Bright Nights Community Forum

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Bright Nights Community Forum

• Bipolar Disorders
• University of Michigan Depression Center
• Ann Arbor Public Library

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Bright Nights Forums

• U-M Depression Center and Ann Arbor Public
  Library
• Presentation on topics of interest relevant to
  mental health in community
• Panel of experts from U-M Depression Center and
  Professionals in community
• Q/A format
• Improve community awareness of resources
  available.

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Bright Nights Forums

• Bipolar Disorder March 29th
• Suicide May 24th
• Sleep and Depression October 2006

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Aretaeus of Cappadocia

• Melancholia mania
• 2 forms of the same disease
• Mania manifests as euphoria, but others display
  furious rages
• Melancholics possible for them to fly into
  rage..

First to describe mixed affect
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Understanding Affective Disorders

• Kraepelin proposed affect to consist of 3
  components
• Volition
• Energy Drive
• Emotion
• Happy / Sad
• Intellect
• Rate of thoughts
• Content of thoughts

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Celebrities with Bipolar Disorder
Kay Jamison, PhD
Ted Turner
Sylvia Plath
Jean-Claude Van Damme
Ben Stiller
Axl Rose
Margot Kidder
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Affect - Affection
Volition the drive to care for our
offspring Emotion the love for our
children Intellect the thoughts speech
related to our interactions with family and loved
ones
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Normal Affect
- Moods and disposition fluctuate over time
Volition
Emotion
Intellect
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Depression
Volition
Emotion
Intellect
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(No Transcript)
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Mixed Affect
Volition
Emotion
Intellect
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Wilhelm Greisinger

• Mittelformen
• In which a change from depression to manic
  exaltation occurs.
• Melancholia with destructive drives
• Melancholia with long lasting exaltation of
  volition
• In their mild forms, mittleformen are
  indistinguishable from personality deviations.

1817 - 1868
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Epidemiology of Bipolar Disorder

• ECA study lifetime prevalence 1.3
• Bipolar I 0.8
• Bipolar II 0.5
• Including bipolar spectrum disorders
• BP Not otherwise specified 3
• No male or female predominance
• Females with more depression

ECA study Epidemiological Catchment Area
survey. Bebbington P, Ramana R. Soc Psychiatry
Psychiatr Epidemiol. 199530279-292. Dunner DL.
Bipolar Disord. 20035456-463 Lish JD et al. J
Affect Disord. 199431281-29.
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BP Disorder Genetics

• BP disorder is 80 genetics
• - And 100 environmental!
• Having a BP sibling or parent increases
  likelihood of developing BP fivefold compared to
  general population.
• Risk increases with increasing number of affected
  in family.
• Overlap with genetic risk for other mood,
  anxiety, and psychotic disorders.

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Spectrum of Bipolar Disorders

• Bipolar I
• Bipolar II
• Major depression with a strong family history of
  bipolar disorder
• Hypomania
• Antidepressant-induced mania and hypomania
• Cyclothymia
• Rapidly changing mood swings
• NOS
• Secondary mania, due to other illnesses or drugs

Adapted from American Psychiatric Association.
Practice Guideline for the Treatment of Patients
with Bipolar Disorder. 2nd ed. Washington, DC
2002.
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Bipolar Disorders
MANIA
HYPOMANIA
MIXED EPISODE
NORMALMOOD
SUBSYNDROMAL DEPRESSION
DEPRESSION
Hypomania is a milder form of mania with similar
yet less severe symptoms and less overall
impairment. Mixed Episode is an episode that
simultaneously presents symptoms of both
depression and mania.
Stahl SM. Essential Psychopharmacology. New York,
NY Cambridge University Press 2000.
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Misdiagnosis of Bipolar Disorder

• Often mistaken for depression (4070 initially
  misdiagnosed)1-3
• Often see several clinicians without accurate
  diagnosis2
• Mean time to diagnosis long (8 yearsin 1
  study)3,4
• Rate of misdiagnosis worse with comorbidity2

1. Bowden CL. J Affect Disord. 200584117-125
2. Thomas P. J Affect Disord. 200479(Suppl
1)S3-S8 3. Baldessarini R et al. Am J
Psychiatry. 1999156811-812 4. Tondo L et al.
Am J Psychiatry. 1998155638-645.
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Misdiagnosis of Bipolar Disorder

• 2000 NDMDA initial diagnosis (69)

60
60
50
Depression
Anxiety
40
Percent
Schizophrenia
30
Cluster B
26
20
Alcohol abuse
18
17
10
14
0
NDMDA National Depressive and Manic-Depressive
Association N 400 Hirschfeld RM, et al. J
Clin Psychiatry. 200465(suppl 15)5-9.
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Onset of Bipolar Disorder

• Onset in teens for most patients(peak ages,
  1519 years)
• Late onset less rare than was thought (possibly
  6 aged gt60 years)
• Relapse frequent (7590)

Bebbington P, Ramana R. Soc Psychiatry Psychiatr
Epidemiol. 199530279-292 Sajatovic M et al.
Am J Geriatr Psychiatry. 200513282-289 Gitlin
MJ et al. Am J Psychiatry. 19951521635-1640.
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McLean Harvard First-Episode Mania study

• 239 BP with first Manic/mixed episode
• 173 recruited for study
• 151 followed for an average of 4.86 years
• Recovery at 2 years
• Syndromal (DSMIV)98
• Symptomatic (YM) 72
• Functional (occupational) 43

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Disability With Bipolar Disorder

• Bipolar disorder is the 6th leading cause of
  medical disability worldwide among people aged 15
  to 44 years
• Bipolar disorder is associated with a greater
  degree of disability than osteoarthritis, human
  immunodeficiency virus infection, diabetes, and
  asthma

Murray CJ, Lopez AD. Lancet. 19973491436-1442.
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Social Impact of Bipolar Disorder

• Unemployment rate 60, includes college
  graduates
• 65 report impaired long-term relationships

Hirschfeld MA et al. J Clin Psychiatry.
200364161-17 Kupfer DJ et al. J Clin
Psychiatry. 200263120-125.
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Economic Impact of Bipolar Disorder

• The estimated annual societal cost of bipolar
  disorder ranges from 10 billion to 45 billion
• Indirect costs
• 49.5 lost workdays/year/patient
• 180 million lost workdays/year
• 25.9 billion salary-equivalent lost/year

Wyatt RJ, Henter I. Soc Psychiatry Psychiatr
Epidemiol. 199530213-219 Greenberg PE et al.
J Clin Psychiatry. 199354405-418. Begley CE et
al. Pharmacoeconomics. 200119483-495.
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Epidemiological Catchment Area Survey (ECA)
Comorbidity and Bipolar Disorder
Patients
Alcohol-use Disorder
Substance-use Disorder
PanicDisorder
OCD
Regier DA et al. JAMA. 19902642511-2518 Chen
YW, Dilsaver SC. Am J Psychiatry.
1995152280-282 Chen YW, Dilsaver SC.
Psychiatry Res. 19955957-64.
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Substance-Use Disorder BPD

• Bipolar disorder with co-existing substance-use
  disorder is associated with an increase in
• Suicide attempts
• Suicidal ideas
• Seeking hospital admission
• Hospital admission
• Violence
• Aggressive behavior
• Doubled risk of suicide

Potash JB et al. Am J Psychiatry.
20001572048-2050 Scott H et al. Br J
Psychiatry. 1998172345-350 Comtois KA et al.
Biol Psychiatry. 200456757-763 Strakowski SM,
DelBello MP. Clin Psychol Rev. 200020191-206
Strakowski SM et al. Arch Gen Psychiatry.
200562851-858.
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Substance-Use in BPD Treatment Issues

• Less likely to respond to treatment1
• Less likely to adhere to medications1,2
• Less likely to adhere to lithium treatment
• Less likely to gain full remission and resolve
  symptoms
• Remission during hospitalization less likely to
  occur vs no substance-use disorder

1. Goldberg JF et al. J Clin Psychiatry.
199960733-740 2. Aagaard J, Vestergaard P. J
Affect Disord. 198912259266 3. Strakowski SM
et al. Arch Gen Psychiatry. 19985549-55.
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APA Treatment Guidelines for Comorbid BPD and
Substance-Use Disorder

• Treatment should proceed concurrently, preferably
  in a dual-diagnosis program
• Alcohol abuse may affect bipolar pharmacotherapy
• Alcohol-related dehydration may raise serum
  lithium to toxic levels
• Hepatic dysfunction may alter plasma levels of
  valproate and carbamazepine

American Psychiatric Association. Practice
guideline for the treatment of patients with
bipolar disorder (revision). Available at
http//www.psych.org/psych_pract/treatg/pg/Practic
e20Guidelines8904/BipolarDisorder_2e.pdf.
Accessed January 24, 2006.
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Medical Conditions BP

• Migraine
• Thyroid disease
• Lithium
• Type 2 diabetes
• Antipsychotics
• Obesity
• Mood stabilizers
• Antipsychotics
• Polycystic Ovarian Syndrome
• Valproate and other anticonvulsants
• Multiple sclerosis
• Multiple episodes may increase risk of dementia

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Causes of Medical Problems in Bipolar Disorder

• Poor diet
• Smoking1
• Obesity (32)2
• Medications
• Inactivity
• Underutilization of medical resources
• Nonadherence (gt50)3

1. Breslau N et al. Psychological Medicine.
200434323-333 2. Fagiolini A et al. J Clin
Psychiatry. 200263528-5333. Fleck DE. J Clin
Psychiatry. 200566646-652 4. Dailey LF et al.
J Clin Psychiatr. 200566477-484.
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Obesity in Bipolar Disorder

• 35.4 of patients with bipolar disorder had BMI
  30 mg/kg2
• Decreased sense of well being and QOL2
• Increased relapses of depressive episodes2,3
• More likely to have made a suicide attempt4
• Bipolar disorder treatments have been associated
  with weight gain and endocrine changes new
  weight gain increases IR and may promote PCOS in
  predisposed women5

IR insulin resistance PCOS polycystic
ovarian syndrome. 1. Fagliolini A et al. Am J
Psychiatry. 2003160112-117 2. McLaren KD,
Marangel LB. Ann Gen Hosp Psychiatry.200437-17
3. Post RM. J Clin Psychiatry. 200566(Suppl
5)5-10 4. Osby U et al. Arch Gen Psychiatry.
200158884-850 5. Rasgon NL et al. Bipolar
Disord. 20057246-259.
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Treatment Decisions Bipolar Disorder
Sachs GS. Managing Bipolar Affective Disorder.
Science Press Ltd London, UK 2004.
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Guidelines for Acute Mania
AP antipsychotic Cbz carbamazapine ECT
electroconvulsive therapy Li lithium Olz
olanzapine Quet quetiapine Risp
risperidone Vp valproate.
Fountoulakis KN, et al. J Affect Disord.
2005861-10. Keck PE Jr, et al. Postgrad Med
Special Report. 20041-120.
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Guidelines for Acute Bipolar Depression
AD antidepressant Cbz carbamazapine ECT
electroconvulsive therapy La lamotrigine Li
lithium Olz olanzapine Quet quetiapine
Risp risperidone Vp valproate.
Fountoulakis KN, et al. J Affect Disord.
2005861-10. Keck PE Jr, et al. Postgrad Med
Special Report. 20041-120.
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Guidelines for Bipolar Maintenance
Arip aripiprazole Cbz carbamazapine ECT
electroconvulsive therapy La lamotrigine Li
lithium OCBz oxcarbamazepine Olz
olanzapine Quet quetiapine Risp
risperidone Vp valproate Zipr ziprasidone.
Fountoulakis KN, et al. J Affect Disord.
2005861-10. Keck PE Jr, et al. Postgrad Med
Special Report. 20041-120.
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Suicide Risk in Bipolar Disorder

• Patients with bipolar disorder have a higher risk
  of suicide than patients with any other
  psychiatric or medical illness
• Odds ratio for suicide attempts is 6.2, higher
  than any other disorder, including depression

Woods SW. J Clin Psychiatry. 200061(Suppl
13)38-41 Chen YW, Dilsaver SC. Biol Psychiatry.
199639896-899 Goldberg JF, Harrow M. J Affect
Disord. 200481123-131.
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Increased Mortality in Patients With Bipolar
Disorder
Standardized Mortality Ratio
All Causes
Unnatural
Cerebro-vascular
Cancer
CVD
GI
SMR standardized mortality ratio observed
events expected events Unnatural
accidents, suicide, homicide, undetermined
deaths. GI gastrointestinal. Osby U et al. Arch
Gen Psychiatry. 200158884-850.
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Suicide prevention and Lithium
In a meta-analysis of 22 studies the computed
risk-ratio for on vs off lithium was 8.85
Tondo et al, 2001 Acta Psych Scand
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BP Concluding statements..

• Bipolar Disorders are a category of mood
  disorders - with a broad range of severity.
• BP is eminently treatable.
• But requires treatment to be ongoing
• Collaboration between Treatment team and patient
• BP is a serious illness.
• Lives, families, and careers affected
• People die from it

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Prechter Bipolar Genes Project

• Goals
• Determine what keeps BP patients well, and what
  causes problems
• Find the genes involved
• Study
• Track participants for 5 years through interview,
  questionnaires, cognitive testing
• Collect blood sample for DNA analysis

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Prechter Bipolar Genes Project

• For more information
• www.hcpfmd.org
• www.depressioncenter.org
• New toll-free
• 1-877-UM GENES
• (1-877-864 3637)
• Email BPresearch_at_umich.edu

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Panel Members

• Melvin McInnis, MD
• University of Michigan
• Cheryl King, PhD
• University of Michigan
• Juan Lopez, MD
• University of Michigan
• Shabnum H. Sheikh, MD
• St Joseph Mercy Hospital
• Jon-Kar Zubieta, MD
• University of Michigan
• Katharene Schoof, MSW, ACSW
• University of Michigan