Bipolar depression: Diagnosis and Treatment
-
Upload
drscotteaton -
Category
Health & Medicine
-
view
1.017 -
download
4
description
Transcript of Bipolar depression: Diagnosis and Treatment
![Page 1: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/1.jpg)
Depression in Bipolar Affective
DisorderDiagnosis and Treatment
Dr Scott Eaton MBChB, MRCPsych, FRANZCP@drscotteaton
![Page 2: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/2.jpg)
•Disclosure
![Page 3: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/3.jpg)
![Page 4: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/4.jpg)
Goals:•Understand the complexities of
diagnosis of Depression in Bipolar Affective Disorder. Differentiate from depression in Bipolar, unipolar depression and borderline personality disorder.
•Introduction to the CANMET guidelines for treatment of bipolar depression. Review the debate regarding the use of antidepressants.
![Page 5: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/5.jpg)
DSM IV/V• The diagnosis of BP I requires the following:
• A manic episode of at least 1 week’s duration that leads to hospitalization or other significant impairment in occupational or social functioning
• The episode cannot be caused by another medical illness or by substance abuse
• Manic episodes also must include at least 3 of the following symptoms:
• Grandiosity
• Diminished need for sleep
• Excessive talking or pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Increased level of goal-focused activity at home, at work, or sexually
• Excessive pleasurable activities, often with painful consequences
![Page 6: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/6.jpg)
• Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 days’ duration, along with at least 3 of the following symptoms:
• Grandiosity or inflated self-esteem
• Diminished need for sleep
• Pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Psychomotor agitation at home, at work, or sexually
• Engaging in activities with a high potential for painful consequences
• DSMV - “other specified”
![Page 7: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/7.jpg)
• For major depressive episodes, the person experiences 5 or more of the following symptoms for the same 2 weeks, with at least 1 of the symptoms being either of the first 2 listed:
• Depressed mood
• Markedly diminished pleasure or interest in nearly all activities
• Significant weight loss or gain or significant loss or increase in appetite
• Hypersomnia or insomnia
• Psychomotor retardation or agitation
• Loss of energy or fatigue
• Decreased concentration ability or marked indecisiveness
• Preoccupation with death or suicide; patient has a plan or has attempted suicide
• The symptoms cause significant impairment and distress
• The mood is not the result of substance abuse or a medical condition
![Page 8: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/8.jpg)
• Mixed episodes are characterized by the following:
• Persons must meet the criteria for both mania and major depression; the depressive event is required to be present for 1 week only (DSMV only 3 features required)
• The mood disturbance results in marked disruption in social or vocation function
• The mood is not the result of substance abuse or a medical condition
![Page 9: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/9.jpg)
![Page 10: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/10.jpg)
Cases
•Typical presentations
•Small groups
•Formulate questions to help identify bipolar depression or the primary differentials.
![Page 11: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/11.jpg)
![Page 12: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/12.jpg)
Unipolar vs Bipolar
•Why bother?
•Conundrum of over and underdiagnosis.
•Early intervention of the right sort.
![Page 13: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/13.jpg)
•Forty et al - 2008 British Journal Psychiatry
•593 UPD vs 443 BPD
•Lifetime psychopathology screening
•no UPD had bipolar/schizophrenia rel
•reviewed GP and psych case notes
![Page 14: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/14.jpg)
Bipolarity Symptoms
•Psychosis 11vs30% p<.001
•Diurnal Mood variation 50vs60% p.003
•Hypersomnia 21vs43% p<.001
•More episodes of depression 4vs5 p.006
•Shorter episodes 26vs69weeks p<.001
![Page 15: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/15.jpg)
Unipolar symptoms
•excessive self-reproach 96vs87% p<.000
•loss of energy p.05
•loss of libido 63vs35% p<.001
![Page 16: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/16.jpg)
![Page 17: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/17.jpg)
Personality Disorder
•Bassett 2012 ANZJP
•Review
![Page 18: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/18.jpg)
•features of Borderline PD
•fear of abandonment
•impulsivity
•recurrent self-injurious behaviour
•affective instability
•episodic explosive rage/psychosis
![Page 19: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/19.jpg)
•Disturbed Relatedness - identity disturbance, emptiness, unstable relationships.
•Behavioural Dysregulation
•Affective Dysregulation
![Page 20: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/20.jpg)
Differences•Family Hx of mood disorder - bipolar
•life trajectories - greater impact - bipolar
•Childhood Trauma
•Self-mutilation
•“Rapid” cycle vs Prolonged
•deficiency in mindfulness - borderline
•reduced self-control - borderline
•Depression - anger vs Depression - elation
![Page 21: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/21.jpg)
Depressed Borderline
•Earlier age of onset
•greater frequency of depressive episodes
•greater “atypical features”
•comorbid anxiety
•substance abuse
•suicide attempts
•no bipolar family history
![Page 22: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/22.jpg)
Text
![Page 23: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/23.jpg)
Comorbidity
•Borderline - incidence 9% BPD I, 11% BPDII
•Bipolar 1 - Borderline 11%
•BipolarII - Borderline 16%
•Borderline better prognosis!!
![Page 24: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/24.jpg)
![Page 25: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/25.jpg)
![Page 26: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/26.jpg)
•Guidelines first published in 2005
•updated in 07 and 09
•Multinational specialists with interest in Bipolar Disorder
![Page 27: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/27.jpg)
Facts:
•prevalence BP1 0.4%, BP11 1.4%
•lifetime suicide attempts - 1/3
•completed suicide 0.014 per 100person years
•high work impairment
![Page 28: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/28.jpg)
Chronic disease management
•Educated clinicians = later relapse time
•frequent monitoring = better social/occupational function
•symptom checklist = earlier recognition of EWS
![Page 29: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/29.jpg)
Psychosocial• Group psychoeducation
• Interpersonal Psychotherapy
• CBT
• Internet Based Therapy
• improvements in acute depression, long term maintenance, hospitalization, function, adherence.
• Family Focused Therapy improved well being in carers
![Page 30: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/30.jpg)
![Page 31: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/31.jpg)
![Page 32: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/32.jpg)
Bipolar Depression:Pharmcology• First Line Treatments: (dose increase/change
treatment 2-3/52)
• Lithium
• Lamotrigine
• Quetiapine , XR
• Combinations:
• Lithium/Valproate + SSRI (Not Paroxetine)
• Olanzapine + SSRI (not P)
• Lithium + Valproate
• Lithium/Valproate + buproprion
![Page 33: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/33.jpg)
•Second Line Treatments
•Valproate
•Combination Therapy
•Quetiapine + SSRI
•+ modafinil
•Lithium/valproate + lamotrigine
![Page 34: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/34.jpg)
• Third Line Treatments
• Carbamazepine
• ECT
• Olanzapine
• Combination Therapy
• Lithium + Carbamazepine
• Lithium/valproate + Venlafaxine
• Lithium + MAOI/TCA
• Lithium + Pramipexole
• Lithium/CBZ/Valp + SSRI +Lamotrigine
• Quetiapine + SSRI
![Page 35: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/35.jpg)
Not Recommended
•Gabapentin
•Aripiprazole
•Ziprasidone
•Combination:
•+ ziprasidone
•+ levetiracetam
![Page 36: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/36.jpg)
•“Novel Therapies”
•EPA
•NAC
•Pramipexole
![Page 37: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/37.jpg)
Bipolar II Depression
• First:
• Quetiapine, XR
• Second:
• Lithium, Lamotrigine, Valproate
• Lithium/Valproate + antidepressant
• Lithium+Valpraote
• Atypical + antidepressant
• Third:
• antidepressant
• quetiapine + lamotrigine
• + ECT, +NAC, +T3
![Page 38: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/38.jpg)
![Page 39: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/39.jpg)
Antidepressants!!
• Most often used
• Some circumstances - good evidence for worse outcomes (paroxetine/buproprion)
• Strong evidence better than placebo and low rate of SWITCH
• Mood stabilizer reduce risk of switch
• Beware “mild switch”
![Page 40: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/40.jpg)
•suggest:
•SSRI can be used first line WITH a mood stabilizer
•Taper after 6-8/52 remission
•avoid TCA or SNRI
•Not in Mixed state or Rapid cyclers or monotherapy
![Page 41: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/41.jpg)
• The ISBD recommendations for acute treatment of a depressive episode in bipolar disorder include the following:
• Adjunctive antidepressants may be used for an acute bipolar I or II depressive episode when there is a history of previous positive response to antidepressants.
• Adjunctive antidepressants should be avoided for an acute bipolar I or II depressive episode with 2 or more concomitant core manic symptoms, in the presence of psychomotor agitation or rapid cycling.
• For maintenance treatment, the following is recommended:
• Maintenance treatment with adjunctive antidepressants may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy.
![Page 42: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/42.jpg)
• The recommendations for antidepressant monotherapy includes the following:
• Antidepressant monotherapy should be avoided in bipolar I disorder.Antidepressant monotherapy should be avoided in bipolar I and II depression with 2 or more concomitant core manic symptoms.
• The recommendations for antidepressant use in mixed states include the following:
• Antidepressants should be avoided during manic and depressive episodes with mixed features. Antidepressants should be avoided in bipolar patients with predominantly mixed states. Previously prescribed antidepressants should be discontinued in patients experiencing current mixed states.
![Page 43: Bipolar depression: Diagnosis and Treatment](https://reader035.fdocuments.net/reader035/viewer/2022081716/547bfe0eb4af9f68478b4737/html5/thumbnails/43.jpg)