Bipolar Disorder

Bipolar Disorder

Bipolar disorder is characterized by recurrent mood disturbance mixed with mania/hypomania + depression. Thought to be a bridge between unipolar depression and Schizophrenia spectrum disorders. The genetic link in Bipolar disorder is stronger than that of Unipolar depression, but less than that of Schizophrenia.

BPID: 0.6%. BPIID: 0.3%. M:F 1:1. 3-4 manic episodes per year in our setting. Mania is more common in men than women. Mixed episodes are more common in women (w/ rapid cycling). Rapid cycling is more common in women (≥ 4 episodes per year). High risk of relapse post-delivery in women of childbearing age. More common in High SES.

25-50% of patients attempt suicide in the depressive phase. 15% complete suicide.

Classification of Bipolar Disorder

Bipolar I vs Bipolar II Disorder

Etiology

Biological Factors

Psychological Factors

• What are patients with bipolar disorder at an increased risk of?
  • Suicide and self-harm
  • Financial risk
  • Physical health risk: Diabetes mellitus, cardiovascular disease, sexually transmitted diseases, pregnancy
  • Alcohol and drug abuse
  • Driving and accidents
• Characteristics of depression in Bipolar Disorder
  • Early age of onset (18 years old in BPID, Mid 20s in BPIID)
  • High chance of reversed vegetative symptoms (hypersomnia, increased appetite)
  • Increaed risk of relapse
  • Higher familial genetic link
  • More reactive to mood stabilizers and SSRIs
• Investigations
  • Urine tox screen
  • TFTs (Hyperthyroidism, Hypothyroidism)
  • Adrenal function tests (Pheochromocytoma Hyperadrenalism)
  • HIV/AIDS
  • Viral (Rabies)
  • RPR/VDRL (Syphillis)
  • ANA (SLE)
  • CBC (Acute blood loss)
  • BS for MPS (cerebral malaria; watch out for false positives in endemic areas)
  • Head CT (Non-dominant hemisphere stroke or tumor)
  • EEG (Epilepsy)
  • Metabolites of neurotransmitters in urine, serum or CSF (Homovanillic acid, 5-IAA)
• Differentials
  • Drugs (Cannabis, Benzos, Cocaine causing mania, Captopril for BPID)
  • Hypethyroidism:
  • Personality disorder: Mania will be a single episode while in personality disorders it will be persisitent.
  • Psychotic disorder: ****Bizzare delusions will be protracted
  • Non-dominant hemisphere stroke or tumors
• Pharmacological treatment
  • For the acute episode, combining a mood stabilizer and an antipsychotic is associated with better outcomes
  • For maintenance monotherapy with either an antipsychotic or a mood stabilizer can be used
  • Mood stabilizers
    • Lithium: preferred in acute mania
    • Valproic acid: preferred in acute mania and mixed phase
    • Carbamazepine: preferred in rapid cycling and mixed phase
    • Lamotrigine: preferred in depressive phase
    • Topiramate
    • Gabapentin
  • Antipsychotics (Olanzapine, Quietapine, Risperidone): Psychotic features, and as Mood Stabilizers, as depot (long-acting injections)
  • SSRIs (Fluoxetine): add if no response to mood stabilizers. Isolated use can push depressed patients to mania in both BPID and BPIID or precipitate rapid cycling.
  • Typical antipsychoics (haloperidol, ziprasidone): for agitated patients
• Physical therapy
  • ECT: for bipolar that is refractory to therapy and acute mania
• Psychotherapy
  • CBT
  • Family therapy
  • Interpersonal and Social Rhythm therapy (IPSRT)
  • Psychoeducation
• Treatment of Bipolar in teenagers
  • Lithium
  • Aripiprazole (Aripitas)
• Specifiers for diagnosing bipolar disorder
  1. Severity
     1. Mild BPID/BPIID
     2. Moderate BPID/BPIID
     3. Severe BPID/BPIID
  2. Current or Recent episode:
     1. BPID, Manic phase
     2. BPIID, Hypomanic phase,
     3. BPID/BPIID Depressive phase,
     4. BPID/BPIID Mixed phase
  3. Other features
     • BPD with Psychotic features
     • BPD with Rapid cycling
     • BPD with Peripartum onset
     • BPD with Seaonal pattern
     • BPD with Anxious distress
     • BPD with Catatonia
• Good prognostic factors
  • Short duration of episodes
  • Acute
  • Late onset
• Poor prognostic factors
  • Poor pre-morbid function
  • Psychotic features
  • Depressive
  • Male sex
  • Family History
  • Comorbidities
  • Suicidal
• Controlling Bipolar Disorder
  • Medication daily
  • Exercise daily
  • Balanced diet at regular times
  • Routine sleep/wake
  • Avoid alcohol/drugs
  • Counselling (to reduce stress at work/home)
  • Limit caffeine/nicotine during mania
  • Avoid travelling to different time zones
  • Seek treatment immediately you notice Sx of relapse
  • Support groups

Cyclothymic Disorder

Cyclothymia is a chronic disorder with periods of mild depression (< 5 SIGE CAPS) + hypomania which come and go over at least two years lasting for more than 2 years. Think of it as a mild form of BPIID. Bouts of depression are not as bad and do not meet criteria for MDD.

33% risk of developing BPID and BPIID. 0.4-1% prevalence. M:F 1:1

• Differentials (same as BPIID)
  • Drugs (Cannabis, Benzos, Cocaine causing mania)
  • Hypethyroidism:
  • Personality disorder: Mania will be a single episode while in personality disorders it will be persisitent.
• Treatment
  • Rule out thyroid disorder and drugs
  • Patients usually respond to mood stabilizers