Bipolar Disorder and Treatments Kristina Macdonald Amy Mac

Bipolar Disorder and Treatments Kristina Macdonald, Amy Mac. Harg, Tabitha Mason, Angela Mcfalls, Jessica Mc. Michael

Bipolar Disorder’s Criteria l According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV); “Bipolar Disorder is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Manic Episode. ”

What Is Bipolar Disorder? A mood disorder that alters: Feelings Thoughts Behaviors Perceptions (Within episodes of mania and depression) l Bipolar Disorder is previously known as Manic Depression

Clinical Presentations l l Most commonly diagnosed between ages of 18 and 24 Mania, Hypomania, Psychosis, depression

Characteristics of Mania l l l l Feeling of being able to do anything Little sleep is needed Feeling filled with energy Not caring about financial situations Delusions Substance abuse The DSM-IV has a list of symptoms and three or more must be present.

Characteristics of Hypomania l Feeling of creativity Don’t worry about problems seriously Feeling as if nothing can bring you down Have confidence in yourself l Similar to Mania except Hypomania is of lesser intensity l l l

Characteristics of Psychosis l l l Poor attention and concentration Suspiciousness Social withdrawal Feeling that things around you have changed Describing the diagnosis with psychosis is usually used to clarify the severity of the state of the disorder

Characteristics of Depression l l l l Sleep more than you normally would Feeling of tiredness Crying uncontrollably Withdrawing from activities you once enjoyed Staying in bed for days Weight Loss/Weight Gain The DSM-IV has a list of symptoms and five or more must be present during the same two week period.

The Two Sides of Bipolar Disorder l Bipolar II l Episodes of full mania alternating with episodes of major depression Diagnosed in patients typically in early 20’s l Episodes of major depression and hypomania l

Evaluation of Patient l l Make sure no other medical condition is causing mood or thought disturbance Perform a physical examination Look for possibility of substance abuse – Trauma to brain – Seizure disorders – l Perform mental health evaluation – Mental status examination (MSE) l Assesses mood and cognitive abilities l Safety of individual l Examines forms of psychosis

Evaluation of Patient Cont… l l Subjective experience of patient Family’s psychiatric history

Prevalence l l l Lifetime= 1% Males and Females = no difference Age = all ages – Highest prevalence is in the 18 to 24 year age group l First degree relatives = incidence of BP increases Affects roughly 1/100 adults Very little data about kids and teenagers Linked to disturbed electrical activity in the brain l (Griswold, 2000) l l l

Bipolar Disorder Difficulties (Griswold, 2000) Children Adolescents Pregnancy Hyperactivity is most Common; Makes BP Difficult to diagnose Symptoms similar to adults Psychosis can be a Presentation of BP. Substance abuse can be Present which makes Diagnosis difficult Planning of pregnancy is a Necessity because of Medication Rapid cycling could occur

What Causes Bipolar? l No single cause may ever be found for bipolar disorder. Among the biological factors observed in bipolar disorder, as detected by using imaging cans and other tests, are the following: – – – Over secretion of cortisol, a stress hormone. Excessive influx of calcium into brain cells. Abnormal hyperactivity in parts of the brain associated with emotion and movement coordination and low activity in parts of the brain associated with concentration, attention, inhibition, and judgment. (Well Connected, 2002)

How Serious is Bipolar Disorder? According to Well-Connected, 2002: l Risk for Suicide – An estimated 15 -20% of patients who suffer from bipolar disorder and do not receive medical attention commit suicide. l l l In a 2001 study of Bipolar I disorder, more than 50% of patients attempted suicide; the risk was highest during depressive episodes. Patients with mixed mania, and possible when it is marked by irritability and paranoia, are also at particular risk. Many young children with bipolar disorder are more severely ill than are adults with the disorder. According to a study in 2001, 25% of children with the disorder are seriously suicidal.

Seriousness of Disorder Cont. l Thinking and Memory Problems In a 2000 study, it was reported that bipolar disorder patients had varying degrees of problems with short- and long-term memory, speed of information processing, and mental flexibility. (Medications used for bipolar disorder, however, could have been responsible for some of these abnormalities and more research is needed to confirm or refute these findings) –

Seriousness of Disorder Cont. l Substance Abuse – – Cigarette smoking is prevalent among bipolar patients, particularly those who have frequent or severe psychotic symptoms. Some experts speculate that, as in schizophrenia, nicotine use may be a form of self-medication because of its specific effects on the brain. Up to 60% of patients with bipolar disorder abuse other substances (most commonly alcohol, followed by marijuana or cocaine) at some point in the course of their illness.

Seriousness of Disorder Cont. l Effect on Loved Ones – – It is very difficult for even the most loving families and caregivers to be objective and consistently sympathetic with an individual who periodically and unexpectedly creates chaos around them. Often family members feel socially alienated by the fact of having a relative with mental illness, and they conceal this information from acquaintances.

Seriousness of Disorder Cont. l Economic Burden – – In 1991, the National Institute of Mental Health estimated that the disorder cost the country $45 billion, including direct costs (patient care, suicides, and institutionalization) and indirect costs (lost productivity, and involvement of the criminal justice system. ) In one major survey, 13% of patients had no insurance and 15% were unable to afford medical treatment.

Treatment of Bipolar Disorder (a four phase process) Evaluation and diagnosis of presenting symptoms Acute care and crisis stabilization for psychosis or suicidal or homicidal ideas or acts Movement toward full recovery from a depressed or manic state Attainment and maintenance of euthymia This four phase process was according to (Himanshu P. Upadhyaya, MBBS, MS. , 2002)

Treatments l Inpatient Care l l l Assess the patient Diagnose the condition Ensure safety of patient and others – This care is necessary for: l Psychotic features l Suicidal or homicidal ideations

Treatments l l Antidepressant therapy Mood stabilizer – – – l Lithium carbonate Sodium divalproex Carbamazepine Antipsychotic Agents – – Risperidone Haloperidol

Treatments l Electroconvulsive therapy (ECT) – – – Inpatient basis Severe cases Patient requires hospitalization often l l Faster than medications for therapeutic responses Memory loss before and after treatments 3 -8 sessions Medications are still required in maintenance phase of treatment

Mood Stabilizers (Upadhyaya, 2002) Mood Stabilizer Common Adverse Effects Doses Special Concerns Lithium carbonate (Eskalith CR, Lithobid) Lethargy or sedation, tremor, enuresis, weight gain, overt hypothroidism occurs in 5 -10% of patients 300 -600 PO tid/qid Must be adjusted by monitoring serum level and patient response Hypothyroidism, diabetes insipidus, polyuria, polydipsia Sodium divalproex/ valproic acid (Depakote, Depakene) Sedation, platelet dysfunction, liver disease, weight gain 10 -20 mg/kg/d Must be adjusted by monitoring serum levels Elevated liver enzymes or liver disease, bone marrow suppression Carbamazepine (Tegretol) Suppressed WBS, dizziness, drowsiness, rashes, liver toxicity(rarely) 200 mg PO bid Must be adjusted by monitoring serum blood levels Drug-Drug interactions, bone marrow suppression

Mood Stabilizers Cont… Gabapentin (Neurontin) Headache, Not established fatigue, ataxia, dizziness, sedation, weight gain Withdrawal seizures Lamotrigine (Lamictal) Sedation, Not established dizziness, nausea Stevens. Johnson syndrome or emesis, diplopia, ataxia, headache, sleep disruption, benign rash Topiramate (Topamax) Nephrolithiasis, psychomotor slowing, somnolence Not established Decrease doses in liver or renal impairment

Mood Stabilizers Cont… Felbamate (Felbatol) Liver Disease, Not photosensitivity, Established headache, somnolence Vigabatrin Weight gain, (Sabril); agitation, Investigational insomnia drug Not Established Aplastic anemia Unknown

Psychotherapy Is not an effective treatment by itself, but can be used in addition to medication Types of therapy include: -cognitive behavior therapy -psychoeducation -interpersonal therapy -multifamily support groups l

Cognitive Behavior Therapy l l More effective with the depressive part of bipolar disorder “…Involves identifying irrational thought patterns and altering [them] to better reflect reality” ***Activities such as “daily mood logs” can help (Wilkinson 2002)

Psychoeducation Learning signs and symptoms of his/her disorder; what triggers mood alteration l More useful for mania ---Being able to identify signs and symptoms of mania is helpful in the prevention of a “full blown manic episode” (Wilkinson 2002). l

Interpersonal Therapy Helps to improve social skills and thereby provides patients with more stability in interacting with others l Activities include: - role playing - modeling - “guided in vivo practice” (Wilkinson 2002) l

Multi-family Therapy Parent involvement in a child with BD by teaching the child: -relaxation techniques -anger management -decision-making skills -communication/listening skills -seeing that children don’t become “victims of their illnesses” (Wilkinson 2002) l

An Alternative Combination l A combination of lithium and valproate can be effective in treatment if monotherapy fails.

Treatment for Children and Adolescents l l l Lithium is one of the original treatments for bipolar states in youth In a study in which chlorpramzine (thorazine) was used, approximately 30% to 50% of youths had an improvement with mood stabilizing In Frazier et al’s 2001 experiment, an eight week study of using olanzapine monotherapy in 23 children and adolescents shown that there were significant improvements of mania and depression on doses ranging from 2. 5 mg/day to 20 mg/day

Treatment Trends in the Elderly l l l The number of new lithium users per year fell from 653 to 281 in 2001 for older patients The number of divalproex users rose from 183 in 1993 to 1090 in 2001 Though there has been a decline in elderly lithium patients using lithium, lithium will continue to be a mainstay until other mood stabilizers are researched more extensively

Choosing the site of Treatment According to the American Psychiatric Association, 2000: l One of the first decisions the psychiatrist must make is the overall level of care that the patient requires. – Acute episodes of bipolar disorder are frequently of such severity that patients require treatment in either a full or partial hospital setting. (The least restrictive setting that is likely to allow for safe and effective treatment should be chosen. ) l If the patient is lacking the capacity to cooperate with treatment. – Patients who are unable to care for themselves adequately, cooperate with outpatient treatment of their mood disorder, or provide reliable feedback to their psychiatrist regarding their clinical status are candidates for full or partial hospitalization, even in the absence of a tendency toward intentional self-harm.

Site of Treatment Cont. l If the patient is at risk for suicide or homicide – l Patients with suicidal or homicidal ideation require close monitoring. Patients at high risk may benefit from hospitalization, during with close observation, restricted access to violent means and more intensive treatment are possible. If the patient lacks psychosocial supports – Recovery from acute bipolar episodes is aided by an environment that encourages safety, constructive activity, positive interpersonal interactions, and compliance with treatment. If the home environment lacks these features or exposes the patient to undesirable or dangerous activities, such as alcohol or drug abuse, admission to a hospital or an intensive day program may be necessary.

Works Cited Bipolar Disorder. (2002). Well Connected A. D. A. M. Inc. Retrieved from www. well-connected. com. Dinan, Timothy G. (2002, April 27). Lithium in bipolar mood disorder. British Medical Journal, 324 (7344), 898 -991. Griswold, Kim S. (2000, September). Management of Bipolar Disorder. American Family Physician. www. findarticles. com/cf_0/m 3225/6_62/65286755/print. jhtml Hirshfeld, R. , Clayton, P. J. , Cohen, I. , Fawcett, J. , Keck, P. , Mc. Clellan, J. , et al. (2000). Practice Guidelines for the Treatment of Patients With Bipolar Disorder. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2000, 503 -562. Nathan, Peter F. , Gorman, Jack M. (1998). A guide to treatments that work. New York: Oxford University Press. Schlozman, Steven C. (2002, November). The Shrink in the Classroom. An Explosive Debate: The Bipolar Child. Association for Supervision and Curriculum Development. (89 -90). Shulman, Kenneth I. (2003, May 3). Changing prescription patters for lithium and valproic acid in old age: Shifting practice without evidence. British Medical Journal, 326 (7396), 960 -962.

Works Cited Cont. Srinath, Rajeev J. et al. (2003, February). The Index Manic Episode in Juvenile. Onset Bipolar Disorder: The Pattern of Recovery. Canadian Journal of Psychiatry. Vol. 48 (1). Retrieved Oct. 22, 2003, from EBSCO Academic Search Elite Database. Sternstein, Aliya & Gross, Neil. (2002, August 12). Some uplifting news about depression. Business Week, (3795), 69. Treatment. Journal of Mental Health Counseling, (24) 348+. Retrieved Oct 21, 2003, from EBSCO Academic Search Elite database. Upadhyaya, Himanshu P. et al. (2002, October). Mood Disorder: Bipolar Disorder. e. Medicine. www. emedicine. com/ped/topic 240. htm. Wilkinson, Greta et al. (2002). Bipolar Disorder in Adolescence: Diagnosis and