have one manic episode will have anotherepisode will have another
Four years after remission of the first Four years after remission of the first episode, 60% had relapsed episode, 60% had relapsed
Without treatment, bipolar clients will Without treatment, bipolar clients will have 9-10 episodes in their lifetime, and have 9-10 episodes in their lifetime, and each episode will last 1-4 months each episode will last 1-4 months
The interval between episodes will The interval between episodes will diminish (kindling to episodes) diminish (kindling to episodes)
Episodes will become more treatment Episodes will become more treatment resistantresistant
The course of BD (NIMH)The course of BD (NIMH)
Episodes of mania and depression typically recur across the life span
Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms
A small percentage of people experience chronic, unremitting symptoms despite treatment
without treatment…without treatment… natural course of bipolar disorder tends to
worsen over time, a person may suffer more
frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared
proper treatment can help reduce the frequency and severity of
episodes help people with bipolar disorder maintain
good quality of life
Children and Children and adolescents?adolescents?
Both children and adolescents can develop bipolar disorder more likely to affect the children of parents who
have the illness children and young adolescents with the illness
often experience very fast mood swings between depression and mania many times within a day
Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated
Mixed symptoms also are common in youths with bipolar disorder
Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms
NIMHNIMH Bipolar disorder in children and
adolescents can be hard to tell apart from other problems that may occur in these age groups irritability and aggressiveness
can indicate bipolar disorder can be symptoms of
attention deficit hyperactivity disorder conduct disorder oppositional defiant disorder other types of mental disorders more common among
adults such as major depression or schizophrenia Drug abuse also may lead to such symptoms
of course…of course… For any illness, however, effective
treatment depends on appropriate diagnosis
Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional
Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist
ImagingImaging New brain-imaging techniques allow researchers to
take pictures of the living brain at work, to examine its structure and activity
without the need or surgery or other invasive procedures magnetic resonance imaging (MRI) positron emission tomography (PET) functional magnetic resonance imaging (fMRI)
the brains of people with bipolar disorder may differ from the brains of healthy individuals
may develop a better understanding of the underlying causes of the illness
may be able to predict which types of treatment will work most effectively
NIMH clinical studiesNIMH clinical studies real-world studies Unlike traditional clinical trials
multiple different treatments and treatment combinations
include large numbers of people with mental disorders living in communities throughout the US and receiving treatment across a wide variety of settings
Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
the whole pointthe whole point
improve treatment strategies and outcomes evaluate how treatments influence other
important, real-world issues such as quality of life ability to work social functioning
assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans
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