Bipolar disorder: A new horizon

By

Prof. Dr. Hni Hamid DessokiActing Dean, Faculty of Applied Health Sciences

Prof. of Psychiatry DepartmentBeni Suef University

Supervisor of Psychiatry Department, El-Fayoum University APA member

Dr. Ahmed Abd elaziz EzzatLecturer of psychiatry- faculty of medicine- Bani Suif

University

Dr. Mohammed Sultan Lecturer of psychiatry- faculty of medicine- Elfayoum

University

Objectives

• To know about subtle bipolar disorder

• To know about bipolar disorder in special

population

• To learn the different lines of treatment in

guidelines

for different episodes of bipolar disorder.

Prof. Hani Hamed Dessoki, M.D.Psychiatry

Prof. Psychiatry

• Acting Dean, Faculty of Applied Mental Health sciences

Beni Suef University

Supervisor of Psychiatry Department

El-Fayoum University

APA member

Hidden Bipolar Disorder

Agenda• Introduction

• Epidemiology

• Coast

• Hidden bipolar disorder

• Challenges

• Conclusion

راب الوجدانىطاالض

تسلم يا غصن الخوخ يا عود الحطب

يجي الربيع تطلع زهورك عجب

و انا ليه بيمضى ربيع، ويجى ربيع

"..!!قلبى حتة خشب"و لسه برضك

"أجهلك"إنسان أيا إنسان ما

فى الكون و ما " أتفهك"ما

"أضألك"

شمس ، و قمر ، وسدوم ، و

ماليين النجوم

مخلوقة " موهوم"و فاكرها يا

..!!لك

"حزين"دخل الربيع يضحك لقانى

"لم قلت مين"نده الربيع على إسمى

حط الربيع أزهاره جنبي و راح

"..!!للميتين"و ايش تعمل األزهار

Can you diagnose bipolar easily?????

Digestive

disorder (6%) Musculoskeletal

disorders (4%)

Endocrine (4%)

Neuropsychiatric

disorders (28%)

Cancer (11%)

Cardiovascular

disease (22%)

Sense organ

impairment (10%)

Other non-communicable

diseases (7%)

Respiratory

disease

(8%)

Schizophrenia

Bipolar disorder

Dementia

Substance-use andalcohol-use disorders

Other mental disorders

Epilepsy

Other neurological disorders

Other neuropsychiatric disorders

MDD

2%

10%

2%

2%

4%

3%

1%

2%

3%

Prince et al. Lancet 2007;370(9590):859–877

Contribution (%) by different non-communicable diseases to

disability-adjusted life-years (DALYs) worldwide in 2005

Psychiatric disorders – underestimated and disabling conditions

Percent of misdiagnosis in bipolar disorder

• Percent?

• Other possibilities?

Post test Question 2

The most commonly diagnosed personality disorder in

bipolar disorder is

1. Avoidant Personality Disorder

2. Obsessive-Compulsive Personality Disorder

3. Borderline Personality Disorder

4. Histrionic Personality Disorder

5. Schizotypal Personality Disorder

Epidemiology • Bipolar I: range from 0.5% to 7.5%.

Bipolar II > bipolar I

• Frequently misdiagnosed as recurrent major depression

• The estimated life time prevalence of bipolar spectrum is as high

as 4%.

• Men = female

• Bipolar II : female > male

• The majority of cases have an onset before the age of 30.

Cost of Bipolar Disorder

BAD is not only a chronic, severe psychiatric disorder,but also expensive to treat and expensive to society.

WHO report , BAD ranked :• 6th in the top 10 causes of disability worldwide in the 15-to 44-year age

group.

• 3rd among mental illnesses after unipolar major depression andschizophrenia as the source of disease burden in established marketeconomies. (Murray & Lopez, 1996)

Costs of Bipolar Disorder

Direct Cost

Cost of Misdiagnosis

Cost of Comorbidity

Indirect Cost

Psychosocial Consequences of Bipolar Disorder

• Greater unemployment rate (6 times greater than US average)

• Negative impact on relationships of patients with

bipolar disorder

• 38-68% disruption in family relationships

• 49% marital difficulties

• 73% job and school-related problems

• Higher divorce rate (vs general population)

• 23.5% of patients with bipolar disorder (compared

with 11.95%)

*Average in female with onset at age 25.1. Kogan JN, et al. Bipolar Disord. 2004;6(6):460-469.

2. Albanese MJ, Pies R. CNS Drugs. 2004;18(9):585-596.

3. Matza LS, et al. Drug Benefit Trends. 2004;16(9):476-481. 4. Morselli PL, et al. Bipolar Disord. 2004;6(6):487-497.

5. Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64(2):161-174.

Bipolar disorder is multidimensional

Subsyndromal Mania (Hyperthymia)

Mania

Depression

Maintenance

Subsyndromal Depression(Dysthymia)

Hypomania

Young AH et al. Practical Management of Bipolar Disorder, Cambridge University Press, 2010.

Comorbidity: alcohol

Mixed

5.9%9.3%

31.9% 52.7%

Frequency of symptoms

n=146, bipolar I; n=86, bipolar II

Follow up: a12.8 years; b13.4 years Judd et al 2002; 2003

Time asymptomatic

Time depressed

Time manic / hypomanic

Time cycling / mixed

2.3%1.3%

50.3% 46.1%

Bipolar I disordera Bipolar II disorderb

Irrespective of the bipolar subtype, patients spend the majority

of their time in depressed state

*Akiskal HS, et al. J Affect Disord

2000 Sep;59 Suppl 1:S5-S30

Bipolar Disorder:Subtypes

• Mixed Mania

• Simultaneous mania and depression

• May be > 40% prevalence of episodes*

• Rapid Cycling

• > 4 episodes/year

• Bipolar II

• Hypomania (< 4 days duration) alternating with depression

• Secondary Mania

• e.g., drugs, tumor, CVA, lupus, endocrine, infectious, Huntington’s, Wilson’s

Problems of bipolar disorder

• Recurrent long-term illness

• Misdiagnosis

• Suicide risk:

• At least 25% attempt suicide

• Suicide rate: 11-19%

• 25-50% suicidal ideation in mixed mania

• Co morbidity complications

• Psychosocial consequences

Cost of Misdiagnosis; the High Rate of Misdiagnosis

Most frequent misdiagnosisUnipolar depression—60%

Average of 3.5 misdiagnoses and 4 consultations before an accurate diagnosis

was made

2000 NDMDA Bipolar Survey1*

35% of patients were symptomatic for 10 years before correct diagnosis made

10+ years

*(N=600) patients with bipolar disorder; not all patients responded to all survey questions.NDMDA=National Depressive and Manic Depressive Association.

1. Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64(2):161-174.

69%Misdiagnosed

Misdiagnosis is common in bipolar disorder

• ~70% of patients are initially misdiagnosed

• Most frequent misdiagnoses:

• Major depressive disorder – 60%

• Anxiety disorder – 26%

• Schizophrenia – 18%, schizoaffective disorder – 11%

• Borderline/antisocial personality disorder – 17%

• Substance abuse or dependence – 14%

• Bipolar-II identified late after initial unipolar depression diagnosis

1Hirschfeld et al. J Clin Psychiatry 2003; 2Manning et al. Compr Psychiatry 1997

14%

46%

6%

41%

0

20

40

60

80

Patients With Bipolar Disorder General Population

Alcohol abuseSubstance abuse

Prevalence of Bipolar Disorder and Substance Abuse

1. Levin FR, Hennessy G. Biol Psychiatry. 2004;56(10):738-748.2. Regier DA, Farmer ME, Rae DS, et al. JAMA/1990;264:2511-2418.

% P

reva

len

ce

Ra

te

100

N=20,291

Clinical Features that predict Bipolarity

Early age of onset

Psychotic depression before age 25

Postpartum, seasonal onset

Rapid onset

More than 5 episodes of depression

Cyclothymic, hyperthymic personality traits

Switching or lack of efficacy with antidepressants

Mixed depressive states

Family history of bipolar disorder or several generations with depression

Reverse vegetative symptoms (overeating, oversleeping)

“Pseudo-Unipolar” Forms

• Bipolar II (major depressive and hypomanic episodes).

• Bipolar III (major depressive episodes and antidepressant-associated hypomania).

• Bipolar IV (major depressive episodes superimposed on hyperthymic temperament).

• Other Candidates: Recurrent depressions with abrupt onset and offset; seasonal depressions, even without discernible hypomanic episodes.

Okasha 2008

Other Conditions Considered for Inclusion in the Bipolar Spectrum

• Episodic obsessive-compulsive forms.

• Periodic states of irritability.

• Acute suicidal crises in the absence of clear-cut affective symptoms.

• Cyclical neurasthenic or sleep complaints.

• Severe brief recurrent depressions.

• Impulse-ridden behaviours in the realms of control of aggression, gambling and paraphilias.

Okasha 2008

Conditions whose Boundaries with Bipolar Disorder are Regarded as

Uncertain

• Schizoaffective disorder

• Borderline personality disorder

• Substance use disorders

• Adult-attention-deficit/hyperactivitydisorder

Okasha 2008

manic

Suicide risk in bipolar disorder

• Suicide is a particular risk in patients with bipolar disorder

• Completed suicide occurs in 10–15% of patients with bipolar I

disorder1

• 30–60 fold higher than in the general population2

• Risk of suicide is particularly high during the first years after

diagnosis1

• Suicidal ideation or attempts in individuals with bipolar disorder

are more likely to occur during depressive or mixed episodes1

1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. APA,

2000;2Baldessarini et al. CNS Spectr 2006

Steps to improve diagnosis

Leverich & Post 1998; Hirschfeld et al 2000; Benazzi 2002

Accurate history tracking

Close monitoring of mood changes

Systematic probing for manic and depressive symptoms

Look for indicators of bipolarity

Key Challenges

Magdy Wahib |21 March 201432

Unmet Medical needs

GPs delayed diagnosis

Cross

diagnosis of

Bipolar

StigmaSelecting the right

treatment option

From IV to 5

DSM-522 Chapters

DSM-IV17 Chapters

22 Chapters:

1. Neurodevelopmental Disorders

2. Schizophrenia Spectrum & Other

Psychotic Disorders

3. Bipolar & Related Disorders

4. Depressive Disorders

5. Anxiety Disorders

6. Obs-Compulsive & Related

7. Trauma- & Stressor-Related

8. Dissociative Disorders

9. Somatic Symptom Disorders

10.Feeding & Eating Disorders

11.Elimination Disorders

12.Sleep/Wake Disorders

13. Sexual Dysfunctions

14. Gender Dysphoria

15. Disruptive, Impulse-Control &

Conduct Disorders

16. Substance Related & Addictive

Disorders

17. Neurocognitive Disorders

18. Personality Disorders

19. Paraphilic Disorders

20. Other Mental Disorders

21. Medication-induced

Movement…Med Effects

22. Other Conditions (v codes)

• The first change in the DSM-V that will affect people

with bipolar disorder is the categorization.

• Instead of being classified as a mood disorder,

bipolar disorder is now in the category of “bipolar

and related disorders.”

• Depressive disorders are now in their own category,

instead of being in the mood disorder category with

bipolar disorder.

Changes to Bipolar Disorder Treatment in the New

DSM-5

• Mixed episodes have also been eliminated. Instead of

labeling an episode as mixed, the provider will now

have the option to specify a manic or depressive

episode with a certain specification, “with mixed

features” attached to it.

Changes to Bipolar Disorder Treatment in the New

DSM-5

• A bipolar 2 diagnosis can now include episodes with

mixed features.

• According to past editions of the manual, a person

who had mixed episodes would not be diagnosed

with bipolar 2. This change has made it easier to put

people in less severe categories than bipolar 1.

Changes to Bipolar Disorder Treatment in the New

DSM-5

Face the Facts

• Bipolar disorder is serious and relatively common.

• Bipolar disorder is a life long disease with

unpredictable episodes.

• Bipolar disorder is a progressive disease causing

impairment in neuroplasticity /cellular resilience with

systemic consequences.

Future goals

Earlier diagnosisAccurate

diagnosis

Bipolar Disorder: Treatment Challenges

• Can be difficult to diagnose

• Complicated to treat

• Polypharmacy is a standard of care

• High morbidity and mortality

• Recurrent illness in >90% of patients care

• Functional recovery often lags behind symptomatic

recovery

• Recurrent episodes may lead to progressive deterioration in

functioning

• Number of episodes may affect subsequent treatment

response and prognosis

1. McElroy SL and Keck PE, Biol Psych 2000; 539-557.

2. Thase MD and Sachs GS, Biol Psych 2000; 558-572.

3. APA Bipolar Guidelines Am J Psych 2002;159 (Suppl4):1-50.

4. Tohen et al. Arch Gen Psych 1990:47:1106-1111.

5. Dion G et al. Hosp and Community Psych 1988;39(6);652-657.

6. Goodwin FK. Jamison KR: Manic Depressive Illness 1990.

7. Keck PE Jr, et al. Am J Psych 1998; 155(5):646-652.

8. Tohen et al. Biol Psych 2000; 48:467-476.

9. Tohen et al. Am J Psych 2003; 160:2099-2107.

Relapse is very Common

Euthymia

Symptoms

Syndrome

Remission

Response

Recovery – 6 months

Continuation

treatmentMaintenance

treatment

Relapse Recurrence

Potential Predictors of Relapse

• Number of past episodes and interval

between episodes

• Stressful life events

• Medication treatment

• Psychodemographic/psychosocial factors

• Clinical factors

• Substance abuse

Altman S, et al. J Psychiatr Pract. 2006;12(5):269-282.

Evaluation of Mania

• Young Mania Rating Scale items*:

• Elevated mood

• Increased motor activity

• Sexual interest

• Sleep

• Irritability

• Speech

• Language

• Content

• Disruptive/aggressive behavior

• Appearance

• Insight

*Possible Score = 0-60

Take Home Message

• Can you predict bipolarity??????