Transcript Part I -- bipolar basics

Part I -- Bipolar Basics
Kurt Weber, PhD
[email protected]
Mental Health America – Brown County
Bemis International Center
St Norbert College
May 13, 2008

“Manic-depression distorts moods and
thoughts, incites dreadful behaviors,
destroys the basis of rational thought, and
too often erodes the desire and will to live It
is an illness that is biological in its origins, yet
one that feels psychological in the experience
of it; an illness that is unique in conferring
advantage and pleasure, yet one that brings
in its wake almost unendurable suffering
and, not infrequently, suicide.

“I am fortunate that I have not died from my
illness, fortunate in having received the best
medical care available, and fortunate in
having the friends, colleagues, and family
that I do.”

Kay Redfield Jamison, PhD, An Unquiet Mind,
1995, p 6
Purpose of today…

Some foundation information that mental
health professionals and “consumers”
should know…
Bipolar disorder


formerly known as manic-depressive disorder
brain disorder




causes unusual shifts in a person’s mood, energy, and
ability to function
Some people alternate mania and depression,
others have episodes of mostly one kind
Episodes vary in duration from days to years
the symptoms of bipolar disorder are severe



damaged relationships
poor job or school performance
suicide
good news

treatable

bipolar disorder can be treated, and people with
this illness can lead full and productive lives
Types of Bipolar Disorders





The classic form of the illness, which involves recurrent
episodes of mania and depression, is called bipolar I
disorder
Some people, however, never develop severe mania but
instead experience milder episodes of hypomania that
alternate with depression; this form of the illness is called
bipolar II disorder
When 4 or more episodes of illness occur within a 12-month
period, a person is said to have rapid-cycling bipolar
disorder
Some people experience multiple episodes within a single
week, or even within a single day
Rapid cycling tends to develop later in the course of illness
and is more common among women than among men
demographics


Approximately 23 million Americans suffer from
bipolar disorder
National Comorbidity Study-Replicated (NCS-R)


National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC)




the lifetime prevalence of bipolar disorder is 51%
lifetime prevalence of bipolar I disorder of 33%
Native Americans have the highest incidence
Asians and Hispanics have the lowest
World Health Organization (1990)

bipolar disorder is the sixth leading cause of disability
worldwide among people 15-44 years old





Studies suggest that bipolar disorder clients
will be fully symptomatic 8% of the time, and
symptomatic 59% of the time
30% of bipolar clients have both manic and
depressive episodes
32% have mixed manic and depression
22% have only manic episodes
10% have only mixed episodes
Depressive episodes in BD

Depression
most frequent episode
 episodes last longer (254 weeks) than manic
episodes (55 weeks)

comorbidity




485% of bipolar clients will have an anxiety
disorder
708% will have a personality disorder
Suicidal ideation is also highly associated
with comorbid substance abuse
There is a strong association of suicide
attempts and comorbid anxiety disorders
suicide

NIMH (2000)



Suicide is a significant risk in bipolar disorder,
the highest of any psychiatric disorder at 20%
As many as 25-50% of clients will make a
suicide attempt
Most suicidal ideation occurs during
depressed or mixed episodes
features and subtypes (Mays)
Bipolar I






Psychomotor
Sleep
Suicide
Switching to
Gender
Prevalence
retarded
hypersomnia
+++
mania
m=f
1%
Bipolar II
agitated or retarded
insomnia/hypersomnia
++++
hypomania
f>m
1-2%
mixed episodes





50% of clients have mixed mania
state of mind characterized by symptoms of both
mania and depression
more common in bipolar children and women
may feel agitated, angry, irritable, and depressed
all at once
combines a high activity level with depression

particular danger of suicide or self- injury
Rapid cycling






frequently recurring (4+ episodes/yr) treatment resistant
depression alternating with hypomanic/manic episodes
most commonly seen in female clients and with bipolar II
disorder
15-25% of clients
early onset common
not known whether antidepressants can initiate rapid
cycling
Variations include



ultra-rapid (1 day to 1 week)
ultradian (<24 hours)
continuous
gender issues


no gender difference in the incidence of bipolar I
both have onset in puberty


Manic episodes



men may have a slightly earlier onset
equal frequencies among men and women
Women are more likely to be treated than men and
receive treatment earlier in the illness (NESARC)
no evidence of difference in treatment
responsiveness to mood stabilizers
Women…


more frequent and more severe episodes of
depression
more comorbidities



anxiety, obesity, migraine, thyroid
greater relative increase in AODA and suicide
more rapid cycling and mixed states
Women with BD…


have a high risk of anovulatory disorders and
polycystic ovary syndrome (PCOS)
metabolic condition that occurs in 7-15% of
reproductive-aged women
elevated androgens
 chronic anovulation
 insulin resistance
 elevated LDL with low HDL
 3x risk of endometrial cancer

pregnancy


50% of women with bipolar disorder have the onset
of symptoms within 1 year of menarche (Mays)
however, most are not accurately diagnosed until
they have had a child and developed postpartum
depression



67% of bipolar women will have postpartum depression
33-50% of postpartum depressions begin during
pregnancy and worsen postpartum
Suicide risk for the new mother is 70x higher
during baby's first year of life if mother has
postpartum depression
risk factors and
warning signs for PPD






Previous postpartum depression (50-75%)
Having a mood disorder - bipolar disorder
gives 25% risk
Single motherhood
Stressful events
Substance abuse
Mood disorder symptoms during pregnancy


No psychotropic drugs are known to be safe for
pregnancy or breastfeeding
however, bipolar disorder itself is also dangerous
for pregnancy due to




substance abuse
poor self-care
suicide
medication for bipolar reproductive-age females

recall that 50% of pregnancies in the US are unplanned
Causes

“…has anyone found the true cause of
bipolar disorder? It would be wonderful to
say that X or Y was the cause, but the
answer is not that simple”
biopsychosocial model



Most scientists believe that mental illnesses
are caused by a combination of several
factors working together
In bipolar disorder, these factors are usually
divided into biological and psychological
causes
In plain English, the main reasons mental
illness develops are physical (biological) and
environmental
genetic origins



if one parent has bipolar illness, chances are 1:7 that their
child will
however, there are relatively few studies of the heritability
of bipolar disorder
why?


numerous subtypes of the disorder
categorical distinction between major depression and bipolar
disorder (the presence of one manic episode) that confounds all
genetic studies of depression since the disorders seem to be clearly
related at some level
so, what is inherited?



neurotransmitter functioning!
neurotransmitter system has received a
great deal of attention as a possible cause of
bipolar disorder
some studies suggest that a low or high level
of a specific neurotransmitter such as
serotonin, norepinephrine or dopamine is
the cause

other studies indicate that an imbalance of
these substances is the problem


the specific level of a neurotransmitter is not as
important as its amount in relation to the other
neurotransmitters
still other studies have found evidence that a
change in the sensitivity of the receptors on
nerve cells may be the issue
sounds like…


researchers are quite certain that the
neurotransmitter system is at least part of
the cause of bipolar disorder
further research is still needed to define its
exact role
Typical course of BD (Mays)


median age of onset is 19
first episode


most likely to be mania in males, depression in females
Severe psychosocial stressors appear more important in the
first episode than latter episodes, i.e. there is “kindling” to
stress – each episode requires less stress to occur





90% of clients who have one manic episode will
have another
Four years after remission of the first episode, 60%
had relapsed
Without treatment, bipolar clients will have 9-10
episodes in their lifetime, and each episode will last
1-4 months
The interval between episodes will diminish
(kindling to episodes)
Episodes will become more treatment resistant
The course of BD (NIMH)



Episodes of mania and depression typically
recur across the life span
Between episodes, most people with bipolar
disorder are free of symptoms, but as many
as one-third of people have some residual
symptoms
A small percentage of people experience
chronic, unremitting symptoms despite
treatment
without treatment…



natural course of bipolar disorder tends to worsen
over time, a person may suffer more frequent
(more rapid-cycling) and more severe manic and
depressive episodes than those experienced when
the illness first appeared
proper treatment can


help reduce the frequency and severity of episodes
help people with bipolar disorder maintain good quality
of life
Children and adolescents?

Both children and adolescents can develop
bipolar disorder





more likely to affect the children of parents who have the
illness
children and young adolescents with the illness often
experience very fast mood swings between depression and
mania many times within a day
Children with mania are more likely to be irritable and prone
to destructive tantrums than to be overly happy and elated
Mixed symptoms also are common in youths with bipolar
disorder
Older adolescents who develop the illness may have more
classic, adult-type episodes and symptoms
NIMH

Bipolar disorder in children and adolescents can be
hard to tell apart from other problems that may
occur in these age groups

irritability and aggressiveness


can indicate bipolar disorder
can be symptoms of





attention deficit hyperactivity disorder
conduct disorder
oppositional defiant disorder
other types of mental disorders more common among adults such
as major depression or schizophrenia
Drug abuse also may lead to such symptoms
of course…
For any illness, however, effective treatment
depends on appropriate diagnosis
 Children or adolescents with emotional and
behavioral symptoms should be carefully
evaluated by a mental health professional
 Any child or adolescent who has suicidal
feelings, talks about suicide, or attempts
suicide should be taken seriously and should
receive immediate help from a mental health
specialist

Imaging





New brain-imaging techniques allow researchers to take
pictures of the living brain at work, to examine its structure
and activity
without the need or surgery or other invasive procedures
 magnetic resonance imaging (MRI)
 positron emission tomography (PET)
 functional magnetic resonance imaging (fMRI)
the brains of people with bipolar disorder may differ from
the brains of healthy individuals
may develop a better understanding of the underlying
causes of the illness
may be able to predict which types of treatment will work
most effectively
NIMH clinical studies


real-world studies
Unlike traditional clinical trials




multiple different treatments and treatment combinations
include large numbers of people with mental disorders living in
communities throughout the US and receiving treatment across a
wide variety of settings
Individuals with more than one mental disorder, as well as those
with co-occurring physical illnesses, are encouraged to consider
participating in these new studies
Systematic Treatment Enhancement Program for Bipolar
Disorder (STEP-BD)
the whole point

improve treatment strategies and outcomes

evaluate how treatments influence other
important, real-world issues such as
quality of life
 ability to work
 social functioning


assess the cost-effectiveness of different
treatments and factors that affect how well
people stay on their treatment plans