Professional Documents
Culture Documents
However, for most patients not manias, but depressions define bipolar
In fact,
more than 3 episodes of depression for every manic episode,
Also depressive episodes last much longer than manic episodes,
Clinician side:
do not adequately ask prior h/o of hypomania
Borderline PD (BPD), anxiety disorder or adjustment disorder
In case of anxiety disorders:
Diagnosis more complex as very high comorbidity of anxiety in BPAD
ie both diagnosis may be correct
BPAD and BPD differences:
h/o of sexual or physical trauma
BPD more likely
self-mutilation or dissociative symptoms
f/h/o mood illness
marked episodic PMA activation, BPD less likely
absence of sexual trauma/self-mutilation
Focus on longitudinal, rather cross-sectional approach
diagnosis is prognosis (Kraepelin)
Symptomatology
Insomnia Hypersomnia
Decreased appetite Hyperphagia
Psychomotor agitation Psychomotor retardation
Other atypical symptoms
Somatic complaints Psychosis and/ or pathological guilt
Mood lability or manic symptoms
Course of illness
Later onset > 25 yrs Earlier onset < 25 yrs
Long current depression > 6 months Multiple depressions 5 episodes
Family history
No bipolar disorder Bipolar disorder
Proposed by Task Force on Diagnostic Guidelines of the
strategies for improving diagnosis:
the development of risk predictors
Greater use of standardized assessments
Integrating self-report measures with careful characterization of
longitudinal course may provide the best cross-sectional strategy for
diagnosis.
Thus, Clinicians and patients should recognize that
any initial diagnosis is provisional,
subject to later re-examination,
Depression - MC as well as most difficult-to-treat phase of BPAD
3 times more depressed more than are manic (naturalistic treatment)
Many decades-long deficit in clinical treatment research
Conventional treatment toward the end of 20th century -
AD augmentation of mood stabilizers
STAR-D study
20-50% AD-induced mania
Another concern: AD use in BPAD depression may
precipitate or exacerbate mixed (manic) symptoms
may be assoc with increases in suicidality
Thus, AD-induced suicidality in children and adults
may actually represent the induction of mixed states by ADs in individuals
with undetected BPAD.
Incorrect assignment of BPAD among individuals who truly have
MDD (similar to opposite) may have undesired consequences
Ineffective or modestly effective drugs (for ex, lithium therapy,
lamotrigine) or
Substantial toxic and poorer tolerable drugs(2nd generation APs) given
Treatment options poorly delineated, in absence of mood stabilizer
Li, CBZ, LTG and VAL
none have acute AD effects and none approved by FDA for this indication
Typically involved in the long-term prophylaxis of BPAD
BPAD depression breakthrough these agents alone and in combination is
quite common
Prevented by addition of an atypical AP a primary recommendation
MOA:
increases hippocampal level and cortical gray matter volume;
increases Bcl-2 at blood levels decrease the size of lesions in neurodegenerative disorders
Long-term Li maintenance
decrease medical comorbidity. increase in longevity in patients compared to other agents
Result less likely diagnosis in old age
Levothyroxine (T4)
100mcg per week to final dosage of 300mcg per day
Only in women with treatment-refractory depression in BPAD compared to
placebo
Augmentation with Li
Rational strategy to use in virtually any patient with BPAD depression who
is not already on Li
Minocycline
Anti-inflammatory, neuroprotective, anitbiotic
100mg twice a day
Some AD efficacy in BPAD depression
As approx. 1/3rd with BPAD depression have inflammation as marked by
increased CRP, IL-1, IL-6 or TNF alpha
Ketamine
Acute onset (within 2hrs) of AD effects in depressed patients (including
BPAD)
IV 0.5mg/kg over 40 minutes
Effects typically lasts only 3 to 5 days
Associated antisuicidal effects so frequently used in emergency rooms
Scoplamanine
IV - Rapid-onset AD effect
Oral Augmentation greater benefit than patients with unipolar
depression
Sleep Deprivation
One night sleep deprivation dramatic, overnight AD effects
Can be sustained by Li, phase advance and bright light therapy
- Quetiapine
- Olanzapine + Fluoxetine
- SSRIs with MS
- ECT
Potential options for maintenance
- MS + LA
- MS + Quetiapine
- MS + Olanzepine + Fluoxetine
- MS + Olanzepine
Use antidepressants always in combination with MS or anti manic drugs
Pregnancy, Postpartum and Lactation
Pregnancy and postpartum period most vulnerable time in a womens life for mental
health problems, especially true with BPAD
Pharmacological treatment becomes additionally complex during the continuum of
pregnancy and postpartum period
Misdiagnosis of BPAD depressive episodes as unipolar depression common
Risks triggering manic and psychotic symptoms severe outcomes including
Baby harm thoughts, suicide and (more rarely) infanticide
Diagnosis becomes more difficult due to inherent disruptions to sleep, energy and appetite, both
before and after delivery
Accurate diagnosis needed differentiating
Not only b/w UD and BPAD depression, but also
b/w subtypes of BPAD (I, II and mixed)
Some, common meds used in BPAD adverse effects to developing fetus
Risks of fetal & maternal exposure to untreated illness weighed against the risks of exposure to
medications (teratogenicity, obstetric complications, birth, neonatal and neurodevelopmental
outcomes
BIPOLAR RATES IN WOMEN
NCS lifetime prevalence 3.9% among adult population
BPAD I:
Similar b/w men and women
Women with BPAD experience more depressive episodes during the active phases of illness
compared to men
BPAD II
Higher in women
Depressive symptoms 30times more prevalent than hypomanic symptoms
BIPOLAR RATES DURING PREGNANCY AND POSTPARTUM PERIOD
70% of women with BPAD have acute mood episode (depression most frequent)during
pregnancy,
Although the postpartum phase may be most vulnerable
The risk of depression was consistently higher in BPAD patients compared with UD
Women with previous diagnoses of PMS and PMDD sensitive to hormonal changes
Higher risk for MDD or BPAD episodes during pregnancy and postpartum
Serum albumin concentration decreases affects medications that are highly protein bound
increase amounts of unbound drug dosage reduction
Afferent and efferent arterioles dilate during pregnancy 50% increase in RBF and
clearance
increased elimination rate of drugs that are cleared by kidneys subtherapeutic concentrations
At DELIVERY
Plasma volume drops dramatically
Predisposing women to toxicity if dosages increased throughout pregnancy
Renal clearance and hepatic metabolism return to preconception levels over the course of
1-2weeks
LAMOTRIGINE
FDA pregnancy category C
During lactation is generally acceptable; however, infants monitored for toxicity
Lamotrigine clearance is dramatically increased through the course of pregnancy.
Clearance returns to normal rapidly after delivery
Drug concentrations should be monitored closely during pregnancy to ensure continued clinical
benefit and dosage adjusted accordingly
Dosage should be reduced after delivery to prevent toxicity
Extensive evidence support use and safety during pregnancy, with most data suggesting no
increased risk of congenital malformations
Seems among the safest choices for BPAD management during pregnancy
VALPROATE
Should not be used during pregnancy due to well-documented dose-dependent teratogenic risks
associated with use
MC associated with NTDs and spina bifida
Foalte supplementation recommended before conception and throughout pregnancy
Generally considered compatible with lactation
CARBAMAZEPINE
MC associated with NTDs and spina bifida, although at rates lower than seen with valproate
Folate supplementation recommended
Generally considered compatible with lactation
OXCARBAZEPINE
Risks in pregnancy and lactation are largely unknown at this time
LITHIUM
Exposure during 1st trimester increases the risk of fetal cardiac abnormalities
A fetal ECHO and level-2 USG recommended during 2nd trimester
To reduce the risk of toxicity in both mother and infant, Li doses should be held or reduced around the time
of delivery
Not considered compatible with breastfeeding
ATYPICAL ANTIPSYCHOTICS
Use has increased in pregnancy, however, data remain limited
No increased risk of congenital malformations
FDA category C with exception of clozapine and lurasidone (category B)
QUETIAPINE
Has the lowest placental transfer of SGAs
If a woman is clinically stable on quetiapine prior to conceiving, continuing on therapy is a reasonable
treatment strategy.
Greater incidence of sedation issue for women trying to be alert to care child after delivery
Excreted in breast milk
LURASIDONE
Limited data
Summary of SGAs use in pregnancy and lactation
SGAs not shown an increased risk of congenital malformations.
MC effect on infants is a higher likelihood of large wt for GA
Infants exposed to an SGA could have withdrawal symptoms or EPS after delivery
Breastfeeding is typically not recommended with use of SGA
If a woman is clinically stable on an SGA, becomes pregnant
the benefits of mood control and
risks of relapse and fetal effects must be evaluated
ECT
Should remain an option of last resort for pregnant women
Due to risks of switching to mania when using SSRIs for depressive symptoms, which can be even more
difficult to manage during pregnancy
To conclude
Keep mothers stable the best prevention of postpartum mood change is to maintain psychiatric
stability during pregnancy and through delivery and the postpartum year
Be familiar with fetal development and windows of risk during pregnancy
Treatment decisions during pregnancy must be made in conjunction with a treatment plan for the
postpartum period and lactation
Teratogenic classifications and lactation classifications should be considered but with the
understanding that they provide incomplete information
Patients and families do best when they can make informed decisions based on comprehensive
discussions with a clinician about risks and benefits
When using Li, discontinue medication when contractions start to prevent maternal and
fetal toxicity after delivery
If a patient is on an antiepileptic drug before conception, consider use of a atypical AP for
the 1st trimester, if possible, return to the antiepileptic drug in 2nd and 3rd trimesters
If Li or paroxetine has been the most effective medication for a patient, consider changing to
a lamotrigine or SGA for 1st trimester
For (1) the strength of the existing evidence, the grades are as follows:
A = substantial evidence from at least one controlled clinical trial
B = large amount of data from partially controlled and opened clinical case series
C = a modicum of clinical and case series data including case reports
D = theoretic approaches with as yet relatively little data support