Update on Bipolar Disorder

1. Update on Bipolar Disorder Ronald R. Berges, D.O. Medical Director for Behavioral Health Services Mahaska Health Partnership, Oskaloosa, Iowa

2. Update on Bipolar Disorder • “Manic-Depression” • Manic-Depressive Psychosis • Bipolar Affective Disorder • Bipolar Disorder • Cyclothymia • Cyclothymic Disorder • Bipolar Disorder NOS

3. Update on Bipolar Disorder • Bipolar Disorder by definition has to include a manic episode. DSM V criteria are as follows: • a distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week ( or any duration if hospitalized) • during the period of mood disturbance three(3) or more of the following symptoms have persisted, (four if the mood is only irritable) and have been present to a significant degree: • Inflated self esteem or grandiosity • Decreased need for sleep

4. Manic episode (continued) • More talkative than usual, or pressure to keep talking • Flight of ideas or subjective experience that thoughts are racing • Distractibility – (attention too easily drawn to irrelevant external stimuli) • Increased goal directed activity (socially, work, school, or sexually) – or psychomotor agitation. • Excessive involvement in activities with a high potential for painful consequence ( unrestrained buying sprees, sexual indiscretions, foolish business investments, etc) -These symptoms do not meet criteria for a mixed episode. -The mood disturbance is severe enough to cause marked impairment in social and occupational functioning, or in relationships with others. - The symptoms are NOT due to effects of a substance, drugs of abuse, medication or general medical treatment (hypothyroidism, etc)

5. Mixed Episode • Criteria are met for both a Manic Episode and a Major Depressive episode nearly every day for a 1 week period. • Mood disturbance causes marked impairment in occupational and social function, or in relationships with others. • Symptoms are not due to the effects of a substance, drugs of abuse, a medication or general medical condition.

6. Hypomanic Episode • Distinct period of persistently elevated, expansive or irritable mood, lasting at least 4 days, clearly different from the usual nondepressed mood. • During the period of mood disturbance, three or more of the following symptoms persist (or 4 if mood is only irritable): • Inflated self esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas/racing thoughts • Distractibility • Increase in goal directed activity – social, vocational, sexual • Excessive involvement in pleasurable activities with high potential for painful consequence

7. Hypomanic episode (Continued) • Episode is an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. • Disturbance in mood and change in functioning is observed by others. • Episode is NOT severe enough to cause marked impairment in social or occupational functioning. • Symptoms are not due to physiological effects of a substance, drugs of abuse, medication, or a general medical condition.

8. Bipolar Disorders • Bipolar Disorder, Type I, Single Manic Episode • Bipolar Disorder, Type I, Most recent episode Hypomanic • Bipolar Disorder, Type I, Most recent episode Manic • Bipolar Disorder, Type I, Most recent episode Mixed • Bipolar Disorder, Type I, Most recent episode Depressed • Bipolar Disorder, Type I, Most recent episode Unspecified • Bipolar Disorder, Type II (recurrent major depressive episodes with hypomanic episodes) • Cyclothymic Disorder • Bipolar Disorder Not Otherwise Specified

9. Famous Bipolar people • Mozart • Thomas Edison • Robin Williams • Jim Carrey • Van Gogh • Patty Duke • Ted Turner • Charlie Sheen • Charlie Pride • Abraham Lincoln?

10. Update on Bipolar Disorder • Treatment options • Thorazine (1954) Phenothiazine antipsychotic was the original anti-manic agent • Side effects may be significant – Multiple receptor blockade – muscarinic, alpha adrenergic, dopaminergic • Injectable form useful in emergency situations • Great anti-emetic • May develop tardivedyskinesia. • Useful for intractible hiccups

11. Update on Bipolar Disorder • Lithium (1970) • Found in the original formula of soft drink 7 Up. • Excreted unmetabolized by kidney. • Good mood stablization. • Regular labs for kidney function, thyroid function needed. • EKG • May cause EPS and/or tremor. • Avoid use of NSAIDS. • Adequate fluid intake necessary.

12. Update on Bipolar Disorder • Anticonvulsants - Depakote/Depakene/Divalproex Sodium good mood stablizer, levels required, LFTs. Good for anger - Tegretol/Carbamazepine good mood stabilizer, good in traumatic brain injury, has more interactions with other medications, need CBC in addition to traditional LFTs and serum levels. - Trileptal/Oxcarbazepine fairly good mood stabilizer, serum levels not necessary, well tolerated by kids.

13. Update on Bipolar Disorder • Lamictal/Lamotrigine – Well tolerated. Minimal side effects. Serum levels not done Routinely. Slow titration, watch for rash/ Stevens Johnson. Neurontin/Gabapentin – Well tolerated, need high doses, poor mood stabilizer, but Good for chronic pain, anxiety, headache.

14. Update on Bipolar Disorder • Atypical Antipsychotics • Most have benefit for mood symptoms common in Bipolar disorder. A number of them have been FDA approved for treatment of Bipolar disorder or subsets i.e. mania • Risperdal (Risperidone), effective, some EPS, problematic rare increases in prolactin may cause gynecomastia. Depot injection (RisperdalConsta) helpful for compliance. • Zyprexa (Olanzepine), great mood stabilizer, minimal EPS but metabolic concerns bear consideration. Annual Hgb A1C, regular monitoring of lipids. Available in 4 week depot injection (ZyprexaRelprev)

15. Update on Bipolar Disorder Atypical Antipsychotics (Continued) 3. Seroquel /Seroquel XR (Quetiapine) – sedative effect is helpful.Has some mood benefits in major depression as well. 4. Geodon (Ziprasidone) – approved for mixed or manic episodes. Prolonged QTC may be problematic in some patients. Short acting injection used in ERs. 5. Abilify – (Aripiperazole) Partial dopamine agonist and dopamine antagonist. Oral tablets, short acting injection and monthly AbilifyMaintenna injection make this drug versatile.

16. Update on Bipolar Disorder Atypical Antipsychotics, (continued) 6. Invega (Paliperidone) active metabolite of Risperdal/Risperidone. Oral and 4 week depot injections available to improve compliance. 7. Latuda (Lurasidone) currently approved to treat Bipolar depression.

17. Update on Bipolar Disorder • Antidepressants in Bipolar Disorder – To treat or not to treat? • TCAs – known for inducing switches into mania • MAOI – not recommended • SSRI – commonly used, be cautious with dosing • Wellbutrin – best choice – least likely to cause cycling of mood or switch into mania.

18. Update on Bipolar Disorder • Others • Benzodiazepines have long been an adjunct in treatment of mania. Lorazepam, Diazepam and Clonazepam most commonly used. • Other typical, first generation antipsychotics have been used in the past, not used much anymore.