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Ask-the-Doctor Bipolar Disorder NAMI 2009

Ask-the-Doctor Bipolar Disorder NAMI 2009. Descartes Li, M.D. Associate Clinical Professor University of California, San Francisco Chief, UCSF Bipolar Program http://psych.ucsf.edu/Patients/Bipolar_Program.asp. Questions. What questions that you would like reviewed?. The Limbic System.

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Ask-the-Doctor Bipolar Disorder NAMI 2009

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  1. Ask-the-DoctorBipolar DisorderNAMI 2009 Descartes Li, M.D. Associate Clinical Professor University of California, San Francisco Chief, UCSF Bipolar Program http://psych.ucsf.edu/Patients/Bipolar_Program.asp

  2. Questions What questions that you would like reviewed?

  3. The Limbic System

  4. What are theSubtypes of Bipolar Disorder? Bipolar I: Depression with Classic Mania Bipolar II: Depression with Hypomania Bipolar III: Antidepressant Associated Hypomania

  5. Major Depressive Disorder Cyclothymic Disorder Dysthymic Disorder Bipolar I Disorder Bipolar II Disorder

  6. Major Depressive Disorder—Diagnostic Criteria Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks At least 1 of these 2 symptoms: • Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning DSM-IV-TR™ 2000.

  7. Major Depressive Disorder—Diagnostic Criteria Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks DSM-IV-TR™ 2000.

  8. DSM-IV Diagnostic CriteriaHypomanic Episode: A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 4 days. B. During the period of the mood disturbance, three or more of the following symptoms (four if the mood is only irritable): APA Diagnostic and Statistical Manual. 1994

  9. DSM-IV Diagnostic CriteriaHypomanic Episode: • 1) inflated self-esteem or grandiosity • 2) decreased need for sleep (eg, feels rested after only 3 hours of sleep) • 3) more talkative than usual or pressure to keep talking APA Diagnostic and Statistical Manual. 1994

  10. DSM-IV Diagnostic CriteriaHypomanic Episode: (continued) • 4) flight of ideas or subjective experience that thoughts are racing • 5) distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) • 6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation APA Diagnostic and Statistical Manual. 1994

  11. DSM-IV Diagnostic CriteriaHypomanic Episode: (continued) • 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) APA Diagnostic and Statistical Manual. 1994

  12. DSM-IV Diagnostic CriteriaHypomanic Episode: (continued) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. APA Diagnostic and Statistical Manual. 1994

  13. DSM-IV Diagnostic CriteriaHypomanic Episode: (continued) E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism) APA Diagnostic and Statistical Manual. 1994

  14. DSM-IV Diagnostic CriteriaManic Episode: A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. Same as for hypomanic episode

  15. DSM-IV Diagnostic CriteriaManic Episode: (continued) C. The symptoms do not meet criteria for a Mixed Episode. D.The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

  16. DSM-IV Diagnostic CriteriaManic Episode: (continued) E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).

  17. Bipolar Disorder: DIG FAST Mnemonic D – Distractibility I – Insomnia G – Grandiosity (or inflated self esteem) F – Flight of Ideas (or racing/crowded thoughts) A – Activities (increased goal directed activities) S- Speech (pressured) T- Thoughtlessness (impulsivity, ie, increased pleasurable activities with potential for negative consequences: sex, money, traveling, driving)

  18. What is Rapid Cycling? • Four or more mood episodes per year. • Considered more treatment-refractory. • Individuals with bipolar disorder may go through periods of rapid-cycling that may last years. • Associated with antidepressant monotherapy.

  19. What is a Mixed Episode? Rapidly alternating moods (sadness, irritability, euphoria) accompanied by criteria for both a Manic Episode and a Major Depressive Episode. Duration of 1 week. Frequently includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking.

  20. Controversy about antidepressants in bipolar disorder • They can cause hypomania where there was none. • They can induce cycling, or make it worse. • They may keep a person from becoming truly stable. • And they might, just might, cause some long-term harm, perhaps even irreversible harm.

  21. Step #1: Stop Cycling • Interventions: • Stop antidepressants • Prevent mania or hypomania From http://www.psycheducation.org/depression/ADwithoutAD.htm#stop

  22. Summary Recommendations 1. Do not use antidepressants if rapid cycling or severe insomnia/agitation (suggesting bipolar mixed state) is already present. 2. Do not use antidepressant if there is a history of mania or hypomania on an antidepressant, use a mood stabilizer. 3. If you are on an antidepressant and are not doing well, try stopping that antidepressant to see if things are more stable (or at least, no worse).

  23. Treatment options for bipolar depression What are they? • Optimize mood stabilizer or AAP • Lamotrigine • Psychotherapy • Dark therapy • Exercise • Electroconvulsive Therapy (ECT) • Antidepressants?!? Remember prevention!

  24. (Atypical) Antipsychotics: Don’t be afraid of the word “antipsychotic”

  25. Atypical Antipsychotics (AAPs) Olanzapine (Zyprexa) 2.5mg-20mg/day Quetiapine (Seroquel) 12.5-600mg/day Risperidone (Risperdal) 0.25mg-6mg/d [also, Invega (paliperidone)] Ziprasidone (Geodon) 20-160mg a day Aripiprazole (Abilify) 5-30mg a day listed in order of rate of weight gain/sedation (greatest to lowest)

  26. Psychotic Disorders:Atypical Antipsychotics • Multiple receptor effects: serotonin and dopamine receptor subtypes • Lower rates of side effects (compared with older antipsychotics), including tardive dyskinesia • Neuroleptic malignant syndrome rare • High rate of “metabolic syndrome”: weight gain, dyslipidemia, hyper-cholesterolemia, hyperglycemia (diabetes)

  27. How to manage weight gain Initial target should be weight stabilization, then weight loss • Exercise and diet (for some people depression itself causes weight gain) • Avoid (if possible) medications that cause significant weight gain • Lower the dosage of medications • Antidote medications are only marginally helpful: amantadine, metformin, topiramate, H-2 blockers

  28. Evidence-based, psychosocial treatmentsfor bipolar disorder • Cognitive-behavioral therapy (CBT) • Interpersonal and Social rhythm psychotherapy (IPSRT) • Family-focussed therapy (FFT) • Psychoeducation

  29. Cognitive Behavioral Therapyof bipolar disorder • Recognition and Diagnosis of Bipolar Disorder • Medication Treatments for Bipolar Disorder • Symptom Monitoring: An Early Warning System • Cognitive Changes in Depressive Episodes and Mania • Behavioral Changes and Problems in Depressive Episodes and Mania • Psychosocial and Interpersonal Problems: Communication Cognitive-Behavioral Therapy for Bipolar Disorder,by Monica Ramirez Basco, A. John Rush, The Guilford Press 1996,

  30. CBT techniques for bipolar disorder • a diary of significant events and associated feelings, thoughts and behaviors • questioning and testing assumptions or habits of thoughts that might be unhelpful and unrealistic • gradually facing activities which may have been avoided • trying out new ways of behaving and reacting.

  31. Evidence-based, psychosocial treatmentsfor bipolar disorder • Cognitive-behavioral therapy (CBT) • Interpersonal and Social rhythm psychotherapy (IPSRT) • Family-focussed therapy (FFT) • Psychoeducation

  32. Interpersonal and Social Rhythm Therapy • Interpersonal Therapy • Social Rhythms and The Social Rhythm Metric • “Zietgebers” • Find the right balance: how much rest, activity, stimulation is ideal? • Maintaining the balance • Adapting to changes in routine (planned and unplanned)

  33. The Social Rhythm Metric

  34. Evidence-based, psychosocial treatmentsfor bipolar disorder • Cognitive-behavioral therapy (CBT) • Interpersonal and Social rhythm psychotherapy (IPSRT) • Family-focussed therapy (FFT) • Psychoeducation

  35. Expressed Emotion and Bipolar Disorder Intensity of negative interactions in close personal relationships (e.g., family, living situation) • Criticism – predicts mania and depression • Hostility – predicts mania and depression • Over-involvement – predicts depression

  36. Family-Focused Treatment (FFT) of Bipolar Disorder • 21 outpatient sessions over 9 months • Assessment of patient and family • Psychoeducation about bipolar disorder (symptoms, early recognition, etiology, treatment adherence, self-management) • Communication enhancement training (behavioral rehearsal of effective speaking and listening strategies) • Problem-solving skills training Miklowitz DJ & Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press, 1997.

  37. Family-Focused Treatment (FFT) and Medication Delays Relapses More Than Crisis Management (CM)+Medication Cumulative Survival Rates Over 2-Year Follow-Up (N=101) FFT+Medications Cumulative Survival Rate CM+Medications Weeks of Follow-Up CM vs. FFT 2(1)=8.71, p=.003; FFT, mean survival=73.5 weeks; CM, 53.2 weeks. Miklowitz DJ, et al. Arch Gen Psychiatry 2003;60(9):904-912.

  38. Family-Focused Treatment Enhances Drug Adherence More Than Crisis Management: Rates Over a 2-Year Follow-Up 16% 44% 39% % of Patients 34% 45% 21% 2 (2)=9.1, p=.01. Miklowitz DJ, et al. Arch Gen Psychiatry 2003;60(9):904-912.

  39. 6 IPSRT (n=18) ICM (n=20) 5 Social RhythmMetric Score 4 3 2 0 10 20 30 40 50 60 70 80 Weeks of Treatment Change in Stability of Social Rhythmsas a Function of Time in Treatment p=.006 ICM=Intensive clinical management. IPSRT=Interpersonal social rhythm therapy. Frank E, et al. Biol Psychiatry 1997;41(12):1165-1173.

  40. Probability of Hospitalization if a Relapse Occurred: 2-Year Study • FFT: 55% • IFT: 88% Conclusion: Family intervention can help patients and families to avoid the need for rehospitalization during a period of symptom deterioration Rea MM, et al. J Consult Clin Psychol 2003;71(3):482-492.

  41. Evidence-based, psychosocial treatmentsfor bipolar disorder • Cognitive-behavioral therapy (CBT) • Interpersonal and Social rhythm psychotherapy (IPSRT) • Family-focussed therapy (FFT) • Psychoeducation

  42. What is psychoeducation? A course in which you will learn: • What bipolar disorder is • Techniques and tips to better manage the disorder

  43. Psychoeducation 21 groups sessions of 90 minutes each Topics include: • Awareness of the disorder (6 sessions) • Symptoms, etiology, triggers, course • Drug Adherence (7 sessions) • Review of medications, blood tests, alternative therapies • Avoiding substance abuse (1 session) • Early Detection of New Episodes (3 sessions) • Regular habits and stress management (4 sessions) • Includes problem-solving strategies Psychoeducation Manual for Bipolar Disorder, by F. Colom and E. Vieta, Cambridge University Press, 2006.

  44. Overview of Bipolar Disorder Group Sessions UCSF Introduction (Li) Self Awareness (Donovan) Medications (Li) Sleep and Substances (Li) Living a Healthy Lifestyle (Lehr) Coping with Depression (Lehr) Communication Skills (Thomas) The Future: A Review (Li)

  45. Hormones and Mood

  46. Hormones and Mood • The basis of estrogen effects on mood is likely to be extremely complex, not simple • Too much estrogen may also be bad, perhaps associated with anxiety/agitation • High levels of estrogen can act to enhance the stress response, at least in rats Molecular Psychiatry (2004) 9, 531–538 • Antidepressants can improve hormone-related hot flashes and mood problems, with or without supplemental estrogen Brizendine Current Psychiatry; October 2003 • Use of hormone replacement is controversial because of risks (breast and endometrial cancer) Check out http://www.project-aware.org/index.shtml

  47. Hormones and Mood More suicidal events (attempts, completed suicides) occur in the first week of the cycle. ?Low levels of estrogen in that phase, perhaps leading to low levels of serotonin Saunders and Hawton Psychol Med. 2006 Jul;36(7):901-12 What is Premenstrual Dysphoric Disorder (PMDD)? A more severe form of PMS. symptoms can only occur in the second half of the cycle

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