BIPOLAR DISORDER AND MANAGEMENT

1. Bipolar disorder and
management

2. Bipolar disorder
• Also known as manic depression, a mental illness that
causes a person’s moods to swing from extremely
happy and energized (mania) to extremely sad
(depression)
• Chronic illness; can be life-threatening
• Most often diagnosed in adolescence

3. Epidemiology
Mortality/Morbidity
 Bipolar disorder has significant morbidity and mortality rates.
 Approximately 25-50% of individuals with bipolar disorder attempt
suicide, and 11% actually commit suicide.
Race: No racial predilection exists.
Sex
 Bipolar I disorder occurs equally in both sexes; rapid-cycling bipolar
disorder (4 or more episodes a year) is more common in women than
in men.
 Incidence of bipolar II disorder is higher in females than in males.

4. Epidemiology
Age
 The age of onset of bipolar disorder varies greatly.
 The age range for both bipolar I and bipolar II is from childhood to
50 years, with a mean age of approximately 21 years,(15-19
years),(20-24 years).
 Onset of mania in people older than 50 years should lead to an
investigation for medical or neurologic disorders such as
cerebrovascular disease.

5. Contributing factors
Evidence is mounting of the contribution of glutamate to both bipolar
and major depressions
catecholamine hypothesis, which holds that an increase in epinephrine and
norepinephrine causes mania and a decrease in epinephrine and
norepinephrine causes depression.
Hormonal imbalances and disruptions of the hypothalamic-pituitary-
adrenal axis involved in homeostasis and the stress response may also
contribute to the clinical picture of bipolar disorder.
Biochemical causes

6. Contributing factors
Mania serves as a defense against the feelings of
depression
Psychodynamic
Environmental
External stresses or the external pressures may serve to
exacerbate some underlying genetic or biochemical
predisposition.
Pregnancy is a particular stress for women with a manic-
depressive illness history and increases the possibility of
postpartum psychosis

8. Mania-Clinical symptoms
• Inflated self-esteem or grandiosity.
• Decreased need for sleep
• More talkative than usual
• Flight of ideas or subjective experience that
thoughts are racing.
• Distractibility
• Increase in goal-directed activity or
psychomotor agitation.
• Excessive involvement in pleasurable
activities that have a high potential for painful
consequences

9. Depression- Clinical symptoms
• Depressed mood
• Diminished interest or pleasure in all, or almost all, activities
• Decreased or increased appetite
• Significant weight loss or gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death
• Recurrent suicidal ideation or attempts

13. Akiskal's Schema of Bipolar
Subtypes
Bipolar I: full-blown mania
Bipolar I ½: depression with protracted hypomania
Bipolar II: depression with hypomanic episodes
Bipolar II ½: cyclothymic disorder
Bipolar III: hypomania due to antidepressant drugs
Bipolar III ½: hypomania and/or depression associated with substance use
Bipolar IV: depression associated with hyperthymic temperament
Bipolar V: recurrent depressions that are admixed with dysphoric
hypomania
Bipolar VI: late onset depression with mixed mood features, progressing to
a dementia-like syndrome Psychiatric Clinics of North America 22:3, September 1999;
Medscape Family Medicine, 2005;7[1]

14. Bipolar Disorder Diagnosis
• The Diagnostic and Statistical Manual of Mental Health
Disorders (DSM) is published by the American Psychiatric
Association (APA) and is the guideline by which the medical
community diagnoses mental health issues.
• The term “bipolar disorder” made its debut in the third edition
of the DSM (DSM-III), published in 1980. This term replaced
“manic depressive disorders,” and better represented the
polarity between moods of mania and depression.
• The DSM-5, published in May 2013, has also seen some changes
in regard to bipolar disorder.

15. DSM-5 criteria
Bipolar I
Manic episodes lasting at least a week, or by symptoms of
mania so severe that a person requires immediate
hospitalization. A person will also normally experience a
depressive episode of about two weeks. For a bipolar I
diagnosis, a person’s manic and depressive symptoms
must deviate from their normal behavior.
Bipolar II
Cycle of depressive episodes shifting back and forth with
hypomanic episodes, without experiencing full-blown
manic or mixed episodes.

16. DSM-5 criteria
Other Specified
Bipolar and Related
Disorder (previously
called Bipolar Not
Otherwise Specified)
Those with a past history of a major depressive
disorder who meet all the requirements for
hypomania except the duration of their episodes.
This can also include those exhibit too few
symptoms of hypomania to be diagnosed with
Bipolar II, though the duration of their episodes is
4 days or more.
Cyclothymia
At least 2 years of hypomanic episodes shifting
back and forth with episodes of mild depression.
This diagnosis is considered a mild form of bipolar
disorder because the symptoms do not meet the
requirements for other types of bipolar disorder.

18. AACAP guideline for assessment of
bipolar in children

19. Non-pharmacological
treatment
• Interpersonal, family and group therapy
• Cognitive-behavioral therapy (CBT)
• Electroconvulsive therapy (ECT)
• Psychoeducation

20. Basic principles to handle
bipolar patients
• Take extra time to listen and communicate with patients and their
families
• Encourage peer to peer support
Create and foster a therapeutic alliance
Offer education about the diagnosis and treatment
• Educate patient and family about the seriousness of the illness
and benefits of appropriate therapy
• Provide the patient with patient education materials

21. Basic principles to handle
bipolar patients
• Educate the patient and family about medication treatment
options, therapeutic effects, possible adverse effects, and the
likely need for long term medication
• Encourage the patient and family to express their treatment
preferences
Enhance adherence with treatment

22. Monitorand manage symptoms and risk
• Encourage the patient to permit ongoing involvement of one or more
trusted family members or friends in the patient's treatment
• Solicit information from family and other third parties when assessing
risk, especially suicide risk, substance use, and social isolation
• Encourage open discussion about risky behavior
• During times the patient is well, engage the patient and family (or
partner) to develop interventions that target reckless behavior during
future illness episodes
• Encourage self monitoring of mood and medication use
• Encourage regularity of sleep, daily activities, and medication use

23. Pharmacological treatment
For the depressive phase of this illness, anti-depressant
medications can relieve depressed feelings, restore normal
sleep patterns and appetite, and reduce anxiety.
Anti-depressant medications are not addictive.
They slowly return the balance of neurotransmitters in the
brain, taking one to four weeks to achieve their positive
effects.

24. Pharmacological treatment
During acute or severe episodes of mania, several different
medications are used.
Some are used to calm the person’s manic excitement; others
help to stabilize the person’s mood.
Some medications are also used as preventive measures as
they help to control mood swings and reduce the frequency
and severity of depressive and manic phases.
Long term medication may be required to prevent recurrent
episodes.

25. Agents used for bipolar
disorder

27. Initial Treatment Guidelines for
Bipolar Disorder

28. 6/22/2016