bipolar disorder and other mood disorders and other mood disorders.pdfbipolar disorder, and their...
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Bipolar Disorder and Other Mood Disorders
Jed Magen, DO MSChair, Department of PsychiatryCollege of Osteopathic Medicine
College of Human MedicineMichigan State University
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As George Orwell observed, “From the totalitarian point of view history is something to be created rather than learned.”
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Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder
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“Cross cutting specifiers” catatonia with mixed features with anxious distress
Copyright © 2013. American Psychiatric Association.
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A 19 year old male presents with a labile mood, alternately somewhat grandiose, then depressed looking. He reports that he has discovered his “mission” which is to unify art and music. He will do this personally. He reports that he is not sure what reality is and it is only what he thinks it is at the moment.
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He is alert and oriented. His language skills are very good and he denies hallucinations or delusions. Speech is normal in rate and rhythm. He can recall 3 objects at 5 min. He spells “world” forward and backwards. He does serial sevens without difficulty. He names objects without difficulty.
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He reports that he has racing thoughts and then launches into an explanation of the mathematical properties of complex sea shells. He discusses tangents, cosigns and then abruptly says, “ I’m writing a book on this and I’ll give you a copy.”
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He reports sleeping irregularly, sometimes 8-9 hours, sometimes as few as 4. He does not report being fatigued during the day.
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prevalence is about 1-2% alternating “normal” periods with manic or depressive
episodes no inter-episode deterioration*
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peak age of onset-14 to 19 20-24 second peak equal sex ratio over age 60, look for identifiable organic etiology significant suicide rate
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Episode vs Disorder
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Manic Episode Criteria distinct period of abnormally and persistently elevated,
expansive or irritable mood, lasting at least 1 week
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Criteria inflated self-esteem or grandiosity decreased need for sleep more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing
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Criteria distractibility increase in goal-directed activity or psychomotor agitation excessive involvement in pleasurable activities that have
high potential for painful consequences increased energy/activity
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Hypomanic Episode persistently irritable, expansive or elevated mood “more days
than not” with 3 other criteria Does not significantly interfere with functioning
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Mixed Episode
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Bipolar I Disorder Manic episodes and mixed feature or depressed episodes in
various combinations
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Bipolar I Disorder Manic Episode With mixed features Major Depressive Episode
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Bipolar II Disorder Hypomanic episodes Major depressive episodes
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British joke about their view of Europe:
“Fog in Channel, Continent Cut Off”
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Rapid Cycling Bipolar Disorder presence of at least 4 episodes in last 12 months extremely refractory to treatment
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many patients have intercurrent personality difficulties that impact on compliance and relationship with treatment team
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People tend to spend more time in episode(usually depression) than out of episode
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etiology is unclear strong genetic component
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Spectrum concept: bipolar disorder with psychosis vs schizophrenia
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Serendip is the old Arabic name for Ceylon, now known as Sri. Lanka. The origin of the word “serendipity” is in a Persian fairy tale, The Three Princes of Serendip, whose traveling heroes were “always making discoveries, by accidents and sagacity, of things they were not in quest of.”1 In the 16th century, the tale was translated from Persian to Italian, and from Italian to French. Horace Walpole (1717-1797), an English man of letters, encountered it in a collection of oriental tales in French, and coined the English term “serendipity” in a letter to his friend, Horace Mann, dated June 28, 1754.2
According to the Doctor Out, of Zebulon column in the Archives of Internal Medicine, “serendipity signifies a mental state in which serenity and stupidity are blended,” as for example, “the serendipity of a cow chewing its cud under a shady tree,” or “the sort, of thing that happens to you when on a dull day collecting fossils you find instead a, beautiful woman/man who proves to be neither geologist nor archeologist.
Thomas Ban in: The role of Serendipity in Drug Discovery Dialogues in clinical neuroscience 2006 Sep; 8(3): 335–344.
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Treatment lithium divalproex (Depakote) carbamazepine (Tegretol) lamotrigine (Lamictal)
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gabapentin (Neurontin) oxcarbazepine (Trileptal) second generation antipsychotics
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Lithium 60+% response rate narrow therapeutic window numerous side effects significant interactions
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Lithium hypothyroidism decrease in renal concentrating capacity?
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Lithium doses range from 900 to 1800 mg approximately BID dosing check 12 hour trough serum levels after 5 days
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check thyroid function yearly check renal function every 3 years or so check lithium levels as needed (every couple of months)
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lithium may be adequate treatment for uncomplicated manic episode
60+% of patients need multiple medications for good control
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Carbamazepine• 100mg BID to start, increase every day/few days to about
800+ mg• trough levels
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Side effects• leucopenia • thrombocytopenia• aplastic anemia very rare• HLA-B 15:02 associated with Stevens-Johnson Syndrome,
more prevalent in Asian populations
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with psychosis, usually antipsychotic is added for depression, antidepressants or psychotherapy plus lithium
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BEWARE! Antidepressants may induce manic episode in susceptible individuals
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lamotrigine seems to treat both bipolar depression and bipolar manic episodes, but is more effective for depression
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divalproex 20mg/kg starting dosage trough levels
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"I hate to advocate drugs, alcohol, violence or insanity to anyone, but they've always worked for me.“
Hunter S. Thompson
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Side Effects weight gain leukopenia possible risk of polycystic ovaries?
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over all, fewer and less severe side effects than lithium acceptable first-line tx for bipolar disorder, but worry about
endocrine issues in women
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lamotrigine is acceptable first line treatment 25 mg PO qd for 2 weeks, THEN 50 mg PO qd for 2 weeks double dose weekly to maintenance at 200 mg/day PO or more Better for depression than mania
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second generation antipsychotics• some with FDA approval, most not• efficacy compared to mood stabilizers is not clear
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“Second-generation antipsychotics are increasingly used for bipolar disorder, and their effectiveness compared with therapeutic alternatives merits further research.”
Pillarella J., Higashi A, Alexander GC, Conti, R. Trends in Use of Second-Generation Antipsychotics for Treatment of Bipolar Disorder in the United States, 1998–2009 Psychiatr Serv. 012 Jan;63(1):83-86
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other agents generally second line or for augmentation of response
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treatment alliance education monitoring
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develop reasonable relationship with your patient help patients understand early symptoms of their episodes
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people enjoy Manic Episodes, at least for a while..
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psychotherapies are useful for enhancing compliance, for interpersonal relationships and to help patients gain insight into their illness
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Salmon
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omega-3 fatty acids may be treatment, implying signal transduction mechanisms
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"Somewhere between 1910 and 1912 in this country, a random patient, with a random disease, consulting a doctor chosen at random had, for the first time in the history of mankind, a better than fifty-fifty chance of profiting from the encounter
Lawrence J. Henderson physiologist, chemist, philosopher, sociologist, 1878-1942 Harvard University
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Persistent Depressive Disorder periods of depressed mood more days than not for 2 years with
some other depressive symptoms
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Persistent Depressive Disorder may be a group of disorders no well tested treatments antidepressants and psychotherapies
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Cyclothymic Disorder numerous periods with hypomanic symptoms and depressive
symptoms not meeting criteria for Major Depressive Disorder
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Cyclothymic Disorder may be more numerous in families of bipolar probands
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Cyclothymic Disorder most likely treatment is mood stabilizers, psychotherapy may
be useful, if any treatment is needed
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substance induced mood disorder
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medical conditions hypothyroidism iatrogenic etiologies
medicationssurgical interventions