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bipolar affective disorder

A major mood disorder characterized by episodes of major depression & mania or hypomania, formerly called manic-depressive psychosis, circular type. Diagnostic criteria: 1) bipolar I disorder requires one or more episodes of mania 2) bipolar II disorder requires one or more episodes of hypomania & is excluded by the history or presence of a manic episode. Epidemiology: - affects ~8 million people in U.S., ~40 million worldwide [45] - PREVALENCE 9.8% IN ONE STUDY [5]; LOWER IN OTHER POPULATIONS - 20% OF NON-RESPONDERS TO ANTI-DEPRESSANTS [12] Genetics: - polymorphism in tph2 gene associated with bipolar disorder [11] - pdlim5 is commonly increased in the brain of patients with bipolar disorder, schizophrenia, & major depression - overexpression of RIC3 in brains from patients with bipolar disease or schizophrenia - associated with variations in cacna1c & cacnb2 [19] - other implicated genes: CPLX2 Clinical Manifestations: 1) episode may be manic, depressed, hypomanic, or mixed manic type 2) mixed episodes: manic (irritable, talkative) but depressed rather than euphoric 3) elevated, expansive or irritable mood > 1 week, grandiosity, decreased need for sleep 4) symptoms causing disruption of social or occupational functioning - impulsive behavior - spending sprees [2] 5) manic episode may be presenting feature of bipolar 1 disorder a) increased goal-directed activity b) impulsive behavior c) increased sexual activity d) aggression 6) patients with bipolar 1 disorder may never have a major depressive episode [29] 7) chronic disorder, does not resolve with age [37] Laboratory: 1) thyroid function tests 2) anti-nuclear antibody 3) urine drug screen (patients presenting with manic episode) - amphetamines in urine - cocaine in urine - benzoylecgonine in urine Complications: 1) suicide rate, 10-15% if untreated [2] 2) substance abuse increase risk of mania with antidepressants 3) adverse pregnancy outcomes, regardless of treatment [17] 4) increased risk of dementia; lithium carbonate may be protective [38] 5) increased risk of mortality a) largely due to 1] cardiovascular disease 2] lung disease a] chronic obstructive pulmonary disease b] influenza or pneumonia b) possible a result of 1] lifestyle of the mentally ill 2] adverse effects of medications [16] c) other contributions from 1] diabetes mellitus 2] accidents 3] colon cancer (women only) [21] Differential diagnosis: - hyperthyroidism, thyrotoxicosis - partial-complex seizures - systemic lupus erythematosus - adverse effects of corticosteroids - schizophrenia spectrum disorders [35] - personality disorders [35] - drug abuse, alcohol abuse [35] - attention deficit hyperactivity disorder [35] Management: 1) mood stabilizer a) not initial therapy for patients presenting with mania or depression b) lithium carbonate - most effect mood stabilizer - patients on lithium 3 times less likely to attempt suicide than patients on valproate [3] - diminishes risk of suicide (odds ratio = 0.13) & all-cause mortality (odds ratio = 0.38) in patients with bipolar disease or unipolar depression [20] - initiation of lithium carbonate with 24 hours of delivery prevents postpartum psychosis [18] - 1st line agent [34] - may be 1st line agent in elderly [24] - lamotrigine may better than lithium in the elderly [37] - NEJM favors lithium over lamotrigine [43] - lithium more effective than divalproex for reducing manic symptoms in elderly [32] - early treatment may improve response rate [25] c) valproic acid (drug of choice for mixed episodes) [2] - combination of lithium carbonate plus valproate may be better than either alone for preventing relapse [13] - lamotrigine may better than valproic acid in the elderly [37] d) other mood stabilizers [2] - carbamazepine - oxcarbazepine (Trileptal) - lamotrigine (Lamictal) for depressive episodes [9] - preferable to valproic acid, carbamazepine & lithium in the elderly [37] - long-acting gabapentin injection prevents psychiatric rehospitalization (RR=0.6) [34] - adjunctive levothyroxine may be of benefit [36] e) life-long therapy with mood stabilizer [23] 2) patients presenting with severe mania or psychosis a) hospitalize if possible for high-risk behaviors [43] b) antipsychotics (1st line) better than anticonvulsants for manic episodes [15] - quetiapine - olanzapine (Zyprexa) - risperidone (Risperdal) - long-acting risperidone injection prevents psychiatric rehospitalization (RR=0.6) [34] - aripiprazole (Abilify) [14] - long-acting perphenazine injection prevents psychiatric rehospitalization (rr=0.6) [34] - haloperidol - most effective agent [15] - significantly more effective than all other agents except risperidone & olanzapine [15] - sublingual dexmedetomidine 120 ug or 180 ug reduces mild to moderate agitation 42] 3) patients presenting in the depressive phase - fluoxetine/olanzapine (symbyax) fda-approved for treatment of bipolar depression [9,12] - quetiapine monotherapy also fda-approved for treatment of bipolar depression [12] - lumateperone (Caplyta) FDA-approved to treat with depressive episodes associated with bipolar 1 disorder & bipolar 2 disorder as monotherapy or adjunctive therapy with lithium or valproate [41] 4) antidepressants - add to lithium or lamotrigine for severe depression - do not use SSRIs (or other antidepressants) alone; may trigger manic attack [14] - Symbyax, 1st FDA approved agent for bipolar depression [4] - adjunctive antidepressants may be stopped after remission of depression in bipolar 1 disorder [44] 5) intensive clinical management - adjunctive psychotherapy in addition to medication [40] - education, sleep hygiene, non-specific support - attention to physical symptoms &/or interpersonal & social rhythms therapy (ipsrt) may be of benefit [6] - bright light mid-day (noon) may improve depression [33] 6) elecroconvulsive treatment may benefit patients with treatment-resistant depression [26,28] - number needed to treat to benefit 1 person = 3 [26] 7) omega 3 fatty acids, 1-2 g/day may be of benefit [7] 8) screening: mood disorder questionnaire

Interactions

disease interactions

Related

mood disorder questionnaire

Specific

bipolar I disorder bipolar II disorder; bipolar depression

General

mood disorder

Database Correlations

OMIM correlations

References

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