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What are the classifications of Bipolar disorder?
- Bipolar I
- Bipolar II
- cyclothymic disorder
- bipolar disorder not otherwise specified
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Define mood disorders by types of episodes
- Major Depressive Disorder: single major depressive episode
- Recurrent Major Depressive Disorder: two or more major depressive episodes
- Bipolar I: Manic episode
 major depressive or mixed episode - Bipolar II: major depressive episode + hypomanic episode
- Dysthymic dosorder: chronic subsyndromal depressive episodes
- Cyclothymic disorder: Chronic fluctuations beteween subsyndromal depressive and hypomanic episodes (2yr for adults and 1yr for children and adolescents)
- Bipolar Disorder not otherwise defined: Mood states do not mbeet criteria for any specific bipolar disorder
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Diagnostic Criteria for Episodes: Major depressive episode
- Impairment of functioning or need for hospitalization
- DSM-IV-TR criteria
- >2week period of: depressed mood, loss of interest or pleasure in normal activities
- and ≥5 of following symptoms:
- mood: depressed or sad (adults) irritable (children)
- decreased interest and pleasure in normal activities
- decreased appetite, weight loss
- insomnia or hypersomnia
- psychomotor retardation or agitation
- decreased energy or fatigue
- fellings of guilt or worthlessness
- impaired concentration and decision making
- suicidal thoughts or attempts
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Diagnostic Criteria for Episodes: Manic
- •Marked impairment in functioning and need for hospitalization
- •Begins abruptly, symptoms increase over several days
- •Severe stages - bizarre behavior, hallucinations, paranoia, delusions
- •Not drug or medication induced
- DSM-IV-TR criteria
- •≥1week: elevated expansive or irritable mood
- •≥3 of the following symptoms: (4 if mood is only irratable)
- DIGFAST
- Distractability - poor attention
- Indiscretion - pleasurable activities, high risk of consequences
- Grandiosity - inflated self esteem, paranoia
- Flight of ideas - rapid, racing thoughts
- Actvity increase - energized, restless
- Sleep deficit - decreased need
- Talkative - pressure of speech
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Diagnostic Criteria for Episode: hypomanic
- NO marked impairment of social or occupational functioning, delusions or hallucinations
- DSM-IV-TR criteria
- ≥4days: elevated expansive or irritable mood
- ≥3 of the following symptoms (4 if only irritable):
- IGFAST
- Grandiosity - inflated self esteem
- Flight of ideas - rapid, racing thoughts
- Actvity increase - energized, restless
- Sleep deficit - decreased need
- Talkative - pressure of speech
- can switch to manic episode
- pts are usually more productive and creative
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Diagnostic Criteria for Episode: Mixed
- Impairment of functioning or need for hospitalization
- DSM-IV-TR criteria
- ≥1week of daily symptoms
- both major depressive disorder and manic episode
- comorbid alcohol and substance abuse, severe anxiety, higher suicide rate, poorer prognosis
- young old and women
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Diagnostic Criteria for Episode: rapid cycling
- Impairment of functioning or need for hospitalization
- DSM-IV-TR citeria
- >4 episodes in 12 mos (major, manic, hypomanic or mixed)
- 10-20% of bipolar patients are rapid cyclers
- poorer prognosis and response
- Risk Factors: alcohol, antidepressants, stimulant use, hypothyroidism, menstral
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Which mood episode is not characterized by an impairment of social or occupational functioning, or have a need for hospitalization to prevent self-harm, harm to others or presence of psychotic symptoms?
Hypomania
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What is the difference between manic and hypomanic mood episodes?
- manic episodes are more severe than hypomanic episodes
- hypomanic - no marked impairment of function, delusions or hallucinations - duration is less
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Suicide attempts occur in what percent of patients with Bipolar disorder? Which bipolar disorder type is more likely to attempt suicide?
- 50%
- Type II is more likely to attempt suicide than type I
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What are the non-pharmacological treatments for Bipolar Disorder
- Therapy: psychotherapy, interpersonal, cognitive behavioral
- reduce stress
- sleep
- nutrition
- exercise (3xwk)
- ECT: severe mania, mixed episodes, psychotic depression, rapid cycling, poor responders
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Treatment: Acute Mania in bipolar disorder
- Mood Stabilizers
- Lithium
- Valproic Acid (valproate, divalproex sodium)
- Carbamazepine ER
- FGA's & SGA's: mono or +lithium/VPA
- Aripiprazole
- olanzapine
- quetiapine
- risperidone
- ziprasidone
- haloperidol
- Alternatives: HD benzos (clonazepam and lorazepam)
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Treatment: Acute Bipolar Depression
- Quetiapine
- Lamotrigine - mono and add-on for refractory bipolar depression
- Alternatives: Antidepressants (TCA's and venlafaxine can induce mania in bipolar I) w/d 2-6 mos after remission
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Treatment: Bipolar Maintenance Therapy
- Mood Stabalizers
- Lithium
- VPA
- Carbamazepine
- Lamotrigine - bipolar I, mono and adj. in refractory bipolar depression
- SGA's
- aripiprazole
- olanzapine
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Treatment: rapid cycling
- Valproate
- Alternative: Nimodipine (anticonvulsant properties, high lipid solubility, good penetration to brain)
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Drug of choice for euphoric mania
Lithium
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Drug of choice for mixed, irritable/dysphoric mania and rapid cycling
Valproate
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What percent of women relapse postpartum
20-50%
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Is breastfeeding okay for women taking lithium? What about Valproate?
Lithium - It is discouraged, babies concentrations are between 10& 50%
VPA - it's okay but baby should be monitored
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Which is safer for avoiding nerual tube defect during the first trimester of pregnancy, Valproate or Carbamazepine?
- Valproate risk is ~5%
- Carbam. risk is ~0.5-1%
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