1. Alison C. Lynch MD MS April 19, 2017
Bipolar Disorder
Alison C. Lynch MD MS
April 19, 2017

2. No disclosures

3. Objectives—Bipolar disorder
Overview of bipolar disorder
Diagnosis
Identification
Treatment
Cases to illustrate common issues
Is it bipolar disorder?
Pregnancy
Chronic conditions
Starting meds
Urgencies/emergencies
By the end of this presentation, I hope you will feel like you have refreshed your knowledge about what bipolar disorder is, the current diagnostic criteria, as well as how to identify it and some basic treatment strategies. We will also discuss some common issues that come up when treating bipolar disorder, and we will do this by working through some cases.

5. Bipolar disorder is common
~2.6% of US population (5.7 million Americans)
Sixth leading cause of disability worldwide
Average age of onset is 25 years old
About 2/3 of people with bipolar disorder have at least one close relative with bipolar disorder or major depression
Gender distribution ~1:1
We will talk more about gender and bipolar disorder a little later in this presentation
2.6% 12-month prevalence (Kessler, NIMH prevalence studies)
3.9% lifetime prevalence
World Health Organization

6. Bipolar disorder causes serious problems
People with bipolar disorder experience severe mood swings that impair their daily life and negatively affect their relationships

7. Bipolar disorder phases
Mania
Hypomania
Depression
Euthymia
Bipolar disorder
Major depression
Mania—a distinct period of abnormally and persistently elevated, expansive, or irritable mood AND abnormally and persistently increased activity or energy lasting at least one week or resulting in hospitalization; also with at least 3 of the following--grandiosity/self-esteem, decreased need for sleep, more talkative or pressure to keep talking, racing thoughts, distractibility, increased goal-directed activities or agitation, excessive risk taking (associated and persistent increase in activity or energy is new in DSM5)
Hypomania—less severe and briefer than mania
Depression—low mood, loss of interest/pleasure, sleep/appetite/energy, attention, motivation, hopelessness, guilt, etc.
Euthymia—stable mood in moderate range
Depression occurs twice as often as mania
Relapse occurs in 37% of people over a year and 60% over 2 years

8. Types of bipolar disorder
Type I: at least 1 episode of mania (+/- depression)
Type II: hypomania + depression
Rapid cycling: at least 4 episodes of depression, mania, or both in 1 year
Mixed features: features of mania and depression simultaneously

9. Bipolar disorder is often missed
Especially bipolar II
Can look like depression, as people are more likely to seek care for this problem than for mania/hypomania
20-40% of people diagnosed with MDD have a bipolar illness
Treatment resistant depression?
We are still trying to understand how frequently TRD is actually bipolar
About half of people with bipolar disorder are getting treatment for it an any given time
Bipolar disorders in DSM-5: strengths, problems and perspectives
Jules Angst, International Journal of Bipolar Disorders 2013 (August), 1:12

10. Recognizing bipolar disorder
Consider bipolar in people with depression (in particular those who have not responded to antidepressant treatment)
Ask about history of mania or hypomania symptoms
Ask about family history of bipolar disorder
Screen with the Mood Disorders Questionnaire (MDQ)

11. Bipolar Disorder in Clinical Populations
Family Practice in the US
BD-I 3%
108 outpatients diagnosed with depression or anxiety in a private family practice setting
BD-II 18%
In a private family practice setting, 108 patients with a diagnosis of depression or anxiety disorder were evaluated. Over ¼ of these patients had bipolar disorder, most of whom had bipolar II disorder.
Reference
Manning JS et al. (1997), Compr Psychiatry 38(2):
Other BD 5%
Manning JS, et al. Compr Psychiatry. 1997;32: 11

13. Bipolar Disorder in Clinical Populations
Patients Treated for Depression
in a Family Medicine Clinic
649 outpatients receiving treatment
for depression
Screened positive* for bipolar disorder
21%
This study evaluated over 600 outpatients who were receiving antidepressant treatment for depression. Over one in five of these patients screened positive for bipolar disorder using the MDQ.
Reference
Hirschfeld RM et al. (2005), J Am Board Fam Pract
MDQ sensitivity = 58%,
MDQ specificity = 93%; based on SCID for DSM-IV
*Using the Mood Disorder Questionnaire (MDQ) Hirschfeld RM, et al. J Am Board Fam Pract. 2005;18: 13

15. Is it bipolar or is it borderline?
BPAD
Episodes of mania or depression lasting days to weeks
More physical and mental energy and activity than normal
Racing thoughts and ideas
Talking more and faster
Making big plans
Risk taking
Impulsiveness (substance abuse, sex, spending, etc.)
Less sleep, but no feeling of being tired
Borderline PD
Longstanding pattern of swings:
moods, 
relationships,
self-image, and
behavior 
Mood cycles can fluctuate throughout the day
Overly strong emotional responses to upsetting life events
Often try to hurt themselves
Often have chaotic relationships with people
History of trauma as a child is more common

16. Treatment is beneficial
Lithium
Reduces relapse (prophylaxis)
Reduces suicides
Improves the course of the illness
May lower risk of dementia in people with bipolar
Treatment in general
Reduces suicide rate
Reduces mortality risk from chronic disease

17. FDA-Indicated Treatments
Acute Mania: Monotherapy
Lithium
Divalproex
Olanzapine
Chlorpromazine
Quetiapine
Aripiprazole
Risperidone
Ziprasidone
Carbamazepine ER
Acute Mania: Combination with lithium or valproate
Olanzapine
Quetiapine
Aripiprazole
Maintenance
link to the increasing complexity of pharm treatment
Lithium
Lamotrigine
Olanzapine
Aripiprazole
Quetiapine (in combination)
Bipolar Depression
Olanzapine / fluoxetine combination
Quetiapine

18. Sometimes it is best to start a drug now
Lithium: 300mg qhs x3d, then 600mg qhs
Check 12 hour level after 1 wk
TSH, creatinine
Depakote: ER 500mg qhs, increase dose by 250mg up to mg qhs
Check 12 hour level after 3d at steady dose
CBC, LFTs, weight
Lamotrigine: 25mg qd x2wks, then 50mg qd x2wks, then 100mg qd
Watch for rash, advise how to manage
Better for depression than mania

19. Primary care providers need to know about mood stabilizers
Lithium
Drug level affected by many antihypertensives (including ACE-Is, diuretics)
Long-term use can cause chronic kidney injury
Hypothyroidism
Pregnancy category D
Valproic acid/Depakote
Weight gain
Liver enzyme elevation, thrombocytopenia
Lamotrigine
Stevens Johnson Syndrome

20. Numerous treatment options exist
Psychotherapy is beneficial for bipolar
Cognitive behavior therapy
Family-focused therapy
Interpersonal and social rhythm therapy
Psychoeducation
Combine psychotherapy with medications

21. Symptom-targeted strategies can also be helpful
Restore or maintain a good sleep pattern
Sleep hygiene, trazodone
Symptom monitoring
Build/maintain a good support system
Stress management
Take medications consistently (pill box, reminder system, medication set up services)
Avoid triggers including drugs and alcohol

22. Bipolar disorder affects lifespan
Bipolar shortens life expectancy by 9 years
Higher mortality rate, esp due to chronic medical conditions
Suicide (19%, 8-10x rate of general population)
Accidents/unintentional injuries (~10x rate)
Increased risk of chronic diseases
Cardiovascular disease (31%)
Cancer (14%)
COPD (>2x), diabetes (~3x)
Influenza/pneumonia (~4x rate of gen pop)
Rates of death from chronic diseases and suicide were lower in people who were getting treatment than those with untreated mental illness

23. Gender can affect bipolar course
Women more likely to have BPAD-II than man
Women more likely to have seasonal pattern of symptoms
Women more likely to have depression, mixed mania, rapid cycling
Women more likely to have co-morbid thyroid disease, migraine, obesity, and anxiety disorder
Women more likely to experience delayed diagnosis and delayed treatment
Mood stabilizers work the same in men and women
10/13/16: Update****
Psychiatr Clin North Am Sep;26(3):
Gender differences in bipolar disorder.
Arnold LM.

24. Co-occurring substance abuse is common with bipolar disorder
Among people with bipolar type I, ~60% have a substance abuse diagnosis
~46% have an alcohol misuse disorder
~40% misuse drugs other than alcohol
Co-occurring conditions make diagnosis and treatment more complicated
Sometimes someone may appear manic but they might actually be intoxicated on meth, K2, or another substance

25. Case 1
Patient with depression who does not get better with antidepressant treatment
Medication nonadherence is the most common cause of depression treatment failure
Maybe they are not on the right medicine
Treatment-resistant depression: 2 medication trials at therapeutic dose for at least 2 months each without improvement
Consider bipolar depression, as it often does not respond to usual antidepressant medications
Gotto J, Rapaport MH Treatment options in treatment resistant depression. Primary Psychiatry [serial online] Available at:  Accessed September 18, 2006. 

26. Case 2
Patient is new to you, has previously been diagnosed with bipolar disorder, is currently stable on lithium, quetiapine, and diazepam; would like you to write prescriptions to continue this treatment.
Other health conditions include obesity, HTN, arthritis, asthma.
Pearls: bipolar disorder is underdiagnosed and misdiagnosed; common conditions that may present like bipolar disorder are depression and borderline personality disorder; ask about discrete manic or hypomanic episodes
Check lithium level, creatinine, TSH. Check weight and BMI, BP, lipids, A1c. Consider benzo dependence and risks of benzo use.

27. Case 3
You see a 29 yo female with depression and start your preferred SSRI. Patient gets manic.
Manic symptoms after starting an antidepressant—it is still bipolar disorder

28. Case 4
Patient shows up in primary care clinic and is clearly manic. What should you do?
Psychiatry consult
Hospitalize?
Emergency room
Start a mood stabilizer

29. Case 5
Patient with history of bipolar disorder, not taking medications now, depressed.
Start a medication to treat depression—which one?
Lithium, depakote, lamotrigine
Atypical antipsychotic

30. Case 6
Patient with bipolar disorder, 29 yo female, taking lithium 1200mg qhs. Gets pregnant, now her psychiatrist won’t see her because he doesn’t take care of pregnant patients. She comes to you for help.

31. Bipolar disorder complicates pregnancy and lactation
Pregnancy neither protects from nor exacerbates bipolar disorder
Many women require ongoing treatment during pregnancy and lactation
Mood stabilizers pose risk to developing fetus and nursing infant
Postpartum period is a time of high risk for onset and recurrence of bipolar disorder (including postpartum psychosis), consider prophylaxis

32. Case 7
Patient with bipolar disorder, stable on medications. What advice should you give to maintain stability?
Sleep
Travel
Stress management
Medication adherence
Diet/exercise/weight
Screening and prevention
Chronic conditions

33. Am Fam Physician. 2012 Mar 1;85(5):483-493.

35. DSM 5 updated the diagnosis of bipolar disorder
Tries to address prior underdiagnosis of bipolar disorder (esp type II) and overuse of NOS specifier
Recognition that sometimes a person does not fully meet the diagnostic criteria for severity or duration of hypomania but likely still has a bipolar illness (specifiers)
MDE specifiers
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