Bipolar Disorder Michael Coudreaut, MD Consultation liaison psychiatry at Intermountain Medical Center; Adjuctive assistant professor, Departments of psychiaitry, University of Utah; Salt Lake City, Utah Objectives: Recognize major features of bipolar disorder Discuss the effects Bipolar Disease can have on sleep Identify safe treatments
Bipolar Disorder Lecture by Michael Coudreaut MD No Disclosures Consultation Liaison Psychiatry Intermountain Medical Center Adjunct Assistant Professor, U of U Dept. of Psychiatry
Manic Episode A. 1 week B. 3 or 4 of below 1. Grandiosity 2. Need for Sleep 3. Pressured Speech 4. FOI/Racing Thought 5. Distractibility 6. Goal Directed 7. Risky Behavior C. Marked Impairment D. Not.
Hypomania A. 4 day mood change B. Same 7 criteria for mania C. Unequivocal change in functioning D. Observable by others E. Not marked impairment/no need for hospitalization F. Not...
Notables BD II no longer considered a milder form of BD I BD I age of onset = 18 BD II age of onset = 25 10 fold increased risk among relatives of BDI/BD II
Notables cont. Schizophrenia and BD likely share genetic origin. Familial co aggregation exists Women have more rapid cycling, mixed states, depression and alcoholism Suicide risk 15X general population Pts with BD die a number of ways related to their illness Sig. decrease in life expectancy
Notables cont. again BD II is more chronically debilitating and Patients spend more time depressed Different age of onset. 18 vs. 25 Risk of BD II highest among relatives with BD II compared to BD I or depression Rapid cycling associated with poorer prognosis
Substance/Medication Induced Bipolar and Related Disorder A. Mood Change B. Evidence from Hx., labs, or PE show 1 & 2 1. After intoxicaton or withdrawal 2. The agent can cause mood change C. Not bipolar disorder D. Not delirium E. Symptoms cause sig. distress or impairment in functioning
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified Bipolar and Related Disorder 1. Short duration hypomanic and depressive episodes 2. Hypomanic episodes with insufficient symptoms and MDE 3. Hypomanic episode without prior MDE 4. Short duration cyclothymia
Diagnose MDQ Rule out BD I/II before treatment for depression Explore bad outcomes with antidepressants Ask the patient directly, Do you think you have bipolar disorder? Explore family history and meaning of family history
Diagnose some more Collateral info Have you ever stayed up all night painting the garage?...in your underwear?
Neuroimaging in BD BD and BPD display differential patterns of functional connectivity. Das et al. 2014 Abnormal FC in medial cortex in euthymic BDII Marchand et al. 2014 PET shows phase specific abnormalities of metabolism. Dell Osso 2014
Treat Go evidenced based first BAD I mania has the lion share of FDA approved medications for BD
Phases of Bipolar Disorder Type I
Pharmacology for Bipolar Disorder Antipsychotics Anticonvulsants Lithium
Antipsychotics for Acute Mania Aripiprizole Asenapine Quetiapine and XR Risperdone Olanzapine Ziprazidone Chlopromazine
Acute Mania Treatment Divalproex sodium Lithium Carbamazepine
FDA Approved Maintenance Meds 1. Lamotrigine 2. Lithium 3. Olanzapine 4. Aripiprazol 5. Risperidone Consta 6. Quetiapine with Li+ or Valproate 7. Ziprazadone with Li+ or Valproate
FDA approved BAD depression meds 1. Quetiapine 2. Lurasidone 3. Olanzapine/Fluoxetine
Case Presentation 28 year old underemployed male hospitalized with 1 st manic episode at 22. BMI of 35, alcohol use and occasional meth use admitted for suicidal ideation and who reports chronic insomnia irritability, racing thoughts. Lamictal 200 mg po qam Seroquel 400mg qhs Lithium 600 mg qhs Clonazepam 1 mg Bid.
Donald Rumsfeld There are known knowns; there are things we know that we know. We Also know there are known unknowns There are also unknown unknowns.
Sleep in BD Sleep deprivation appears to precipitate mania Depressives are hypersomnic Rapid resolution of first episodes of mania occurs with sleep restoration Nowlin Finch et al. 1994
Sleep/plasticity/mental health SWS and REMS important for memory consolidation and synaptic plasticity. Many psych meds, ie. Li+, antipsychotics, antidepressants, AEDs, and exercise increase Brain Derived Neurothrophic Factor (BDNF) or Nerve Growth Factor (NGF) Jain 2014, Angelucci 2005, Taler 2013
Specific sleep effects of commonly used psych meds Olanzapine increases sleep efficiency, SWS by 83% @ 10mg, decreased REM Sharpley 2000 Clozapine had a 6% decrease in SWS Kluge 2014 Gabapentin, Pregabalin, Carbamazepine reduce sleep latency and increase SWS Jain 2014, Legros 2003 Lithium increases SWS. Decreases REM. Ota 2013
Specific med effects on Sleep VPA improved efficiency and SWS in pts. with PLMD Ehrenberg 2000 Haloperidol in mania showed no improvement in sleep promotion but was equal in efficacy to Olanzapine. Moreno 2007 Olanzapine increased sleep time, efficiency, SWS and REM and subjective sleep Haloperidol and risperidone showed increase stage 2 in same study. Gimenez 2007
Electroconvulsive Therapy Sleep effects? Seizure induced neurotrophic effects Increased rates of neurogenesis Synaptogensisis Glial proliferation, particularly in hippocampus (in rats) Wennstrom 2004, Chen 2009
Psychotherapy CBT Interpersonal Psychotherapy DBT Mindfulness/Meditation Supportive Therapy/instill hope
Reading Feeling Good By David Burns, MD The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness by Mark Williams A Brilliant Madness By Patty Duke Borderline Personality Disorder Survival Guide Alexander Chapman Overcoming BPD: A Family Guide Valerie Porr