Bipolar disorder: discussion points

Mental Talking #1: Bipolar disorderAhmed E Elaghoury, MD

Egyptian and Arab Boards certified in PsychiatryMScMed Neurology and Psychiatry

Cairo, EgyptTaif, Saudi Arabia

Mental Talking Webinar 2

DSM5 spots Bridge: schizophrenia and depressive

ds BP 1: Manic episode BP 2: Hypomanic episode + MDE,

NEVER manic Manic vs Hypomanic: duration,

impairment & psychosis Bipolar diathesis: a disorder

susceptibility Oct 2016


Confusing points Elevated mood: heightened mood

+ feelings of euphoria, elation and well-being

Expansive mood: unrestrained emotional expression + grandiosity

Irritable mood: irascible mood of angry impatience + aggression

Irritable mood: non specific, weak diagnostic

Oct 2016Colman AM. Oxford dictionary of psychology. 2015


DSM5 specifiers Current / most recent episode: manic / hypomanic

/depressive WITH:

• anxious distress• mixed features• melancholic features• atypical features• mood-congruent psychotic features• mood-incongruent psychotic features• Catatonia• rapid cycling• peripartum onset• seasonal pattern

Course: partial / full remission Severity: mild, moderate / severe

Oct 2016


The Mitchell et al. “probabilistic” (or likelihood) approach

There are no pathognomonic characteristics of bipolar I depression

Common in BP I depression / Converters:• Atypical depressive features• Psychomotor retardation • Psychotic features ± pathological guilt • Lability of mood / Manic sx

Bipolar depressed patients:• Earlier age of onset: <25ys• More prior episodes of depression: ≥5• Shorter depressive episodes: < 6ms• Family history of bipolar disorder

Oct 2016Mitchell, Philip B., et al. "Diagnostic guidelines for bipolar depression: a probabilistic approach." Bipolar disorders 10.1p2 (2008): 144-152.


The International Society for Bipolar Disorders (ISBD) Task Force Report on

Antidepressant Use in Bipolar Disorders (2013)

It is not currently possible to make firm clinical recommendations that are soundly evidence based

The evidence for antidepressant-associated mood switching is mixed and the ability of mood stabilizers to prevent such responses to antidepressant treatment unproven

Clinicians are encouraged to consult our consensus-based recommendations (PMC 4091043)

From an initial 25 items in six domains, the 12 statements were rated by at least 80% of ISBD experts as ESSENTIAL or IMPORTANT and were included in the ISBD recommendationsOct 2016

Pacchiarotti I, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry. 2013 Nov;170(11):1249-62. doi: 10.1176/appi.ajp.2013.13020185. PMID: 24030475; PMCID: PMC4091043

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091043/


Antidepressant-induced Mania/Hypomania

Prevalence, course and prognosis: Unknown STEP-D: little/no switch Other prospective RCTs: < 1% Known 20% transition and switch: Uni Bi, regardless

antidepressant Rx. The Viktorin et al. Swedish registry study (2014)

• > 3,000 Pts with bipolar disorder started antidepressants• Nearly 35%: antidepressant monotherapy • Antidepressant monotherapy: ↑ risk of mania• No risk of mania: antidepressant + mood stabilizer

Vieta E. Antidepressants in bipolar I disorder: never as monotherapy. Am J Psychiatry. 2014 Oct

• IBSD Statement- Did not discuss efficacy Ostacher MJ, Perlis RH, Geddes J. Monotherapy Antidepressant Treatment

is Not Associated With Mania in Bipolar I Disorder. Am J Psychiatry. 2015 Jun• Confirmation bias -Indication bias -NNH

Landén M, Viktorin A. Response to Ostacher et al. Am J Psychiatry. 2015 Jun• Clear difference between the 2 groups

Oct 2016

Perlis RH & Ostacher MJ. Ch 35: Bipolar disorder. In Stern TA et al. MGH comprehensive clinical psychiatry 2nd E, 2016 Viktorin A, et al.. The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. Am J Psychiatry. 2014 Oct; 171(10):1067-73. doi: 10.1176/appi.ajp.2014.13111501. PMID: 24935197.


International Society for Bipolar Disorders Task Force on Suicide report (2015)

SUICIDE ATTEMPTS were significantly associated with:

Female gender Younger age at illness onset Depressive polarity of first illness episode Depressive polarity of current or most recent episode Comorbid anxiety disorder Comorbid substance use disorder Comorbid cluster B/borderline personality disorder, First-degree family history of suicide

SUICIDE DEATHS were significantly associated with: Male gender First-degree family history of suicide.

Oct 2016

Schaffer A, et al. International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder. Bipolar Disord. 2015 Feb;17(1):1-16. doi: 10.1111/bdi.12271. Epub 2014 Oct 20. PMID: 25329791.


International Society for Bipolar Disorders Task Force on Suicide report (2015): I

Pooled suicide rate in bipolar disorder:164 per 100,000 person-years

Male : Female Suicide disorder: 1.7:1 People with bipolar disorder: 3.4-14% of all suicide

deaths Self-poisoning and hanging: the most common

methods 23-26% of people with bipolar disorder ATTEMPT

SUICIDE, with higher rates in clinical samples Lithium or anticonvulsants: strongly suggestive for

prevention of suicide attempts and deaths Antipsychotics or antidepressants: limited data

on potential anti-suicide effects of treatment withOct 2016

Schaffer A, et al. Epidemiology, neurobiology and pharmacological interventions related to suicide deaths and suicide attempts in bipolar disorder: Part I of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder. Aust N Z J Psychiatry. 2015 Sep;49(9):785-802. doi: 10.1177/0004867415594427. Epub 2015 Jul 16. Review. PMID: 26185269.


International Society for Bipolar Disorders Task Force on Suicide report (2015): II

At least one study found an effect for each of the following factors on the likelihood of SUICIDE ATTEMPTS OR DEATHS in persons with bipolar disorder : • Sex • Age • Race • Marital Status • Religious Affiliation • Age Of Illness Onset • Duration Of Illness• Bipolar Disorder Subtype • Polarity Of First Episode • Polarity Of Current/Recent

Episode

• Predominant Polarity • Mood Episode Characteristics • Psychosis • Psychiatric Comorbidity • Personality characteristics • Sexual dysfunction • First-degree family history of

suicide or mood disorders • Past Suicide Attempts • Early Life Trauma • Psychosocial Precipitants

Oct 2016

Schaffer A, et al. A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: Part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder. Aust N Z J Psychiatry. 2015 Nov;49(11):1006-20. doi: 10.1177/0004867415594428. Epub 2015 Jul 14. Review. PMID: 26175498.


Substance use & Bipolar ds

Comorbidity: • Irritable and dysphoric mood states• Increased risk of suicide• Increased treatment resistance• Greater need for hospitalization

Oct 2016

Brady, Kathleen T.; Sonne, Susan C. The relationship between substance abuse and bipolar disorder. The Journal of Clinical Psychiatry, Vol 56(Suppl 3), 1995, 19-24.Swann, A. C., et al. (2004), Impulsivity: a link between bipolar disorder and substance abuse. Bipolar Disorders, 6: 204–212. doi:10.1111/j.1399-5618.2004.00110.x*Anabolic steroids; NSAID; cortisol; antiparkinsonian medications; antihistamines; nitrous oxide; amyl-, butyl-, or isobutyl-nitrites; betel nut; kava; or cathinones

Alcohol PCP Other Hall

Sed/Hyp/Anx

Stimulants

Other Sub* /

UnknownI • • • • • •

W • • • •

Mental Talking Webinar 12Oct 2016El-Mallakh RS & Bauer SM. Ch 49: Bipolar (Manic Depressive) Disorders. In: Tasman A et al (ed). Psychiatry, 4th Ed. 2015 John Wiley & Sons, Ltd

Mental Talking Webinar 13Oct 2016

Rosenblat, J.D. and McIntyre, R.S. (2016) ‘Treatment recommendations for DSM-5–defined mixed features’, CNS Spectrums, , pp. 1–8. doi: 10.1017/S1092852916000432.


Rosenblat, J.D. and McIntyre, R.S. (2016) ‘Treatment recommendations for DSM-5–defined mixed features’, CNS Spectrums, , pp. 1–8. doi: 10.1017/S1092852916000432.


Environmental factors: zeitgebers Social rhythms: the social relationships,

social demands or tasks that serve to entrain biological rhythms. Ehlers et al. (1988)

Pathways of relapse:• Stressful life events • Medication non- adherence • Disruptions in social rhythms (daily activity

routine): esp sleep/wake cycle

Oct 2016

Crowe, M., et al. (2016), Social rhythm interventions for bipolar disorder: a systematic review and rationale for practice. J. Psychiatr. Ment. Health Nurs., 23: 3–11. doi:10.1111/jpm.12271Inder ML, et al. Randomized, controlled trial of interpersonal and social rhythm therapy for young people with bipolar disorder. Bipolar Disord 2015: 17: 128–138. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

http://onlinelibrary.wiley.com/doi/10.1111/jpm.12271/full


Health & Medicine

Bipolar disorder: discussion points