Part I -- Bipolar Part I -- Bipolar BasicsBasics

Kurt Weber, PhDKurt Weber, PhDkurt.weber@snc.edukurt.weber@snc.edu

Mental Health America – Brown CountyMental Health America – Brown CountyBemis International CenterBemis International Center

St Norbert CollegeSt Norbert CollegeMay 13, 2008May 13, 2008

“Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.

“I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do.”

Kay Redfield Jamison, PhD, An Unquiet Mind, 1995, p 6

Purpose of today…Purpose of today…

Some foundation information that Some foundation information that mental health professionals and mental health professionals and “consumers” should know…“consumers” should know…

Bipolar disorderBipolar disorder formerly known as manic-depressive disorder brain disorder

causes unusual shifts in a person’s mood, energy, and ability to function

Some people alternate mania and depression, others have episodes of mostly one kind

Episodes vary in duration from days to years the symptoms of bipolar disorder are severe

damaged relationships poor job or school performance suicide

good newsgood news

treatable bipolar disorder can be treated, and

people with this illness can lead full and productive lives

Types of Bipolar Types of Bipolar DisordersDisorders

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder

Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder

When 4 or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder

Some people experience multiple episodes within a single week, or even within a single day

Rapid cycling tends to develop later in the course of illness and is more common among women than among men

demographicsdemographics Approximately 23 million Americans suffer

from bipolar disorder National Comorbidity Study-Replicated

(NCS-R) the lifetime prevalence of bipolar disorder is 51%

National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) lifetime prevalence of bipolar I disorder of 33% Native Americans have the highest incidence Asians and Hispanics have the lowest

World Health Organization (1990) bipolar disorder is the sixth leading cause of

disability worldwide among people 15-44 years old

Studies suggest that bipolar disorder clients will be fully symptomatic 8% of the time, and symptomatic 59% of the time

30% of bipolar clients have both manic and depressive episodes

32% have mixed manic and depression 22% have only manic episodes 10% have only mixed episodes

Depressive episodes in Depressive episodes in BDBD

Depression most frequent episode episodes last longer (254 weeks) than

manic episodes (55 weeks)

comorbiditycomorbidity

485% of bipolar clients will have an anxiety disorder

708% will have a personality disorder Suicidal ideation is also highly

associated with comorbid substance abuse

There is a strong association of suicide attempts and comorbid anxiety disorders

suicidesuicide

NIMH (2000) Suicide is a significant risk in bipolar

disorder, the highest of any psychiatric disorder at 20%

As many as 25-50% of clients will make a suicide attempt

Most suicidal ideation occurs during depressed or mixed episodes

features and subtypes features and subtypes (Mays)(Mays)

Bipolar I Bipolar II

Psychomotor retarded agitated or retarded

Sleep hypersomnia insomnia/hypersomnia

Suicide +++ ++++ Switching to mania hypomania Gender m = f f > m Prevalence 1% 1-2%

mixed episodesmixed episodes

50% of clients have mixed mania state of mind characterized by symptoms of

both mania and depression more common in bipolar children and

women may feel agitated, angry, irritable, and

depressed all at once combines a high activity level with

depression particular danger of suicide or self- injury

Rapid cyclingRapid cycling frequently recurring (4+ episodes/yr) treatment

resistant depression alternating with hypomanic/manic episodes

most commonly seen in female clients and with bipolar II disorder

15-25% of clients early onset common not known whether antidepressants can initiate

rapid cycling Variations include

ultra-rapid (1 day to 1 week) ultradian (<24 hours) continuous

gender issuesgender issues

no gender difference in the incidence of bipolar I

both have onset in puberty men may have a slightly earlier onset

Manic episodes equal frequencies among men and women

Women are more likely to be treated than men and receive treatment earlier in the illness (NESARC)

no evidence of difference in treatment responsiveness to mood stabilizers

Women…Women…

more frequent and more severe episodes of depression

more comorbidities anxiety, obesity, migraine, thyroid

greater relative increase in AODA and suicide

more rapid cycling and mixed states

Women with BD…Women with BD…

have a high risk of anovulatory disorders and polycystic ovary syndrome (PCOS)

metabolic condition that occurs in 7-15% of reproductive-aged women elevated androgens chronic anovulation insulin resistance elevated LDL with low HDL 3x risk of endometrial cancer

pregnancypregnancy 50% of women with bipolar disorder have the

onset of symptoms within 1 year of menarche (Mays)

however, most are not accurately diagnosed until they have had a child and developed postpartum depression 67% of bipolar women will have postpartum

depression 33-50% of postpartum depressions begin during

pregnancy and worsen postpartum Suicide risk for the new mother is 70x higher

during baby's first year of life if mother has postpartum depression

risk factors and risk factors and warning signs for PPDwarning signs for PPD

Previous postpartum depression (50-75%) Having a mood disorder - bipolar disorder

gives 25% risk Single motherhood Stressful events Substance abuse Mood disorder symptoms during

pregnancy

No psychotropic drugs are known to be safe for pregnancy or breastfeeding

however, bipolar disorder itself is also dangerous for pregnancy due to substance abuse poor self-care suicide

medication for bipolar reproductive-age females recall that 50% of pregnancies in the US are

unplanned

CausesCauses

“…has anyone found the true cause of bipolar disorder? It would be wonderful to say that X or Y was the cause, but the answer is not that simple”

biopsychosocial modelbiopsychosocial model

Most scientists believe that mental illnesses are caused by a combination of several factors working together

In bipolar disorder, these factors are usually divided into biological and psychological causes

In plain English, the main reasons mental illness develops are physical (biological) and environmental

genetic originsgenetic origins if one parent has bipolar illness, chances are 1:7

that their child will however, there are relatively few studies of the

heritability of bipolar disorder why?

numerous subtypes of the disorder categorical distinction between major depression and

bipolar disorder (the presence of one manic episode) that confounds all genetic studies of depression since the disorders seem to be clearly related at some level

so, what is inherited?so, what is inherited?

neurotransmitter functioning! neurotransmitter system has

received a great deal of attention as a possible cause of bipolar disorder

some studies suggest that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the cause

other studies indicate that an imbalance of these substances is the problem the specific level of a neurotransmitter is

not as important as its amount in relation to the other neurotransmitters

still other studies have found evidence that a change in the sensitivity of the receptors on nerve cells may be the issue

sounds like…sounds like…

researchers are quite certain that the neurotransmitter system is at least part of the cause of bipolar disorder

further research is still needed to define its exact role

Typical course of BD Typical course of BD (Mays)(Mays)

median age of onset is 19 median age of onset is 19 first episodefirst episode

most likely to be mania in males, depression in femalesmost likely to be mania in males, depression in females Severe psychosocial stressors appear more Severe psychosocial stressors appear more

important in the first episode than latter important in the first episode than latter episodes, i.e. there is “kindling” to stress – each episodes, i.e. there is “kindling” to stress – each episode requires less stress to occurepisode requires less stress to occur

90% of clients who have one manic 90% of clients who have one manic episode will have anotherepisode will have another

Four years after remission of the first Four years after remission of the first episode, 60% had relapsed episode, 60% had relapsed

Without treatment, bipolar clients will Without treatment, bipolar clients will have 9-10 episodes in their lifetime, and have 9-10 episodes in their lifetime, and each episode will last 1-4 months each episode will last 1-4 months

The interval between episodes will The interval between episodes will diminish (kindling to episodes) diminish (kindling to episodes)

Episodes will become more treatment Episodes will become more treatment resistantresistant

The course of BD (NIMH)The course of BD (NIMH)

Episodes of mania and depression typically recur across the life span

Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms

A small percentage of people experience chronic, unremitting symptoms despite treatment

without treatment…without treatment… natural course of bipolar disorder tends to

worsen over time, a person may suffer more

frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared

proper treatment can help reduce the frequency and severity of

episodes help people with bipolar disorder maintain

good quality of life

Children and Children and adolescents?adolescents?

Both children and adolescents can develop bipolar disorder more likely to affect the children of parents who

have the illness children and young adolescents with the illness

often experience very fast mood swings between depression and mania many times within a day

Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated

Mixed symptoms also are common in youths with bipolar disorder

Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms

NIMHNIMH Bipolar disorder in children and

adolescents can be hard to tell apart from other problems that may occur in these age groups irritability and aggressiveness

can indicate bipolar disorder can be symptoms of

attention deficit hyperactivity disorder conduct disorder oppositional defiant disorder other types of mental disorders more common among

adults such as major depression or schizophrenia Drug abuse also may lead to such symptoms

of course…of course… For any illness, however, effective

treatment depends on appropriate diagnosis

Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional

Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist

ImagingImaging New brain-imaging techniques allow researchers to

take pictures of the living brain at work, to examine its structure and activity

without the need or surgery or other invasive procedures magnetic resonance imaging (MRI) positron emission tomography (PET) functional magnetic resonance imaging (fMRI)

the brains of people with bipolar disorder may differ from the brains of healthy individuals

may develop a better understanding of the underlying causes of the illness

may be able to predict which types of treatment will work most effectively

NIMH clinical studiesNIMH clinical studies real-world studies Unlike traditional clinical trials

multiple different treatments and treatment combinations

include large numbers of people with mental disorders living in communities throughout the US and receiving treatment across a wide variety of settings

Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies

Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

the whole pointthe whole point

improve treatment strategies and outcomes evaluate how treatments influence other

important, real-world issues such as quality of life ability to work social functioning

assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans