It's Cycling, Not Polarity Understanding and Diagnosing the Bipolar Spectrum

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1 It's Cycling, Not Polarity Understanding and Diagnosing the Bipolar Spectrum Session 4022: American Psychiatric Nurses Association National Conference, Louisville, KY Andrew Penn, RN, MS, NP, CNS Psychiatric Nurse Practitioner Kaiser Permanente, Redwood City, CA Assistant Clinical Professor, UC San Francisco School of Nursing Board Member-at-Large, APNA, California Chapter 1

2 Disclosures No drug company stock or involvement Off label uses of medications will be discussed in this talk All content 2010 Andrew Penn, RN, MS, NP, CNS. All rights reserved. May not be reproduced without specific permission. 2

3 Objectives Understand the limitations of psychiatric diagnostics Explain how to systematically assess a patient's history for suggestions of bipolarity WARNING: Rapid advances in the diagnosis, pathophysiology, genetics, and treatment of bipolar disorder may render much of this lecture outdated. Stay tuned to the literature! 3

4 Case Study 30 year old female, training to enter a health care field CC: I think I might have bipolar disorder HPI: chronic low mood, anhedonia, anxiety/panic, insomnia, fatigue. Pattern is to have 2 weeks of depression that start and end with no clear precipitant. Currently feeling more confident, sociable, and in good mood. Hx: Chaotic upbringing. First depression age 13. Second depression age 21. Dysthymic since then. Date rape age 25. No Substance abuse No SI/HI/psychosis In psychotherapy Mother schizophrenic, father bipolar Wary of meds 4

5 Case Study Trazodone ineffective for insomnia Mirtazapine some initial response in mood/sleep, lasted about 2 months, then became depressed Paroxetine had used in past, wanted to try again. Became hypomanic. Realized she had similar sx in past. Increased energy, decreased sleep. Dysphoric racing thoughts. Lamotrigine rash (probably benign) on day 2 Lithium doing well. Still cycles, but depressions are shorter and less intense 5

6 How many people are bipolar? #National Comorbidity Study Goodwin/Ghaemi Akiskal/Angst 1.60 % General population percentage 3 % 5 % Highly recurrent depression may be in the bipolar spectrum Goodwin & Jamison, 2007 Manic Depressive Illness 6

7 Haven t we been here before? I m miserable and moody. I m depressed since I was a teenager. I can t sleep well because my thoughts are racing. My marriage is a mess Dx: Unresolved intra-psychic conflicts Dx: Repressed traumatic memories Dx: Bipolar Disorder? 7

8 Overdiagnosed or underdiagnosed? 700 patients reassessed using SCID 145 thought they were bipolar 555 thought they had other diagnosis 63 MET DSM criteria for BP 82 did not meet DSM criteria for BP 27 MET DSM criteria for BP 528 had a non-bp diagnosis 56% false positive misdiagnosis rate 4% false negative missed diagnosis rate Are we overdiagnosing bipolar more than we are missing it? Or are we not agreeing on the diagnosis? 8 Zimmerman, et al 2008 J of Clin Psych 69:6

9 What difference does it make? Who cares? 9

10 25 The perils of misdiagnosis - Rate (%) of lifetime suicide attempts * 23 % Percent Attempting % 17.2 % 0 Unipolar (N=1214) Bipolar I (N=606) Bipolar II (N=253) 1 in 5 bipolar patients die of suicide ** 10 *Rihmer et al. Psychiatric clinics of N. America 1999; **Goodwin & Jamison, 2007 Manic Depressive Illness

11 Costs of misdiagnosis 5% of bipolar pts account for 95% of psychiatric hospitalization costs 21% of money spent on mental illness dollars goes to bipolar disorder $45 billion/year (1991 data) Before atypical antipsychotics Sachs, et al 2003 Biol Psychiatry 11 53

12 Misdiagnosis: bipolar Only 1/3 of Pts seek help within one year of symptom onset 69% were misdiagnosed (usually as MDD) Average of 4 physicians consulted 1/3rd did not receive bipolar Dx for 10 years Age of onset 15-19, most common Hirschfeld et al J Clin Psychiatry 12

13 So, what s the problem? Why do we struggle to diagnose this? 13

14 Which symptoms? Symptoms DSM Diagnosis: Bipolar Disorder Professional consensus Pattern What pattern? 14 Illustrations from wikipedia commons

15 Current diagnostic criteria emphasize polarity not cycling 15

16 Current DSM-IV-TR Mood Disorders Unipolar Mood Disorder NOS Bipolar Major Depression Bipolar I Dysthymia Bipolar II Depression NOS Cylcothymia Bipolar NOS Schizoaffective disorder Substance induced Mood Disorder APA 2000, Diagnostic and Statistical Manual of Mental Disorders, 4 th edition, text revision 16

17 What s the pathophysiology of bipolar disorder? 17

18 Which proteins? STRESS + phenotype? Homeostatic disruption genotype Which genes? Bipolar Phenotype 18 Illustrations from wikipedia commons

19 What influence does PHARMA have on our diagnostic perceptions? 19

20 Bipolar cycling Mania Hypomania Euthymia Dysthymia Depression 20

21 Longitudinal pattern : Bipolar 1 Hypomanic/ Manic 9% Cycling/Mixed 6% #Asymptomatic euthymic 53% Depressed 32% Judd et al. Arch Gen Psychiatry

22 How does the bipolar 1 pt present? Hypomanic/ Manic 20% Depressed 67% Cycling/Mixed 13% Bipolar I patients usually present with depression Judd et al Arch Gen Psychiatry 22

23 Longitudinal Presentation: Bipolar 2 Asymptomatic or euthymic 46% Hypomanic/ Manic 1% Cycling/Mixed 2% Depressed 51% 23 Judd et al. Arch Gen Psychiatry 2003

24 How does the bipolar 2 pt present? Hypomanic 2% Cycling/Mixed 4% Depressed 94% Bipolar II pts present as depressed 24 Judd et al Arch Gen Psychiatry

25 The challenge of diagnosis Your challenge is to look for patterns Pt s may not think of hypomania as significant Ask about significant energy changes Look for cycling more than polarity Memory is colored by present mood state Family can help make the diagnosis Sometimes the question is: How bipolar is this pt? 25

26 The mood disorder spectrum Bipolarity Index Score 100 Bipolar I 80 Bipolar II 60 Bipolar NOS <20 40 Major Depressive Disorder Highly recurrent, antidepressant resistant Major Depressive Disorder Minimally recurrent, antidepressant responsive Relative prevalence in general populations Sachs GS et al 2004 Acta Psychiatr Scand Suppl 422 (not to exact scale) 26

27 Age of Onset 20 First episode age years 15 - First episode before15 or between years 10 First episode years 5 First episode after 45 years 27 Sachs GS et al 2004 Acta Psychiatr Scand Suppl 422

28 Episode Characteristics 20 Mania with euphoria/grandiosity 15 Mixed or irritable mania 10 Clear hypomania or full mania with antidepressants 5 Subthreshold hypomania or clear hypomania with antidepressants 2 Recurrent MDD or any history of psychosis 28 Sachs GS et al 2004 Acta Psychiatr Scand Suppl 422

29 Course of illness 20 - Recurrent, full mania, full recovery 15 - Recurrent manic episodes with incomplete interepisode recovery 10 - Psychotic features during acute mood episodes OR Substance abuse OR legal problems when manic 5 - Recurrent MDD with at least 3 distinct episodes - Borderline PD - Comorbid anxiety or eating disorders - Recurrent hypomania without full inter-episode recovery - history of financial or sexual impulsivity 2 - Hyperthymic temperament * * * Other criteria exist at this level. See Sachs GS et al 2004 Acta Psychiatr Scand Suppl

30 Response to Treatment 20 - Full recovery within 4 weeks of starting mood stabilizer 15 - Full recovery within 12 weeks of starting mood stabilizer OR relapse within 12 weeks of stopping mood stabilizer OR switch to mania within 12 weeks of starting antidepressant 10 Worsening dysphoria or mixed state with antidepressants, but not mania 5 lack of response to at least 3 antidepressants OR switching to hypo/mania when stopping antidepressants OR Partial response to mood stabilizers within 12 weeks OR Antidepressant induced rapid cycling 2- rapid recovery (within a week) with antidepressants 30 Sachs GS et al 2004 Acta Psychiatr Scand Suppl 422

31 Family History 20 - at least one 1st degree relative with documented BD 10-1 st degree relative with MDD, R OR any relative with BD OR Any relative with documented recurrent MDD and behavior suggesting BD 5-1 st degree relative with substance abuse OR relative with documented substance use OR relative with possible BD 2-1st degree relative with possible recurrent unipolar MDD 1st degree relative with diagnosed related illness: anxiety disorders eating disorders ADD 31 Sachs GS et al 2004 Acta Psychiatr Scand Suppl 422

32 30 year old female HPI: chronic low mood, anhedonia, anxiety/panic, insomnia, fatigue. Pattern is to have 2 weeks of depression that start and end with no clear precipitant. Currently feeling more confident, sociable, and in good mood. Hx: First depression age 13. Second depression age 21. Dysthymic since then. Date rape age 25. No Substance abuse No SI/HI/psychosis In psychotherapy Mother schizophrenic, father bipolar Wary of meds 5 - Recurrent MDD with at least 3 distinct episodes 15 - First episode before15 or between years 20 at least one 1st degree relative with documented BD 32

33 Trazodone ineffective Mirtazapine some initial response in mood/sleep, lasted about 2 months, then became depressed Paroxetine had used in past, wanted to try again. Became hypomanic. Realized she had similar sx in past. Increased energy, decreased sleep. Dysphoric racing thoughts. Lamotrigine rash (probably benign) Lithium doing well. Still cycles, but depressions are shorter and less intense 60/100 5 Subthreshold hypomania or clear hypomania with antidepressants 15 - Full recovery within 12 weeks of starting mood stabilizer 33

34 The mood disorder spectrum Bipolarity Index Score 100 Bipolar I 80 Bipolar II 60 Bipolar NOS <20 40 Major Depressive Disorder Highly recurrent, antidepressant resistant Major Depressive Disorder Minimally recurrent, antidepressant responsive Relative prevalence in general populations Sachs GS et al 2004 Acta Psychiatr Scand Suppl 422 (not to exact scale) 34

35 What difference does it make? 35

36 Good treatment follows correct Dx MEDICATIONS First line medications should be proven mood stabilizers Lithium, valproate, quetiapine, lamotrigine Favor mood stabilizers over antidepressants 36

37 Good treatment follows correct Dx PSYCHOTHERAPY Improving diagnostic accuracy Psychoeducation Treating depression Maintaining family support Maintaining circadian rhythms Contingency planning for the future 37 Miklowitz, The Bipolar Disorder Survival Guide 2002

38 With treatment Mania CEILING FLOOR Less cycling, more time euthymic Depression 38

39 Right diagnosis, right treatment improves quality of life Reporting Before Tx Relationship problems 49% 30% Work/School Problems 73% 53% Substance abuse 37% 14% Reporting After Tx Divorce rate 3-6x higher among people with BP Hirschfeld et al J Clin Psychiatry 39

40 What does the future hold Spectrum and dimensional based DSM Confirmatory genetic testing Additional and more effective therapies Psychiatry is the repository of uncertainty 40

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