Bipolar Disorder:Bipolar Disorder:Journey Through Mania Journey Through Mania

and Depressionand Depression

H.E. Logue, M.D.H.E. Logue, M.D.

Bias DisclaimerBias Disclaimer

There is no pharmaceutical support There is no pharmaceutical support for this program.for this program.

I am active in the research field and I am active in the research field and involved in clinical trials for most of involved in clinical trials for most of the major pharmaceutical the major pharmaceutical companies.companies.

Goals and ObjectivesGoals and Objectives

Promote better understanding of the Promote better understanding of the following aspects of Bipolar Disorder:following aspects of Bipolar Disorder: PrevalencePrevalence Recognition and Diagnosis Recognition and Diagnosis Understanding Risk FactorsUnderstanding Risk Factors Genetic PredispositionGenetic Predisposition Treatment ConsiderationsTreatment Considerations Co-morbid ConditionsCo-morbid Conditions Referral ConsiderationReferral Consideration

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Richard Dreyfuss

Kitty Dukakis Liza Minnelli Carman

Miranda Marilyn

Monroe J.P. Morgan Ralph Nader Sir Isaac

Newton Florence

Nightingale Ozzy Osbourne Dolly Parton Boris

Pasternak George Patton Jane Pauley Pablo Picasso Cole Porter Abraham

Lincoln Joshua Logan Jack London Greg Louganis Martin Luther Imelda Marcos Ann Margaret Herman

Melville Burgess

Meredith Kurt Vonnegut Vivian Vance

Victor Hugo Edgar Allen

Poe Leo Tolstoy Michelangelo Ezra Pound Charlie Pride Sergey

Rachmaninoff Patty Duke Thomas

Eagleton Thomas Edison T.S. Eliot Ralph Waldo

Emerson William

Faulkner Eddie Fisher F. Scott

Fitzgerald Betty Ford Harrison Ford Stephen Foster Sigmund Freud King George III Tipper Gore Robert E. Lee Vivian Leigh John Lennon Alexander

Hamilton Joan Rivers Norman

Rockwell

Charles Schultz

King Saul William

Tecumseh Sherman

Neil Simon Rod Steiger William Styron Alfred, Lord

Tennyson King Herod Nathaniel

Hawthorne Ernest

Hemingway Audrey

Hepburn Howard

Hughes Thomas

Jefferson Joan of Arc Lyndon

Baines Johnson

Danny Kaye Ted Turner Mozart Larry King Jessica Lange Mark Twain Mike Tyson Jean Claude

Van Damme Queen

Victoria

Mike Wallace George

Washington Robin Williams Tennessee

Williams Thomas Wolfe Virginia Woolf Lord Tennyson Vincent van

Gogh Peter

Tchaikovsky F. Scott

Fitzgerald Charles Dickens Robert Louis

Stevenson Walt Whitman Sylvia Plath Marlon Brando Art Buckwald John Bunyan Rodney

Dangerfield Charles Darwin King David John Denver Princess Diana

of Wales Charles Dickens Emily Dickenson Theodore

Dostoevski Jack Dreyfus

Drew Carey Dick Cavett Ray Charles Frederick

Chopin Winston

Churchill Dick Clark Rosemary

Clooney Kurt Cobain Natalie Cole Samuel

Coleridge Sheryl Crow Irving Berlin Steven Foster Lord Byron

(George Gordon)

Noel Coward Alexander the

Great Edwin “Buzz”

Aldrin Hans Christian

Anderson Roseanne Barr Ludwig Von

Beethoven William Blake Napoleon

Bonaparte

PrevalencePrevalence

Bipolar Disorder affects approximately 5.7 million Bipolar Disorder affects approximately 5.7 million adult Americans adult Americans

The median age of onset for Bipolar Disorder is The median age of onset for Bipolar Disorder is 25 years.25 years.

An equal number of men and women develop An equal number of men and women develop Bipolar Disorder and it is found in all ages, races, Bipolar Disorder and it is found in all ages, races, ethnic groups and social classes.ethnic groups and social classes.

Bipolar Disorder is the sixth leading cause of Bipolar Disorder is the sixth leading cause of

disability in the world. disability in the world.

Bipolar Disorder results in 9.2 years reduction in Bipolar Disorder results in 9.2 years reduction in expected life span, and as many as one in five expected life span, and as many as one in five patients with bipolar disorder completes suicide. patients with bipolar disorder completes suicide.

Bipolar Disorder SubtypesBipolar Disorder Subtypes

Classic Bipolar DisorderClassic Bipolar Disorder Bipolar IBipolar I Bipolar II Bipolar II

SubtypesSubtypes CyclothymiaCyclothymia Major Depression Unipolar/RecurrentMajor Depression Unipolar/Recurrent Dysthymic DisorderDysthymic Disorder

Bipolar NOS (Not Otherwise Specified)Bipolar NOS (Not Otherwise Specified) Other Considerations Other Considerations

Rapid Cycling (part of Bipolar I)Rapid Cycling (part of Bipolar I) Post-partum OnsetPost-partum Onset Seasonal Pattern Mood DisordersSeasonal Pattern Mood Disorders

Five or more of the following:

Depressed mood Diminished interest or pleasure in activities Significant weight loss/gain or decrease/increase in

appetite 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, or

indecisiveness Recurrent thoughts of death, recurrent suicidal ideation

without a specific plan, or a suicide attempt or a specific plan for committing suicide.

DSM-IV Criteria - DepressionDSM-IV Criteria - Depression

Diagnostic DilemmasDiagnostic Dilemmas

Secondary DepressionSecondary Depression

Depression with…Depression with… Other psychiatric illnessesOther psychiatric illnesses

SchizophreniaSchizophrenia Anxiety Anxiety

Panic disorderPanic disorder Obsessive-compulsive disorderObsessive-compulsive disorder

Personality Disorders Personality Disorders BorderlineBorderline CompulsiveCompulsive

Post-traumatic stress disorderPost-traumatic stress disorder Post-partum depressionPost-partum depression Grief/depressionGrief/depression Practically any psychiatric disorderPractically any psychiatric disorder

Depression with…Depression with… Organic/Medical IllnessesOrganic/Medical Illnesses

HypothyroidismHypothyroidism B-12 deficiencyB-12 deficiency Folate deficiency Folate deficiency TuberculosisTuberculosis Myasthenia gravisMyasthenia gravis Diabetes mellitusDiabetes mellitus Hepatitis CHepatitis C Cushing’s diseaseCushing’s disease MononucleosisMononucleosis Parkinson’s diseaseParkinson’s disease CHRONIC FATIGUE SYNDROMECHRONIC FATIGUE SYNDROME

DSM-IV Criteria - ManiaDSM-IV Criteria - Mania

Three or more of the following:

Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep

talking 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

Mood SymptomsMood Symptoms

Euphoria/ManiaEuphoria/Mania Depression (in mixed state)Depression (in mixed state) Anxiety Anxiety AngerAnger HostilityHostility IrritabilityIrritability

Behavioral SymptomsBehavioral Symptoms

Energized ActivityEnergized Activity Diminished Need to/for SleepDiminished Need to/for Sleep ImpulsivityImpulsivity

Anger with Violence Anger with Violence Elevated LibidoElevated Libido Diminished InhibitionsDiminished Inhibitions Reckless BehaviorReckless Behavior

Cognitive SymptomsCognitive Symptoms

Racing Rapid ThoughtsRacing Rapid Thoughts Diminished Insight/InvincibilityDiminished Insight/Invincibility Sensory Hyperacuity Sensory Hyperacuity HallucinationsHallucinations DelusionsDelusions Perceptual DistortionsPerceptual Distortions Distractible Disorganized ThoughtsDistractible Disorganized Thoughts

S-H-O-TS-H-O-T S: Symptomatology

Do the symptoms appear to be manic or depressed or repeated episodes of depression or mania or continuing mood swings?

H: History What is the history of the person? The history of the

family? Is there a family history of mood swings, mood disorders, substance abuse in persons with mood disorders or Bipolar diagnosis?

O: Ongoing illness What is the progression of the illness? What is the

course of the disease? Does it continue to go on in a progression appearing as a Bipolar disease course?

T: Treatment response If one looks at the response of the treatment one should

get a good deduction as to the nature of the illness.

Understanding Risk FactorsUnderstanding Risk Factors

Stress (major or prolonged)Stress (major or prolonged) Sleep Deprivation/DisruptionSleep Deprivation/Disruption Alcohol (major problem)Alcohol (major problem) ““Recreational” Drug UseRecreational” Drug Use Discontinuation of MedicationsDiscontinuation of Medications Loss or Perceived Loss (job, family, friends, finances, Loss or Perceived Loss (job, family, friends, finances,

health, etc.)health, etc.) Interpersonal ConflictInterpersonal Conflict Travel Across Time ZonesTravel Across Time Zones Mood-Altering Medications (benzodiazepines, Mood-Altering Medications (benzodiazepines,

antidepressants, antipsychotics)antidepressants, antipsychotics) Death of Loved One or FriendDeath of Loved One or Friend Inadequate Coping SkillsInadequate Coping Skills Early Dementia or Minimal Brain DamageEarly Dementia or Minimal Brain Damage

TreatmentTreatment

Depression: Depression: Pre-Modern EraPre-Modern Era Tincture of Time Tincture of Time

Prescribed trip to EuropePrescribed trip to Europe ActivityActivity

Physical Physical SocialSocial MentalMental

SomaticSomatic Insulin shockInsulin shock Electric shockElectric shock

SpiritualSpiritual

Depression: Depression: Modern Modern EraEra Education and Education and

PsychotherapyPsychotherapy PharmacotherapyPharmacotherapy

1950’s – Tricyclics1950’s – Tricyclics 1960’s – Tetracyclics, 1960’s – Tetracyclics,

etc.etc. 1990’s – SSRIs 1990’s – SSRIs

(Prozac, Paxil, Zoloft)(Prozac, Paxil, Zoloft) SNRI (Wellbutrin)SNRI (Wellbutrin) SSNRIs (Effexor, SSNRIs (Effexor,

Remeron, Cymbalta)Remeron, Cymbalta) SpiritualSpiritual

Depression vs. Bipolar DepressionDepression vs. Bipolar Depression

Treatment StatisticsTreatment Statistics Patients with Bipolar Disorder face up to ten years of Patients with Bipolar Disorder face up to ten years of

coping with symptoms before receiving an accurate coping with symptoms before receiving an accurate diagnosis.diagnosis.

Nearly 9 out of 10 patients with bipolar disorder are Nearly 9 out of 10 patients with bipolar disorder are satisfied with their current medication(s), although side satisfied with their current medication(s), although side effects remain a problem. effects remain a problem.

Participation in a Depression and Bipolar Support Participation in a Depression and Bipolar Support Alliance patient-to-patient support group improved Alliance patient-to-patient support group improved treatment compliance by almost 86% and reduced in-treatment compliance by almost 86% and reduced in-patient hospitalization. patient hospitalization.

Consumers who report high levels of satisfaction with Consumers who report high levels of satisfaction with their treatment and treatment provider have a much their treatment and treatment provider have a much more positive outlook about their illness and their more positive outlook about their illness and their ability to cope with it. ability to cope with it.

Bipolar Disorder Type II Bipolar Disorder Type II (Depressed Type)(Depressed Type)

Incorporate all of the previous slideIncorporate all of the previous slide Recent studies suggest antidepressants Recent studies suggest antidepressants

cause a sooner relapse or conversion to cause a sooner relapse or conversion to maniamania

Treating the Bipolar component is equivalent Treating the Bipolar component is equivalent to casting both broken legs.to casting both broken legs. Mood stabilizersMood stabilizers

Lithium – only drug proven to reduce suicide rateLithium – only drug proven to reduce suicide rate AntidepressantsAntidepressants

1950’s – Richard Dreyfuss1950’s – Richard Dreyfuss 1990’s – Depakote, Tegratol, Trileptal, Lamictal1990’s – Depakote, Tegratol, Trileptal, Lamictal

Atypicals? Atypicals?

Bipolar Disorder Type I Bipolar Disorder Type I (Manic and Depressive)(Manic and Depressive)

ManiaMania AntipsychoticsAntipsychotics

1953 – Thorazine/chlorpromazine1953 – Thorazine/chlorpromazine World’s first psychotropic medicationWorld’s first psychotropic medication Could treat psychosis and maniaCould treat psychosis and mania Other conventional antipsychotics followedOther conventional antipsychotics followed

Risk and BenefitsRisk and Benefits Atypical AntipsychoticsAtypical Antipsychotics

Zyprexa, Seroquel, Abilify, Risperdal, Geodon Zyprexa, Seroquel, Abilify, Risperdal, Geodon Risk and BenefitsRisk and Benefits

AnticonvulsantsAnticonvulsants Depakote, Tegratol, Trileptal, LamictalDepakote, Tegratol, Trileptal, Lamictal Risk and BenefitsRisk and Benefits

Electroconvulsive TherapyElectroconvulsive Therapy

GeneticsGenetics

Like the illness, a complicated topic…Like the illness, a complicated topic… Confounding issues:Confounding issues:

HypersexualityHypersexuality Family disintegrationFamily disintegration Separation of siblingsSeparation of siblings TwinsTwins

Genetic ModelsGenetic Models

Mendelian vs. Polygenic ModelsMendelian vs. Polygenic Models 1 affected parents = 1 in 4 affected offspring1 affected parents = 1 in 4 affected offspring 2 affected parents = 2 in 3 affected offspring2 affected parents = 2 in 3 affected offspring 1 dizygotic/fraternal twin = 1 in 6 affected twin1 dizygotic/fraternal twin = 1 in 6 affected twin 1 monozygotoc/identical twin = 2 in 3 affected twin1 monozygotoc/identical twin = 2 in 3 affected twin

Epistatic ModelEpistatic Model Number 22 is prominently mentioned (same gene Number 22 is prominently mentioned (same gene

as schizophreniaas schizophrenia Gene 21q is also involvedGene 21q is also involved Genes 18p and 18q also are involvedGenes 18p and 18q also are involved