TRICKS OF MANAGING BIPOLAR DISORDER:

WHEN MOOD IS LOW:

Devashish Konar MD

Consultant Psychiatrist

Mental Health Care Centre Kolkata India

Mob: +91 9434009113 +91 97322217121Presented at ANCIPS 2015, Hyderabad

DISABILITY IN BIPOLAR DISORDER

Although the cardinal diagnostic feature of bipolar disorder is periods of abnormal mood elevation (mania or hypomania), patients spend more time depressed than manic and experience greater disability during depressive episode.

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COLLABORATIVE CARE

• The need to provide collaborative care that strengthens the therapeutic alliance by fostering communication and shared decision making between the doctor and patient.

• Clinicians may need to negotiate with the patient to establish an agreeable treatment plan and promote adherence.

• When selecting pharmacotherapy, clinicians must consider patient preferences as well as the potential risks and benefits of available treatments.

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NUMBER NEEDED TO TREAT (NNT) NUMBER NEEDED TO HARM (NNH)

• The NNT is the number of patients who must be treated with 1 intervention versus another to experience 1 additional positive outcome.

• The NNH is the number of patients who would need to be treated with 1 intervention versus another to experience 1 additional negative outcome.

• Treatments with smaller NNTs are more effective, and treatments with higher NNHs are more tolerable.

• Selecting more effective agents for patients with urgent mood symptoms, and more tolerable agents for patients who are concerned about side effects and have less urgent needs.

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CLINICAL URGENCY VS. GREATER TOLERABILITY

• Select agents based on the greater need, clinical urgency or greater tolerability.

• Base treatment selection on available data as well as patient factors and preferences.

• Use formal assessments at each patients visit to track trends over time.

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PERSON FOCUSED APPROACH

• We would also benefit from further information on whether to prioritize efficacy or tolerability based on the urgency of the situation.

• If a patient is experiencing symptoms that urgently need to be resolved, you must use a drug you know will work.

• But, if the situation is not urgent and the patient is concerned about side effects, you may be willing to try a less effective drug that will be well-tolerated.

• Parameters for clinical urgency include the likelihood of a suicide attempt, a psychiatric hospitalization, or a job or relationship crisis.

• These are some of the possible events that would indicate that the patients’ efficacy needs to outweigh tolerability concerns.

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PERSONALISED CARE

• Clinicians must also recognize situations in which tolerability issues may not apply.

• For example, if someone is experiencing depression with horrible insomnia, giving them treatment that may cause drowsiness might not be problematic.

• Clinicians must consider potential benefits as well as harms when assessing side effects.

• For one person, a side effect might be a harm, but for another person, it would be a benefit.

• We should personalize care based on our understanding of an individual patient.

• It is really going from population-based prescribing to personal prescribing.• When a patient is already overweight or has metabolic issues, then drugs

with side effects that would exacerbate those factors should not be under consideration.

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PERSONALIZED PRESCRIBING

• A balance between clinical experience, patient factors, and available evidence is relevant to population versus personalized prescribing.

• At the beginnings of treatment, when you know nothing else about the patients other than what you find out in the first interview, you are informed by the data of the population and your general clinical experience.

• But as you move along and proceed with treatment trials for index patient, you shift into what you know about this particular patient and his or her real response to the treatment as measured by formal assessments.

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FDA

• Only 3 treatments are FDA-approved for the treatment of acute bipolar depression: Quetiapine, Olanzapine-Fluoxetine combination, and Lurasidone.

• Only Quetiapine is approved for the treatment of bipolar II depression.

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LURASIDONE

• Lurasidone is an atypical antipsychotic started being used since 2013.

• It is approved for treatement of depressive episodes associated with Bipolar I Disroder (bipolar depresssion) in adults both alone and in combination with Lithium or Valproate.

• Lurasidone is likely to deliver more efficacy without sacrificing tolerability according to current data.

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NEED TO HAVE MORE AWARENESS

• Treatment remains difficult because of the severity of condition, loss of work days, suicide risk and chance of switching.

• Rampant use of antidepressants in case of Bipolar has to be restrained.

• Awareness in general practitioners, family physicians, and other specialists has to be created.

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REPLICATED PREDICTORS FOR PROGRESSION FROM UNIPOLAR DEPRESSION TO BIPOLAR DISORDER

• Psychosis

• Early age at onset

• Family history of bipolar disorder

• Family history loaded with mood disorders

• Acute onset of mood syndrome

• Multiple prior depressive episodes

• Hypersomnia or psychomotor retardation

• Pharmacologically induced hypomania

• Sub-threshold hypomanic symptoms

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LIST OF PROGNOSTIC INDICATORS OF TREATMENT OUTCOME

• Suicidality

• Presence of a personality disorder

• Quality of family and social support

• Substance use

• History of severity of prior episodes

• The type Bipolar I is most severe

• Treatment onset-the sooner the better

• Age of onset-the younger the more severe

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SUICIDAL RISK MUST BE CONTINUALLY MONITORED

• Presence of suicidal or homicidal ideation, intent, plans

• Access to means

• Psychotic features

• Severe anxiety

• Substance abuse

• History of previous attempts

• Family history or recent exposure

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NEW RECOMENDATIONS FOR ANTIDEPRESSANT USE IN BIPOLAR PATIENT

• 10th International Conference on Bipolar Disorders (ICBD) 2013• International Society for Bipolar Disorder Task Force Report

presentedby Dr Eduard Vieta

• Antidepressants have a questionable benefit-risk ratio and should only be used in certain select cases in bipolar disorder

• They should only be used in bipolar depression in patients with a history of a good response in the past to antidepressants and no history of rapid cycling or switches into mania right away

• Avoid using antidepressant in mixed affective disorder with 2 or more concomitant core manic symptoms and in the presence of psychomotor agitation

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RECOMMENDATION FOR MAINTENANCE TREATMENT WITH ANTIDEPRESSANT

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

• Antidepressant mono-therapy maintenance should be avoided in bipolar I disorder.

• Antidepressant mono-therapy should be avoided in mixed affective state with 2 or more concomitant core manic symptoms.

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SELECTION OF ANTIDEPRESSANT ISBD TASK FORCE REPORT

• Adjunctive treatment with serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants be considered only after other antidepressants have been tried.

• If they are used, they should be closely monitored, owing to increased risk for switch or mood destabilization.

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OPTIONS FOR BIPOLAR DEPRESSION PREVENTION

• Lithium

• Anticonvulsants: Divalproex, Carbamazepine, Lamotrigine

• Second-generation antipsychotics: Quetiapine , Lurasidone , Olanzapine + Fluoxetine combination

• Adjunctive psychotherapy

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LITHIUM

• Useful in all phases of bipolar disorder

• Definite role in suicide prevention

• Side effect profile is more of a media hype

• Monitoring is not very difficult

• Maximum evidence for cortical plasticity

• The drug is still underutilised

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RECONCEPTUALIZING MOOD STABILISERS

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Mood stabilisation from above versus below baseline:

- Euthymia is baseline- Mania, hypomania, and mixed states are

‘above baseline’- Depression and subsyndromal depression are

‘below baseline’

CLASS A MOOD STABILISERS

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• Stabilise mood from above baseline.• Treat and/or prevent mania without causing depression.• Examples

- Lithium as the prototype- Divalproex- Carbamazepine - Olanzapine- Risperidone- Quetiapine

CLASS B MOOD STABILISERS

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• Stabilise mood from below baseline.• Treat and/or prevent depression without

causing mania.• Examples

- Lamotrigine as the prototype- Lithium- Atypical antipsychotics

CHOICE OF MOOD STABILISERS

• Divalproex better for mixed affective

• Lithium better for prevention of depression and suicidal behaviour

• Role of Lamotrizine in prevention of bipolar depression

• Atypical antipsychotics,like,Quetiapine, Lurasidone, Aripiprazole & Olanzapine as mood stabilisers

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WHY FOCUS ON BIPOLAR DEPRESSION ?

• Time depressed is 3 times more than time manic

• Depression is correlated with increased disability, suicidality, and medical comorbidities.

• Number of depressive episodes correlates with degree of cognitive impairment while euthymic.

• Antidepressants are not as effective in bipolar as in unipolar patients and may increase switch into mania

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YOU CAN NOT AFFORD TO MISS BIPOARITY

• Identifying Bipolar Depression has become more important now.

• It starts at early age.

• It is difficult to treat.

• Adding mood stabiliser like Lithium helps.

• Looking for history of Mania/Hypomania in a case of Depression is important to prevent switch.

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