JOURNAL READING

BIPOLAR DISORDER A FOCUS ON DEPRESSION

Oleh THUVIJA DARSHINI GOVINDEV (0902005194)

Pembimbing: dr. Sri Diniari, SpKJ

Case
26 years old, bussinesswoman Main complaint : Seeks evaluation for a pattern of hibernating away each winter Other current symptoms : excessive sleeping, weight gain (9kg) due to increased intake of sweets and excessive alcohol use, anhedonia, lack of motivation, negative ruminations and decreased productivity at work

Past history
Several weeks of sleepless night, increased in mood, energy and libido (college years) Exceeded her credit card limit and was evaluated at an emergency department for alcohol intoxication last episode

The clinical problem

Bipolar I disorder (mania) increased severity of the elevated mood functional disability (characterized by psychosis need for urgent care/ hospitalization) Bipolar II disorder (hypomania) infrequently seek evaluation unless a bipolar diagnosis is already established progression of the illness (e.g becoming mania) Manic depressive illness depressive episode after each mania episode more episode of major depression before the 1st mania/hypomania episode

Key Diagnostic Criteria Distinguishing Bipolar I from Bipolar II Disorder Criteria are from
American Psychiatric Association

Manic Episode (Bipolar I Disorder) Distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 wk (or less if hospitalization is required) Must be accompanied by at least 3 of the following symptoms (4 if mood is only irritable): inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased involvement in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities with a high potential for painful consequences

Hypomanic Episode (Bipolar II Disorder) Distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood lasting at least 4 days Must be accompanied by at least 3 of the following symptoms (4 if mood is only irritable): inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased involvement in goaldirected activity or psychomotor agitation, excessive involvement in pleasurable activities with a high potential for painful consequences

Symptoms do not meet criteria for a mixed episode

Hypomanic episodes must be clearly different from the persons usual nondepressed mood, and there must be a clear change in functioning that is not characteristic of the persons usual functioning
Changes in mood and functioning must be observable by others. In contrast to a manic episode, a hypomanic episode is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization, and there are no psychotic features Symptoms not due to direct physiological effect of medication, general medical condition, or substance abuse

Disturbance must be sufficiently severe to cause marked impairment in social or occupational functioning or to re- quire hospitalization, or it is characterized by the presence of psychotic features Symptoms not due to direct physiological effect of medication, general medical condition, or substance abuse

Diagnosis and Assessment

Initial evaluation (depressed mood) screening for alcohol and drug use assessment of suicidality personal and family psychiatric history physical examination laboratory testing (indicated to rule our additional medical problems that may be contributing to symptoms)

Personal and Family history

The onset of symptoms before 25 years of age More frequent episodes with a shorter duration (i.e <6 months) increase the likelihood of a diagnosis of bipolar depression rather than unipolar depression Presences of hypersomnia and hyperphagia bipolar depression, whereas insomnia and reduced appetite unipolar depression

Clinical assessment (Mood Disorder Questionnaire)

Screening instrument for bipolar disorder in patient presenting with depression 13 yes/no questions regarding symptoms that are typically associated with mania Yes to 7/more questions about symptoms occurring concurrently and associated with at least moderate disability is considered a positive screening result false positive rates between 15 30% reflecting the overlap of symptoms of bipolar disorder with other conditions

Diagnostic Criteria for Major Depression.* Period of at least 2 wk during which five or more symptoms have been present (at least one of the symptoms is either depressed mood or loss of interest or pleasure in nearly all activities) Changes in appetite or decrease or increase in weight, insomnia or hypersomnia, and psychomotor agitation or retardation; decreased energy; feelings of worthlessness or guilt; difficulty in thinking, concentrating, or making decisions; recurrent thoughts of death or suicidal ideation, plans, or attempts Symptoms are either new or worse than before the depressive episode, and they persist for most of the day, nearly every day, for at least 2 consecutive wk

Episode accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning
Symptoms are not due to bereavement or to direct physiological effect of medication, general medical condition, or substance abuse

* In major depression, the persons mood is described as depressed, sad, hopeless, discouraged, or down in the dumps. Criteria are from the American Psychiatric Association.

Management FDA approved treatments for bipolar depression

For acute mania (10 treatments) 1 typical antipsychotic agent lithium 2 anti epileptic agents 6 antitypical antipsychotic Bipolar depression Quetiapine Olanzapine + Fluoxetine (combination)

Antiepileptic drugs
Lamotrigine (FDA approved) maintanence therapy of bipolar I disorder Studies that has been done 1. 7 weeks randomized, double blind, placebo controlled trial of 200mg lamotrigine in 195 patients with bipolar I significant decrease in scores on several depression rating scale 2. 7 10 weeks, placebo controlled trials with varying inclusion criteria (patients with bipolar I, II or both) and dosing regimens (fixed, flexible and 100-400mg) no significant benefit of lamotrigine

3. Meta analysis of all 5 trials (total patients of 1072) modest benefit of lamotrigine as assessed by 50% greater decrease in the MADRS score / scre on the Hamilton Rating Scale for Depression 4. 8 weeks, randomized, placebo controlled trial involving 124 patients with bipolar I or II who were receiving lithium maintenance therapy + 200mg of lamotrigine greater improvement in MADRS score higher response rate compared with placebo

5. Small, randomized, crossover trial involving 31 patients with refractory depression, compared 6 weeks course of lamotrigine, gabapentin and placebo depression symptoms were much improved with lamotigine than with gabapentin or placebo Divalproex sodium approved for acute mania

Antidepressant drugs
Fluoxetine (approved with combination of olanzapine) bipolar depression All FDA approved antidepressants are indicated only for unipolar depression Studies show that antidepressants reduces the risk of recurrent depression but increases the risk of a switch to a hypomanic/ manic episode

Psychotherapy
Very little systematic evaluation of psychotherapy in patients with bipolar depression

Ares of uncertainty
Studies (retrospectively) report a switch to manic/hypomanic episode within 12 weeks after starting an antidepressants Tricyclic antidepressants have been associated with an increase risk of a switch to mania in patients with bipolar I, II or those lack of mood stabilizers Placebo controlled trial using modafinil increases wakefulness in patients with certain sleep disorders (bipolar depression)

Guidelines
Treatment for bipolar depression are currently being revised by the American Psychiatric Association International Society for Bipolar disorders recommend (1st line for bipolar depression) quetiapine lamotrigine lithium monotherapy olanzapine with an SSRI (fluxetine) lithium/divalproex with SSRI/bupropion

Conclusion & Recommendations

Patient has recurrent depression with current symptoms of hypersomnia and hyperphagia and at least 1 pevious manic episode Bipolar I disorder Education on alcohol consumption effects of alcohol abuse on depression encouraged to abstain from drinking consider specific treatment for alcohol dependency

 Initial treatment with quetiapine (300mg daily) monitor for somnolence elevation in the glucose level weight gain tardive dyskinesia 2nd line intervention if quetiapine is poorly tolerated/ if there is no change in depressive symptoms lamotrigine (gradual increase to a dose of 200mg) Antidepressant monotherapy not recommended if antidepressant cotherapy is used, careful monitoring in required for suicidal ideation and a switch to mania/hypomania during treatment

MATUR SUKSMA
THANK YOU
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