Part I -- Bipolar Basics

1. Part I -- Bipolar Basics Kurt Weber, PhD kurt.weber@snc.edu Mental Health America – Brown CountyBemis International Center St Norbert College May 13, 2008

2. “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.

3. “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

4. Purpose of today… • Some foundation information that mental health professionals and “consumers” should know…

5. Bipolar 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

6. good news • treatable • bipolar disorder can be treated, and people with this illness can lead full and productive lives

7. Types of Bipolar Disorders • 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

8. demographics • 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

9. 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

10. Depressive episodes in BD • Depression • most frequent episode • episodes last longer (254 weeks) than manic episodes (55 weeks)

11. comorbidity • 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

12. suicide • 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

13. features and subtypes (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%

14. mixed 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

15. Rapid 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

16. gender 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

17. 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

18. 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

19. pregnancy • 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

20. risk factors and warning 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

21. 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

22. Causes • “…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”

23. biopsychosocial 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

24. genetic 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

25. 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

26. 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

27. 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

28. Typical course of BD (Mays) • median age of onset is 19 • first episode • most likely to be mania in males, depression in females • Severe psychosocial stressors appear more important in the first episode than latter episodes, i.e. there is “kindling” to stress – each episode requires less stress to occur

29. 90% of clients who have one manic episode will have another • Four years after remission of the first episode, 60% had relapsed • Without treatment, bipolar clients will have 9-10 episodes in their lifetime, and each episode will last 1-4 months • The interval between episodes will diminish (kindling to episodes) • Episodes will become more treatment resistant

30. 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

31. 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

32. Children and 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

33. NIMH • 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

34. 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

35. Imaging • 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

36. NIMH 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)

37. the 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