Bipolar and Depression
Dr. Dawn-Elise Snipes PhD, LMHC
Executive Director, AllCEUs.com
Objectives
~ Differentially Diagnose Bipolar Disorder and Depression
~ Recognize general medical conditions and drugs that may mimic depression or mania
~ Understand the goals of psychiatric management of bipolar disorder and depression
~ Identify bipolar patients at increased risk of suicide
~ Understand the link between bipolar disorder and substance abuse
~ Identify key areas of consideration when making a treatment placement decision
~ Learn about the areas which patients with bipolar disorder and their families may need education
~ Familiarize with the most common psychopharmacological interventions for bipolar disorder
Bipolar I and II
~ Bipolar I disorder: at least one episode can be characterized as mania
~ Episodic, lifelong illness with a variable course
~ The first episode may be manic, hypomanic, mixed, or depressive
~ Patients may experience several episodes of depression before a manic episode
Differential Diagnosis
~ Ask about a history of depression accompanied or followed by manic or hypomanic symptoms
~ Assess for substance use disorder, other general medical conditions or medications
~ Medical conditions associated with manic-like symptoms include:
~ Multiple sclerosis
~ Lesions closely linked to the limbic system
~ Hyper or hypothyroid
~ Head injuries
~ Encephalitis
Medications Associated with Manic-like Symptoms
~ L-Dopa
~ Corticosteroids
~ High-dose decongestants
~ Stimulants (weight loss, ADHD)
~ Antidepressants may trigger a manic episode
Substance Use
~ May cause manic-like episodes
~ May help patient self-medicate
~ Stimulants (manic like symptoms)
~ Cocaine
~ Methamphetamines/Amphetamines
~ Ephedrine
~ Ecstasy/MDMA
~ Caffeine
Patients with Bipolar
~ Seek treatment during depressive episodes
~ Rarely volunteer information about manic or hypomanic symptoms
~ Do not see the symptoms of hypomania to be distressing
Suicide
~ Completed suicide rates 10% to 15%
~ Suicide attempts associated with depressive episodes or depressive features of mixed episodes
~ Ask every patient about suicidal ideation
Increased Risk Factors
~ Factors associated with increased risk:
~ Means
~ Lethality
~ Family history of suicide
~ Pervasive insomnia
~ Impulsiveness
~ Psychiatric comorbidity
~ Psychosis
~ Personality disorder
~ Lack of social support
Hospitalization
~ Patients who:
~ Pose a serious threat of harm to themselves
~ Are severely ill
~ Lack adequate social support
~ Demonstrate significantly impaired judgment
~ Have complicating psychiatric or general medical conditions
~ Have not responded adequately to outpatient treatment.
~ Re-evaluate treatment setting regularly
Education
~ Should introduce facts about the illness and its treatment
~ Use printed, verbal and videotaped material
~ Present in an ongoing gradual and consistent process
~ Use psychoeducational groups
Stressors
~ Commonly precede episodes
~ Disrupted sleep-wake cycles may specifically trigger manic episodes
~ Physical illnesses that cause changes in eating and/or dehydration
~ Alter blood plasma levels
~ May require dose adjustment
~ Regular patterns should be promoted
Counselor Activities
~ Preplanning
~ Plan for impairments in functioning
~ Assisting patient in scheduling absences from work
~ Avoid major life changes
~ Plan for the needs of their children while the patient is in an acute state
~ Assist the patient who is able to work in contacting vocational rehab
~ Assist the patient in linking with a case manager and/or services
Medication
~ Severe mania or mixed episodes:
~ Antipsychotic and valproate or lithium
~ Mild to moderate mania or mixed episodes:
~ Monotherapy with an antipsychotic, valproate or lithium
~ Short-term adjunctive treatment with a benzodiazepine may be helpful
~ Mixed episodes:
~ Certain drugs preferred over lithium
~ Atypical antipsychotics preferred over typical antipsychotics
Antidepressants
~ Use earlier for bipolar II depression than for bipolar I
~ Patients with bipolar II disorder have lower rates of antidepressant induced switching into hypomania or mania
~ Antidepressants may increase mood cycling
~ Recommended to combine mood stabilizer with antidepressant
Electroconvulsive Therapy (ECT)
~ May be considered for:
~ Patients who are severely ill
~ Whose mania or depression is treatment resistant
~ Who experience symptoms during pregnancy
Goals of Treatment
~ Prevent relapse and recurrence
~ Reduce cycling frequency and subthreshold symptoms
~ Reduce suicide risk
~ Improve overall functioning
Psychosocial Interventions
~ Address:
~ Illness management
~ Treatment
~ Triggers
~ Relapse Prevention
~ Interpersonal difficulties
~ Coping skills and distress tolerance
~ Cognitive distortions
~ Wellness behaviors and vulnerability prevention
Enhance Treatment Compliance
~ Assess potential barriers: Lack of motivation or excessive pessimism; side effects of treatment; problems in the therapeutic relationship; and logistical, economic, or cultural barriers to treatment.
~ Collaborate with the patient (and, if possible, the family) to min-imize barriers.
~ Encourage the patient to articulate concerns about treatment or its side effects, and consider the patient’s preferences for treatment
~ Recognize that during the acute phase, depressed patients may be poorly motivated and unduly pessimistic and may suffer deficits of memory.
Enhance Treatment Compliance
~ During the maintenance phase, euthymic patients may undervalue the benefits and focus on the burdens of treatment.
~ In patients who prefer complementary and alternative thera-pies, S-adenosyl methionine (SAMe) or St. John’s wort might be considered, although evidence for their efficacy is modest, and careful attention to drug-drug
~ Bright light therapy may be considered to treat seasonal affective disorder as well as nonseasonal depression.
Enhance Compliance…
~ Promote awareness patterns of activity and sleep
~ Work with the patient to anticipate and address early signs of relapse
~ Evaluate and manage functional impairment
Side Effects
~ Bruxism
~ Activation or sedation
~ Headaches (assess etiology and treat)
~ Medications used for migraine treatment, called triptans, and SSRIs both increase the brain chemical serotonin. Serotonin syndrome, which causes flushing, rapid heart rate, and headache, can occur if these medications are taken together.
~ Nausea
~ Divided doses
~ Administer with food
~ Weight gain
~ Evaluate causes
~ Bupropion (not in people with a hx of ED)
Side Effects
~ Sexual Side Effects
~ Bupropion (Wellbutrin XL, Wellbutrin SR, Aplenzin, Forfivo XL) a norepinephrine-dopamine reuptake inhibitor (NDRI)
~ Mirtazapine (Remeron) atypical antidepressant; typically increases appetite
~ Dry Mouth
~ Suicidal ideation
~ Sleep disturbances (nightmares, sleepwalking, easily waking)
~ Constipation
~ https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-guide.pdf
Postpartum Period
~ Associated with increased risk for relapse into mania, depression, psychosis
~ Rate of postpartum relapse is as high as 50%
Prevalence in Children and Adolescents
~ 1%
~ Additional 5% to 6% have mood symptoms NOS
~ Children with bipolar disorder often have:
Mixed mania
Rapid cycling
Psychosis
~ Often comorbid with attention deficit and conduct disorders
Prevalence in Children and Adolescents
~ Children and teens having a manic episode may:
~ Feel very happy or act silly in a way that's unusual
~ Have a very short temper
~ Talk really fast about a lot of different things
~ Have trouble sleeping but not feel tired
~ Have trouble staying focused
~ Talk and think about sex more often
~ Do risky things.
Prevalence in Children and Adolescents
~ Children and teens having a depressive episode may:
~ Feel very sad
~ Complain about pain a lot, like stomachaches and headaches
~ Sleep too little or too much
~ Feel guilty and worthless
~ Eat too little or too much
~ Have little energy and no interest in fun activities
~ Think about death or suicide.
Elderly
~ In patients over 65 years of age, prevalence rates of bipolar disorder range from 0.1% to 0.4%
~ Most manic symptoms are due to a general medical condition or medication
Summary
~ Bipolar can be diagnosed in children, adults and elderly
~ Wide range of medications effective in treatment
~ Psychosocial interventions focus on minimizing stress and increasing routines