How common?

1. Bipolar Disorders in Primary CareJanuary 29, 2013Jennifer Vincent, MDGeneral, Child and Adolescent Psychiatry

2. How common? • Until recently it was believed that no more than 1% of the population has bipolar disorder. • International data indicate a higher prevalence of up to approximately 5% • About as common as ADHD in children and adolescents (3-5%) • Less common than hypertension (20+%) • More common than colon CA in the US (<3%)

3. How deadly? • Individuals with severe and persistent mental illness have an increased risk of heart disease, diabetes, cancer, tobacco-related illnesses and stroke • Tobacco use double that of general population • Bipolar meds contribute • Suicide rate approx 13% (occurring primarily in depressive and mixed episodes) • Life expectancy at birth reduced by 8-11 years in a recent British study (Chang et al, 2011)

4. Suicide in BD: • Occurs almost exclusively during depressive or mixed episodes • Highest risk is first year after diagnosis • Baldessarini et al, CNS Spectrums 2006

5. How costly? “Bipolar disorder has been deemed the most expensive behavioral health care diagnosis, costing more than twice as much as depression per affected individual” -Centers for Disease Control and Prevention

6. Diagnostic issues

7. Have a low threshold for screening in depressed patients • All patients presenting to primary care with depression should have a one-time screen for BD • A one-time screening program for BD, using the Mood Disorders Questionnaire, when patients first present with a major depressive episode can reduce health care costs to managed care plans • Menzin et al, J Clin Psychiatry, 2009 Sep

8. Conversely, bipolar disorder is overdiagnosed • 700 psychiatric outpatients who had been diagnosed with BD by a health care professional • less than half met criteria when reassessed with a Structured Clinical InterviewZimmerman et al, J Clin Psychiatry, 2008 May

9. In psychiatric outpatients overdiagnosed with bipolar disorder: -greater number of Axis I diagnoses in general, Major Depressive Disorder in particular -greater number of Axis II diagnoses in general, Borderline Personality Disorder in particular Zimmerman et al, J Clin Psychiatry, 2008 May

10. Bipolar Mimic #1: Borderline Personality Disorder • BD = distinct episodes of uncharacteristic mood and behavior • Borderline PD = mood lability, irritability and negative affect are enduring core characteristics which may wax and wane, but do not follow an episodic course

11. A particular confound is the efficacy of some medications for Borderline Personality Disorder • Mood stabilizers reduce mood lability, irritability and impulsivity regardless of diagnosis • Therefore response does not equal BD diagnosis

12. Bipolar Mimic #2: Substance Use Disorders • Many patients with Substance Use Disorders who are diagnosed in the community with bipolar disorder may not actually meet criteria for BD • In one study of patients admitted to a dual diagnosis unit for Substance Use Disorder and BD, only 33% (28/85) actually met BD criteria in a retrospective review • Goldberg et al, J Clin Psychiatry 2008

13. Inability to confirm bipolar diagnoses in Substance Use Disorders most often from: • insufficient period of abstinence for assessing mood symptoms • insufficient number of symptoms for mania/hypomania • insufficient duration of mania/hypomania • Goldberg et al, J Clin Psychiatry 2008

14. Bipolar Mimic #2: Substance Use Disorders • Patients not meeting criteria were most often presumed to have bipolar disorder solely on the basis of the presence of mood instability • This had little predictive value for DSM-IV bipolar diagnoses. Goldberg et al, J Clin Psychiatry 2008

15. The problem of self-report Attempts to establish a history of mania/hypomania solely on the basis of patient reports can lead to • underdiagnosis • overdiagnosis

16. The problem of self-report • Patients often have difficulty accurately remembering episodes of mania • Patients with chronic depression have trouble distinguishing between euthymia and elevated mood • Under-report or underestimate the role of substances, especially stimulants such as cocaine, in producing manic symptoms

17. The problem of self-report Therefore, supplemental information from collateral sources such as family members and friends is essential to establishing the diagnosis.

18. Mood Disorders Questionnaire • Many false positives are due to Borderline Personality Disorder • Clarify if positive screen is temporally related to substance use

19. “Life Charting” • Simpler is better • Most helpful when course is long and confusing • Columns with month/year or age, medications, moods, important stressors • Requires clinician assistance—not a realistic “take-home” project

20. After the Diagnosis…

21. Patient Education • The ability to understand and retain information will be affected by • An active mood episode • Medication effects (sedation, cognitive impairment) • Anxiety over the diagnosis • Information overload

22. Patient Education • Acceptance by patient and family of the diagnosis and need for treatment may take time and repetition • Education should be an ongoing process as facts about BD and its treatment are gradually introduced • Printed and online material can be helpful

23. Patient Education:Websites • http://www.dbsalliance.org • Depression and Bipolar Support Alliance • Active community of support and education • List of DBSA-reviewed books for sale on Amazon • http://www.nimh.nih.gov/ • National Institute of Mental Health

24. Patient Education: Memoirs • “An Unquiet Mind: A Memoir of Moods and Madness”, Kay Redfield Jamison, PhD • “Touched with Fire”, Kay Redfield Jamison, PhD • “Call Me Anna”, Patty Duke (Astin) • “A Brilliant Madness: Living with Manic Depressive Illness”, Patty Duke (Astin) and Gloria Hochman • “Daughter of the Queen of Sheba: A Memoir”, Jacki Lyden (NPR correspondent)

25. Patient Education:Self-help texts “The Bipolar Disorder Survival Guide, Second Edition: What You and Your Family Need to Know” • by David J. Miklowitz PhD • *caveat: have not read*

26. Promote treatment adherence • Ambivalence about treatment often shows as poor adherence • Causes include • Lack of insight about having a serious illness • Reluctance to give up hypomania or mania • Concern about overmedication or side effects • Concern about loss of creativity • Concern about cost

27. Promote treatment adherence • Set a precedent of open discussion of such issues prior to and throughout treatment • Maintain a tone of optimism, eg: • Stress that each medication will be on a trial basis; the decision to continue will ultimately be theirs • Inform that many side effects can be corrected with careful attention to dosing, scheduling, and medication formulation

28. Promote mood and sleep hygiene • Stressors commonly precede episodes in all phases; suggest steps to anticipate and/or minimize • Disrupted sleep-wake cycles may specifically trigger manic episodes, including crossing time zones or shift work • Regular patterns for daily activities, including sleeping, eating, exercise

29. Identify “herald symptoms” • Early markers of relapse consistent across episodes for an individual • Help patient and family/friends recognize early signs and symptoms of mania and depression

30. Treatment

31. STEP-BD:Systematic Treatment Enhancement Program for Bipolar Disorder • large naturalistic study (N = 4,360) funded by NIMH initiative to learn about effective treatments for serious mental illness • Similar to STAR-D for depression

32. STEP-BD:“Study 1”: Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression Results for 179 participants: • No difference in recovery between antidepressant* augmentation (23.5%) and placebo augmentation (27.3%) • No difference in switch rate between antidepressant* augmentation (10.1%) and placebo augmentation (10.7%) • High placebo rate not observed, in contrast to STAR-D study of depression treatment • *bupropion (Wellbutrin) and paroxetine (Paxil)

33. STEP-BD:“Study 1”: Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression • But…adding antidepressants to mood stabilizer therapy in BD I and II remains controversial and is still common practice, despite the fact that, overall, placebo-controlled, double-blind maintenance studies do not demonstrate significantly better results

34. STEP-BD:“Study 2”: Depression Psychosocial Treatment Trial Does intensive* psychosocial treatment, added to a mood stabilizer, improve outcome in BD? *up to 30 sessions over nine months

35. STEP-BD:“Study 2”: Depression Psychosocial Treatment Trial • Added to an adequate mood stabilizer, intensive psychotherapy of several types* is effective in helping people recover from a depressive episode, and stay well over a one-year period • Family-focused treatment was best result (77% recovery over one year) though did not differ statistically from other two intensive treatments • *CBT, Interpersonal/Social Rhythm Therapy, Family-Focused Therapy

36. STEP-BD:“Study 2”: Depression Psychosocial Treatment Trial Does intensive psychosocial treatment, added to a mood stabilizer, improve outcome in BD? Yes

37. STEP-BD:Systematic Treatment Enhancement Program for Bipolar Disorder Take-home lesson from STEP-BD: Adjunctive intensive psychosocial treatments but not adjunctive antidepressants yielded outcomes superior to those achieved with mood stabilizers alone

38. Treatment: Medications and Medication Algorithms

41. APA Practice Guidelines 2002 are out of date! • Acute mania/mixed mania: • lithium or valproate or atypical antipsychotic* • if severe: lithium or valproate and atypical antipsychotic* • Acute depression: • lithium or lamotrigine • if severe: lithium and antidepressant • Maintenance • lithium or valproate: • alternatives: lamotrigine, carbamazepine, oxycarbazepine • atypical antipsychotics “may be considered”

42. Texas Medication Algorithm Project (TMAP) • NIMH-funded • Evidence-based and expert consensus • Last update 2007: will need update soon but best algorithm available at present • algorithms for mania and depression • appendices • Medication table with dosage/monitoring information • Table with side effects strategies

43. Do TMAP algorithms improve outcomes in BD? • For bipolar disorder, TMAP algorithm-based care improved outcomes without higher costs for health care services • Kashner et al, Psychiatric Services, 2006 May • Suppes et al, J Clin Psychiatry, 2003 Apr

45. Mania-Stage 1 • When treating pts with mania, hypomania, or rapid cycling, first consideration is to decrease or discontinue antidepressant • Should be done relatively quickly

46. Mania-Stage 1 • Stage 1: for euphoric mania/hypomania or psychotic mania, choose from: • lithium • divalproex/valproate or • atypical antipsychotic [lamotrigine ineffective for mania]

48. Bipolar Depression: Stage 1 • If no mania, lamotrigine • If already on lithium, increase to plasma level > 0.8mEq/l and add lamotrigine • If on antimanic, add lamotrigine • If no antimanic but history of severe or recent mania, antimanic + lamotrigine

49. Bipolar Depression: role of antidepressants • While STEP-BD study and TMAP guidelines do not support use of antidepressants as adjunctive agents in the treatment of bipolar depression, some experts feel there is a subset of patients who may benefit • Recommended that antidepressant monotherapy be avoided in BD I and II • Avoid adjunctive antidepressants in patients with concurrent manic symptoms, substance use disorders, early age of onset of bipolar disorder, and a recent history of mania or hypomania (eg, within the last two to three months) • Continue for approximately 2-6 months after remission

50. Maintenance treatment (prophylaxis) • First-line • Lithium • Lamotrigine • Second-line (less extensive or consistent evidence, or tolerability is poorer) • Aripiprazole • Divalproex/valproate • Quetiapine • Olanzapine