Bipolar Disorder from Bipolar Disorder from Diagnosis to TreatmentDiagnosis to Treatment

Dr. LevkovitzDr. LevkovitzShalvata Mental Health CenterShalvata Mental Health Center

School of Medicine, Tel Aviv School of Medicine, Tel Aviv University University

•Lifelong cyclic illness.•1-5% of population.•Peak onset 15-30 years.•5-10 year delay in correct diagnosis.•Frequent hospitalization.

Public Health Significance of Bipolar Public Health Significance of Bipolar DisorderDisorder

•Repeated job change/loss:financial disaster.•Alcohol/substance abuse.•50% non-adherence to medication.•Increase cardiovascular mortality.•Suicide .

Public Health Significance of Bipolar Public Health Significance of Bipolar Disorder (Con`t)Disorder (Con`t)

Patients with bipolar disorder show:Patients with bipolar disorder show:

Attention, concentration and Attention, concentration and

psychomotor speed.psychomotor speed.

Abstract reasoning and executive Abstract reasoning and executive

controlcontrol

Verbal fluencyVerbal fluency

Verbal memory performance. Verbal memory performance.

Outcome and Suicide of Bipolar 1 and Outcome and Suicide of Bipolar 1 and Bipolar 2 Patients Bipolar 2 Patients ( Angest et al. Acta Psych. Scandi)( Angest et al. Acta Psych. Scandi)

Bipolar 1Bipolar 2Bipolar 2p-Valuep-Value

N1601606060

Recovered %Recovered %15151818

Recurrent %Recurrent %73736060

Chronic %Chronic %14141515

Suicide %Suicide %88660.005*0.005*

GAS (last GAS (last interval)interval)

606065650.03*0.03*

Brain and BipolarBrain and Bipolar

מצביעים על שינויים מצביעים על שינויים PETPETמחקרי הדמיה ב- מחקרי הדמיה ב- ממוקדים בזרימת הדם וצריכת הגלוקוז במוח:ממוקדים בזרימת הדם וצריכת הגלוקוז במוח:

PETPETמחקרי הדמיה ב- מחקרי הדמיה ב- מצביעים על שינויים ממוקדים מצביעים על שינויים ממוקדים

בזרימת הדם וצריכת הגלוקוז בזרימת הדם וצריכת הגלוקוז במוח:במוח:

מצביעים על שינויים ממוקדים PET מחקרי הדמיה ב- בזרימת הדם וצריכת הגלוקוז במוח באפיזודה מאנית .

Suseptibility Loci for BipolarSuseptibility Loci for Bipolar

Overlap with vulnerability to schizophrenia?Overlap with vulnerability to schizophrenia?

18p11.218p11.2

22q11-1322q11-13

GRK3. GRK3.

(Berrettini WH. Biological Psychiatry. 2000(Berrettini WH. Biological Psychiatry. 2000

Kelsoe et al. Proc. Natl. Sci. USA. 2001). Kelsoe et al. Proc. Natl. Sci. USA. 2001).

Psychosocial Therapy for Bipolar DisorderPsychosocial Therapy for Bipolar Disorder

Educate the patient about bipolar disorder.Educate the patient about bipolar disorder.

Foster acceptance of the illness and its Foster acceptance of the illness and its

treatment.treatment.

Encourage medication adherence. Encourage medication adherence.

Monitor mood symptoms daily.Monitor mood symptoms daily.

Promote daily routines and sleep/wake Promote daily routines and sleep/wake

cycles.cycles.

Psychosocial Therapy for Bipolar DisorderPsychosocial Therapy for Bipolar Disorder(Con`t)(Con`t)

Minimise interpersonal oversitmulation , Minimise interpersonal oversitmulation ,

notably significant conflict with caregivers.notably significant conflict with caregivers.

Use interpersonal problem-solving. Use interpersonal problem-solving.

Learn to spot early warning signs of new Learn to spot early warning signs of new

episodes.episodes.

Develop and implement relapse prevention Develop and implement relapse prevention

plans. plans.

Prognosis and ComplicationPrognosis and Complication

Drug Adherence Among Bipolar Patients Drug Adherence Among Bipolar Patients

59% of patients hospitalised for a major affective 59% of patients hospitalised for a major affective

episode are fully or partially noncompliant in the episode are fully or partially noncompliant in the

year following discharge. year following discharge.

Only 21%of patients on lithiume are continuously Only 21%of patients on lithiume are continuously

adherent to it. adherent to it.

Nonadherence is predicted by male gender, Nonadherence is predicted by male gender,

younger age, severe illness, substance misuse, younger age, severe illness, substance misuse,

and lack of family support.and lack of family support.

Factors Associated with Unstable MoodFactors Associated with Unstable Mood

Comorbidity ( Substance abuse, panic disorder, Comorbidity ( Substance abuse, panic disorder,

OCD).OCD).

Manic or mixed episodes. Manic or mixed episodes.

Psychosis at index episode.Psychosis at index episode.

Typical neuroleptics.Typical neuroleptics.

Use of antidepressants?Use of antidepressants?

Psychosocial stressors.Psychosocial stressors.

Noncompliance.Noncompliance.

Morbidity in Bipolar DisorderMorbidity in Bipolar Disorder

Dyslipidemias.Dyslipidemias.

Diabetes Mellitus.Diabetes Mellitus.

Cardiovascular illnesses.Cardiovascular illnesses.

Substance abuse.Substance abuse.

Tobacco dependenceTobacco dependence

Poor Nutrition. Poor Nutrition.

Characteristics of Pharmachological Hypomania/Mania

Less likely with SSRIs vs TCAs ( Peet 1994). “Milder” than spontaneous episodes? Euphoric with MAOI vs dysphoric with TCAs ( Himmelhoch et al. 1991)

Not always preventable with mood stabilizers ( Bottlender et al. 1998)

Adequate lithium level may be protective ( Jann et al. 1982)

Not caused by Atypical Antipsychotic ( Baker et al. 2003)

Thank You !!!Thank You !!!

Bipolar DisorderBipolar Disorder

1-2% of adult population1-2% of adult population

10-20% of all mood disorders. 10-20% of all mood disorders.

Clinical and genetically heterogenous.Clinical and genetically heterogenous.

40% of all cases go untreated !40% of all cases go untreated !

15-25% commit suicide. 15-25% commit suicide.

1998 International Barcelona 1998 International Barcelona “Consensus” on Bipolarity/ “Consensus” on Bipolarity/

Bipolar 1Mixed manic state ( 2 depressive symptoms)Bipolar 2 ( Hypomania >2 days)Somatic treatment induced hypo/mania

(Bipolar 3)Cyclothymic disorder (borderline

personality).Recurrent brief hypomania.

Symptoms Domains of BipolarSymptoms Domains of Bipolar

Bipolar Disorder

Manic Mood and Behaviour•Euphoria•Grandiosity•Pressure speech•Impulsivity•Excessive libido•Social Intrusiveness•Diminished need for sleep

Psychotic Symptoms•Delusions •Hallucinations.

Dysphoric or negative Mood and behavior•Depression•Anxiety•Irritability•Hostility•Violence or Suicide

Cognitive Symptoms•Racing thoughts•Distractibility•Disorganization•Inattentiveness.