Ch7: Bipolar Disorders Medications

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ANTI-DEPRESSANT ERA

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•Antidepressants for adults constitute a multibillion dollar market globally

•in the last five years, prescriptions for children have increased at an exponential rate

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General facts

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•When antidepressants were introduced 40 years ago ( MAOIs ), medications were used primarily to treat depression

•currently, antidepressants are used to treat a variety of disorders, including anxiety, impulsive aggression, and chronic pain

•current literature and practice indicate that all the different classes of antidepressants are about equally effective

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good news/bad news

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-Good –one half to two thirds of depressed clients on any antidepressant respond positively to it; half may progress into full remission within six months of treatment; antidepressants seem to significantly reduce relapse.

-Bad –many responders on meds never reach full remission; 20-30% tend to "poop out"or wear off after about 18 months on antidepressants

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Clinically, "normal" mood is referred to as

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-a state of Euythmia

-concept has two different meanings: a clinical state where one is neither manic or depressed; tranquil or joyous state of mind

-mood assessment is the practice of understanding mood state and introducing pharmacologic agents to keep clients’moods within parameters clinically described as "normal"or "euthymic"

-elevated mood above normal is not described as pathological on the DSM IV, TR, until it reaches Hypomanicstatus

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Depression: Adolescent to YoungAdult

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History of Classification labels used to identify Depression

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•Melancholic depression

•Severe depression

•Reactive/situational depression

•Neurotic depression

•Personality disorder w/depression

•Dysthymia

•Disruptive mood dysregulation

•Persistent Depressive Disorder

•Major Depressive Disorder

•Premenstrual Dysphoric Disorder

•Substance/Medication Induced Depressive Disorder

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The Pendulum Metaphor of Mood Disorder

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Characteristics of Mood Disorder

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-Major depression, also called unipolardepression is characterized by recurring episodes of dysphoriaand negative thinking that also reflected in behavior.

-Bipolar disorder is also cyclic but moods swing from depression to mania over time

-Mood disorders are among the most common forms of mental illness currently

-Mood disorder is so severe that the individual withdraws from life and social interactions

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Characteristics of Mood Disorder 2

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•If left untreated, most episodes of unipolar disorders improve in about six to nine months, however reoccur throughout life often increasing in frequency and in intensity in later years.

•Later episodes of depression are more likely to occur without the influence of psychosocial stress

•Mania rarely occurs alone but rather alternates with periods of depression to form bipolar disorder

•The primary symptom of mania is elation

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Common Vegetative Symptoms in Major Depressive Disorder

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Sleep disturbance (early morning waking, frequent awakening, occasional hypersomnia)
Appetite disturbance (decreased or increased appetite with accompanying weight fluctuations)
General fatigue
Decreased sex drive
Restlessness, agitation, or psychomotor retardation
Diurnal variations in mood (usually feeling worse in the morning)
Impaired concentration and forgetfulness
Pronounced anhedonia (loss of pleasure in most or all things)

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Characteristics of Mania

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•Individuals with mania typically feel faultless, full of fun, and bursting with energy: need for sleep is significantly reduced, tend to be more talkative than usual, and experience racing thoughts and ideas.; tend to make impulsive decisions in a grandiose way and have unlimited confidence; becomes involved in activities that have a high potential for negative consequences such as foolish business investments, wreckless driving, buying sprees, or sexual indiscretions
•Incidence of bipolar disorder is roughly the same in men and women; time of onset is typically between 20-30 years of age and episodes continue throughout the life span

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What is Bipolar Disorder?

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•It is cyclic brain disorder with recurrent fluctuations in mood, energy, and behavior.
•First described as ‘Manic-Depressive Illness by Kraeplin in 1898
•Prevalance 1-4% in population 15-20% suicide rate
•First episode is usually mania in males, depression in females
•Age of Onset: average 20 years, appearance of symptoms in adolescents is not uncommon

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Myths of Bipolar Disorder

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•Uncommon disorder
•Presents mostly as mania
•Onset usually at middle age
•Lithium-responsive disease with a full restoration of functioning
•Lack of comorbidity

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Unipolar VS. Bipolar

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Uniporlar

•Diagnosed when there are problems of depressed mood, but there is no reported history of any manic episodes, hypomanic episodes, or mixed episodes

Bipolar

•Diagnosed when there is a presence of at least one/any manic, hypomanic, or mixed episode.
•Usually also involves the presence of one or more Major Depressive Episode

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Diagnosing Depression

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•Differentials
–Medical Rule outs-UTI, drug interactions
–B12, Folate, Thyroid, Testosterone
•Urinary Tract Infections ( cause depression and psychosis)
•Low testosterone in men makes men depressed
–Chronic pain not adequately treated
–Delirium/Mild Neurocognitve Disorder
–Parent/child conflict
•PHQ,CES or Geriatric Depression Scale
–Useful identifying and monitoring progress

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Diagnosis: What are the Indicators of Bipolar Disorder?

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•Indicators of BD
-Family history, ADD induced (hypo)mania, hyperthymic personality prior to depression, early age at onset, brief episodes of illness
-Hypersomnia, hyperphasia, fatigue, sensitivity to rejection during depressive episode
-May also have: psychotic features, seasonal pattern, severe PMS, abrupt onset and end
•Antecedents to mania
-Increased energy, elevated mood, disinhibition, racing thoughts

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Bipolar Disorder

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•Considerable psychiatric comorbidity
•Substance abuse
•Medical disorders
•Medical “risk factors” (smoking, obesity)
•“Metabolic syndrome” is the presence of 3 or more of the following characteristics:
•Abdominal obesity (waist circumference)
•Hypertriglycerdemia
•Low high-density lipoprotein cholesterol (HDL-C)
•High Blood Pressure
•Fasting hyperglycemia

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Longitudinal Assessment of Bipolar Disorder

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Presentation in Clinical Practice: Bipolar I

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Presentation in Clinical Practice: Bipolar II

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Rapid Cycling

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•Frequency of cycled less than three days
-Occurs around four times a month
-More rapid mood switch (2-3 days or less)
-Can be linked to ultradian cycle-up and down in a day
•Risk of developing rapid cycling
-Higher in women (29.6%) than men (16.5)
-Greated BBP-II (30.3%) than BP-I (6.0%)
•Episode at onset normally depressive
•May have periods of years without rapid cycling
•Comorbidity with anxiety disorders and substance abuse especially in males BP-I

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Diagnostic Issues for Depression:Is it Unipolaror Bipolar?

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•Compared with unipolar, depression in BPD patients associated with:
-Mood liability, motor retardation, greater time spent sleeping (more insomnia in unipolar depression) weight loss, agitation, sudden onset, early age, psychosis, family history.
•Patients with BPD had higher scores on:
-Extraversion, novelty seeking, less judgmental
•Many people (especially BP-II) seek treatment when depressed and don’t recall hypomania, or perceive symptoms as abnormal.

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The Mood Disorder Questionnaire (MDQ)

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•Validated for adolescents and adults
•Very accurate for ruling OUT bipolar
•Some problems w/false positives
•Tips for Increasing Accuracy
–Ask only about clean and sober time
–Differentiate decreased need for sleep and being unable to sleep (tired the next day?)
–What would a significant other say?
–Less reliable with patients with ADHD

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Major Goals for Treatment in Bipolar Disorder

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•Prevent future episodes of mania
•Prevent mixed episodes
•Prevent Episodes of Depression
•Diminish the presence of subsyndromal depression over extended periods of time
•Improve functioning
•Decrease morbidity and mortality

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Why Treat Bipolar Disorder with Psychotherapy?

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•Increase adherence to medication
•Enhance social and occupational functioning
•Enhance capacity to manage stressors in the social-occupational milieu
•Enhance protective effects of family and other social supports
•Decrease denial and trauma and encourage acceptance of the disorder
•Decreased the risk of recurrence

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Empirically Tested Psychotherapies for Bipolar Disorder

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•Cognitive Behavioral Therapy (CBT)
•Psychoeducation (Group)
•Family Focused Therapy (FFT)
•Interpersonal and Social Rhythm Therapy (IPSRT)

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Reasons for Nonadherance

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•Forgetting to take dose
•Side effects
•Insufficient illness knowledge
•Family/friends who advise against medication
•Access problems
•Alcohol and Drug Use

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Interventions to Improve Adherance

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•Most effective interventions only lead to small improvement in adherence or outcomes
–More convenient care
–Reminders
–Self-monitoring
–Reinforcement
–Counseling
–Family Therapy
–Psychological Therapy
–Crisis Intervention
–Telephone Follow-up

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Bipolar Maintenance: General Management

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•Maintain medication
–Educate on chronicity of disorder
–Help establish routine for taking medication
•Maintain psychoeducation and psychotherapy
–Include caregiver psychoeducation
•Monitor for and address adverse effects
•Encourage regular physical and social activity
•Encourage regular sleep pattern
•Address interpersonal impairment
–Neurogonitive, difficulty with sustained attention
–Sleep disturbance

•Train to monitor for prodromal symptoms
–Change in motivated activity, sleep cycle, impulsivity or interpersonal behavior
–Change in affect (usually later in prodromal stage)
–Usually consistent within individual
•Train to address prodromal symptoms
–Small medication adjustment
–Change in daily routine
–Stress reduction
–Increase in social interaction

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Summary (BIPOLAR)

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•The evidence base for the treatment and maintenace of bipolar disorder depression is relatively weak, and practice guidelines differ
•The 3 agents with the most evidence of efficacy or bipolar depression are quetiapine, oalnzapie-fluoxetine, and lurasidone
•More agents have evidence of preventing manic and/or depressive relapse
•Patient and family education are integral, particularly for being vigilant for and addressing prodromal symptoms

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Drug Treatment for Bipolar Disorder

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•Lithium Carbonate is treatment of choice
•One to two weeks of lithium use eliminates or reduces symptoms in approximately sixty to eighty percent of manic episodes without causing depression.
•Lithium is less effective in terminating episodes of depression, so it is often administered with a TCA or a other anti depressant drug
•Treatment of bipolar disorder with a mood stabilizer is typically life long.
•Lithium is not metabolized but is it excreted by the kidney in its intact form
•Typical medications for bipolar disorder include: Carbamazipine Tegretol, valporate (depekote), Topiramate (topamax) and Tiagabine (gabitil).