From: Mental Health in Social Work (Pearson, 2012)

http://www.jacquelinecorcoran.com

Jacqueline Corcoran, Ph.D.

Bipolar Disorder

2.1% (National Comorbidity Study)

Prevalence

Bipolar I At least one manic episode, usually accompanied by a major depressive episode.

Bipolar II Characterized by one or more major depressive episodes accompanied by at least one hypomanic episode.

Mood disorder due to a general medical condition (based on hx, lab findings, or physical exam)

Substance-Induced Mood Disorder MDD

• hx of at least one manic or hypomanic episode

Cyclothymic Disorder• experience of numerous episodes of hypomanic

and depressive symptoms that don’t meet criteria for MDD

• possibility of developing bipolar disorder

Differential Diagnoses

Non-episodic, chronic, rapid-cycling mixed state featuring agitation, excitability, labile affect, aggression, and irritability with child’s age-appropriate functioning significantly impaired

Frequent comorbidity with ADHD & CD Disruptive mood dysregulation disorder

(DSM V)

Bipolar in Children

Suicide: 10-15% School truancy, school failure,

occupational failure, divorce Axis I:

• Eating Disorders• ADHD• Anxiety Disorders• Substance-Related Disorders (60% risk)

Axis II: Borderline Personality Disorder

Medical disorders

Comorbidity

First-degree relatives elevated rates of Bipolar I Disorder (4-24%), Bipolar II Disorder (1-5%), and MDD (4-24%) Twin and adoption studies - evidence of genetic influence Polygenic models promising but core of BPD remains elusive Limbic system Amount of norepinephrine, serotonin, gamma-aminobutyric acid neurotransmitters are abnormal Actions of thyroid and other endocrine glands also account for nervous system changes Biorythms (body’s natural sleep and wake cycles) are erratic - may cause or result from chemical imbalances Damage to areas in brain responsible for emotional activity

Etiology: biological factors predominate

Stressful life events (onset and course)

Early onset 10% rapid cycling Families with high EE Lack of social support Number of previous episodes History of anxiety Persistence of affective

symptoms even when mood is relatively stable

Poor occupational functioning

Other Risk Factors

Mood-stabilizing meds sometimes prescribed with antipsychotic meds to treat BP I

Antidepressants - BP II

Medication

Improvements in 70% of clients Relatively short half life - must be taken

more than once per day Takes 2-3 weeks to establish effect Doesn’t preclude possibility of recurrence

• 36% recurrence rate in 5 yrs. • Combinations (with antidepressant, antipsychotic,

& anticonvulsant drugs) may help

Lithium prescribed for 1 year after first or second episode, permanent after third episode

Lithium Carbonate

Difference between therapeutic and toxic levels is not so great

Monitoring monthly for 1st 4-6 months, every 6 mos. after that

Symptoms: thirst, weight gain, fatigue, hand tremor, muscle weakness, confusion, diarrhea, dizziness, nausea, slurred speech, spastic muscle movements

Importance of Monitoring Blood

Levels

Blocks norepinephrine reuptake, may also break down GABA

Advantages over lithium• stabilize mood in 2-5 days• as effective for stabilizing • more effective for maintenance• has a greater antidepressant effect

Side effects problematic - 50% not taking a year later

Anticonvulsants: Carbamazephine

Comparable to lithium May be better than carbamazepine for

rapid cycling Trend toward prescribing

anticonvulsants as initial tx strategy

Anticonvulsants, cont.: Valproate

Lithium, carbamazepine, and valproate all used with children

Prospects of chronic weight problems and long-term effects on kidney function need to be considered

Medication Used with Children

Coming to terms• Reduce medication non-

adherence• Enhance social and

occupational functioning• Enhance family and

social support• Identify stresses that

may trigger mood episodes

Psychoeducation

Interpersonal therapy• interpersonal conflicts major

source of depression• also assumes sleep/wake cycle

and social rhythms influence course

CBT• challenge cognitions that may

activate episodes and be related to medication compliance

Individual Psychotherapy